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Secondary tumors of the brain
632
American Journal of Surgery
Progress
be but partiahy impaired. However, when the chnician visuahzes gaII-bIadder disease in terms of earIy pathoIogic changes, chronoIogicaIIy at the period of earIy symptoms of extragastric dyspepsia, when the aIert physician reaIIy wishes to make a diagnosis, and often can do so on the history aIone, we find that not onIy must choIecystography fail, but the beautifuIIy cIear cut roentgenogram of the typica normaI gaII-bIadder actuaIIy directs the attention away from it as the source of troubIe. SCH~~NFEL?, HERBERT. The roentgenoIogica1 differentra1 diagnosis between hernia and diaphragmatic reIaxation. Klin. Wcbnscbr., Sept. 3, 1926, v, 1657-1660. Observations show that in the case of a very Iarge defect of the diaphragm the hernia1 sac can appear in the roentgenogram as a uniform domed curve extending from the mediastinum to the IateraI thoracic waI1 and from the vertebra1 coIumn to the sternum, without adhering to tbe contours of tbe projected abdominal organs so that the defect may imitate compIeteIy the characteristic picture of the diapbragmatic arch. On the other hand, it is entireIy possibIe theoreticaIIy that in a case of reIaxation a paper-thin, entireIy reIaxed diaphragmatic sac may mantIe the subjacent abdomina1 organs in a manner anaIogous to the hernia1 sac. In fact such a case was found at autopsy by GIaser in 1903. In such a case the roentgenogram wouId discIose the contours of the diaphragm and thus Iead to an erroneous diagnosis of hernia. From the above considerations it is cIear that the presence of a uniform arch or the appearance of a broken outIine is onIy of conditiona1 vaIue as a differentia1 diagnostic character distinguishing between hernia and reIaxed diaphragm. This mereIy emphasizes the fact that it is difficult to base generaIizations on singIe characters and that interpretation shouId take into consideration a11 the facts possibIe. A report is given of a case of congenitaL true diaphragmatic hernia in which the usual reIiabIe roentgenoIogica1 characteristics were absent. During the roentgen examination the diaphragm aIways showed a uniform arched appearance both in the upright and recumbent positions. The tentative clinical diagnosis was reIaxed diaphragm. The infant died of bronchopneumonia and the autopsy discIosed a true diaphragmatic hernia with crowding of the thoracic organs upward and to the right. WALTER D. Secondary tumors of the brain. J. Am. M. Ass., Aug. 28, 1926, Ixxxvii, 650-654.
SHELDEN,
ApproximateIy 5 per cent of the brain tumors
in Surgery
JUNE, 1927
examined at the Mayo CIinic are metastases from malignant disease eIsewhere in the body. These metastatic tumors present no essentra1 characteristics which distinguish them from primary tumors of the brain. A roentgen examination of the Iungs and head is very important when evidence of secondary tumors is sought;_ and such reports as heaIed tubercuIosis, mrhary tubercuIosis, pIeura1 adhesions, pneumoconiosis and pIeura1 effusions shouId be received with reserve and examinations shouId be made at sufficient intervaIs to determine whether these signs remain constant. Primary carcinoma of the Iung is particuIarIy prone to metastasize to brain, meninges, and bones of the spine. A roentgenogram of the head seIdom gives evidence of secondary tumors in the brain aIthough the skuI1 is quite often invaded by metastatic tumors, notabIy by hypernephroma. Suspicious signs in the bones of the chest or skuI1, themseIves not diagnostic shouId Iead to further study of the osseous system for more positive data. Carcinoma of the nasopharynx often invades the skuI1, and its first cIinica1 symptoms may be ocuIar paIsy, chiasma1 signs or invoIvement of the fifth and other crania1 nerves. For instance, in hypernephroma when the tumor is smaI1 or Iocated peripherarly it may exhibit no signs or symptoms and the various examinations may be negative. A primary tumor with metastasis in the brain may be entireIy missed. Roentgenograms of the chest and skuI1 shouId be taken as soon as symptoms suggesting brain tumor appear both for their immediate value and for comparison with Iater studies. Two iIIustrative cases are cited in detai1. In addition there are tabuIated three groups of metastatic tumors of the brain. Group I, consisting of IO cases? includes latent maIignant disease, the inrtia1 symptoms of which were due to cerebra1 metastases. The importance of the roentgen examination of the chest in these cases is emphasized. Group II in&ides 6 cases of maIignant disease which were symptomless? but demonstrable on exammatron. The inrtia1 symptoms in these were cerebraI. In this group are incIuded three cases of carcinoma of the nasopharynx and 2 cases of carcinoma of the thyroid. Group III incIudes 8 cases in which the mahgnant tumors were removed surgicaIIy, and the cerebral symptoms were the first evidence of recurrence. Three of the cases deveIoped folIowing removaI of breast carcinoma and one each from carcinoma of the sigmoid, hypernephroma, sarcoma of the testis, mahgnant more and tumor of the parotid gIand. There is stiI1 another group of
NEW SUUES
VOL.II, ho.
6
Progress
mahgnant disease which during its cIinica1 course metastasizes to the nervous system with or without the production of definite symptoms. SIMPSON, FRANK E., and FLESHER, ROY E. Radon (radium emanation) as a pahiative agent in the treatment of intra-oral cancer. J. Am. M. Ass., Aug. 28, 1926, Ixxxvii, 655-657. The usua1 technique empIoyed by the authors is as foI1ow-s: If onIy surface irradiation is to be given, approximateIy IOOO mc. screened with 2 mm. siIver and z mm. rubber is appIied to an area 4 to 6 sq. cm. for fifteen minutes. Great care must be taken not to rub or traumatize the Iesion. Sometimes a Iesion is of such irreguIar contour that severa appIications are necessary,: and in these cases due regard must be paid to overIapping. If intratumoraI treatment is also indicated a preIiminary surface irradiation is given with IOOO mc. in order to minimize the danger of metastasis. This procedure is regarded as very important. Then bare g&s tubes are implanted under IocaI anesthesia, each tube containing 0.5 to 1.0 mc. of radon, the tubes being distributed I cm. apart, evenIy throughout the Iesion. These are alIon_ed to remain since the tubes either become encysted or sIough out during healing. A smal1 piece of tissue for microscopic examination is removed with a smal1 sharp punch immediateIy after the first powerfu1 irradiation. To guard against loca1 effects on the fingers the radon tubes are handled with rubber covered forceps 12 inches Iong. The operator during the appIication of the radon is shieIded from the patient by movabIe Iead angIe pIates each weighing about 300 pounds. The Iymphatic gIands of the neck of the patient frequentIy require irradiation, and the radon is applied by means of wooden carriers 4 X 4 X 4 cm. For the protection of the patient a heavy movabIe lead shieId is empIoyed which fits around the wooden bIock carrymg the radon and is suspended above the tabIe on which the patient lies. Between 1919 and 1922 the above radon treatment was employed in 56 unseIected cases of intraora1 squamous ceI1 cancer, none of the cases being favorabIe for operation. The cIinica1 diagnosis was confirmed microscopicaIIy in all of these. There were 52 men and 4 women. The average duration of the disease was 5.3 months. The Iesion was on the tongue in 9 cases, on the floor of the mouth in 3, and bucca1 mucous membrane in 17, the superior maxiIIa in 8, the inferior maxiIIa in 7 and the paIate and tonsi in 12. In 29 cases there were paIpabIe Iymph nodes in the neck; in 23 the submaxiIIary nodes were apparently affected
in Surgery
American Journal of Surgery
633
and in 4 the cervica1 nodes. One case had paIpabIe submaxiIIary and submental nodes; in another there were palpable submental and cervical nodes. In 27 cases no definite nodes couId be detected. Thirty-nine of the 56 cases have been carefuIIy traced. Of these 21 had definitely paIpable lymph nodes when treated. Of these 2 are Iiving, one having been we11 for over five years and the other for over four. years. The remainder died but the majority showed definite improvement for a time. The duration of life after treatment varied from four months to three years, average 16.4 months. Of the 18 patients without nodes 14 are Iiving, 4 for more than five years, 5 for more than four years, and 5 for more than three years. Four of the patients are dead. Three of the latter Iived for more than three years after treatment but a11 died eventuaIIy of recurrence. Of the 9 patients with tongue cancer 6 had paIpabIe nodes in the neck, and 2 of these are living. Of the 3 patients without nodes, 2 are Iiving. The 4 Living patients with tongue cancer have been we11 for five years, four years, three and a haIf years and three years respectively. Assuming that the 17 untraced patients are dead, the tota mortality in this group of 56 unseIected patients is 63.3 per cent. The remainder have been we11 for periods of three to five years, the average duration of freedom from symptoms of cancer being three years and nine months up to the time of this report. SUTHERLAND, CHARLES G. PoIypoid tumors in the pyloric end of the stomach: Reports of three cases. Radiology, June, 1926, vi, 520-522. The first case occurred in a woman aged sixty compIaining of “stomach troubIe” of one year’s duration. Examination revealed a movable, tender mass in the right fIank supposed to be a kidney. A roentgenogram reveaIed a large shadow in the area of the right kidney at the IeveI of the fourth Iumhar vertebra, and cystoscopic examination showed the function of the right kidney to be greatIy impaired. Roentgenoscopy ehcited a narrowing of the antrum of the stomach, pre-pyloric spasm so frequentIy associated with gastric uIcer, and the fiIms presented a saucer shaped defect in the duodenal cap. At operation a soft movable tumor about 6 cm. in diameter was founc1 at the pyIoric end of the stomach. This tumor couId be invaginated into the duodenum. The patient aIso had a gastric uIcer on the Iesser curvature, about 7.5 cm. above the pylorus. The right kidney was resected at a Iater operation when a pyonephrosis with stone was found.
American Journal of Surgery
Progress
be but partiahy impaired. However, when the chnician visuahzes gaII-bIadder disease in terms of earIy pathoIogic changes, chronoIogicaIIy at the period of earIy symptoms of extragastric dyspepsia, when the aIert physician reaIIy wishes to make a diagnosis, and often can do so on the history aIone, we find that not onIy must choIecystography fail, but the beautifuIIy cIear cut roentgenogram of the typica normaI gaII-bIadder actuaIIy directs the attention away from it as the source of troubIe. SCH~~NFEL?, HERBERT. The roentgenoIogica1 differentra1 diagnosis between hernia and diaphragmatic reIaxation. Klin. Wcbnscbr., Sept. 3, 1926, v, 1657-1660. Observations show that in the case of a very Iarge defect of the diaphragm the hernia1 sac can appear in the roentgenogram as a uniform domed curve extending from the mediastinum to the IateraI thoracic waI1 and from the vertebra1 coIumn to the sternum, without adhering to tbe contours of tbe projected abdominal organs so that the defect may imitate compIeteIy the characteristic picture of the diapbragmatic arch. On the other hand, it is entireIy possibIe theoreticaIIy that in a case of reIaxation a paper-thin, entireIy reIaxed diaphragmatic sac may mantIe the subjacent abdomina1 organs in a manner anaIogous to the hernia1 sac. In fact such a case was found at autopsy by GIaser in 1903. In such a case the roentgenogram wouId discIose the contours of the diaphragm and thus Iead to an erroneous diagnosis of hernia. From the above considerations it is cIear that the presence of a uniform arch or the appearance of a broken outIine is onIy of conditiona1 vaIue as a differentia1 diagnostic character distinguishing between hernia and reIaxed diaphragm. This mereIy emphasizes the fact that it is difficult to base generaIizations on singIe characters and that interpretation shouId take into consideration a11 the facts possibIe. A report is given of a case of congenitaL true diaphragmatic hernia in which the usual reIiabIe roentgenoIogica1 characteristics were absent. During the roentgen examination the diaphragm aIways showed a uniform arched appearance both in the upright and recumbent positions. The tentative clinical diagnosis was reIaxed diaphragm. The infant died of bronchopneumonia and the autopsy discIosed a true diaphragmatic hernia with crowding of the thoracic organs upward and to the right. WALTER D. Secondary tumors of the brain. J. Am. M. Ass., Aug. 28, 1926, Ixxxvii, 650-654.
SHELDEN,
ApproximateIy 5 per cent of the brain tumors
in Surgery
JUNE, 1927
examined at the Mayo CIinic are metastases from malignant disease eIsewhere in the body. These metastatic tumors present no essentra1 characteristics which distinguish them from primary tumors of the brain. A roentgen examination of the Iungs and head is very important when evidence of secondary tumors is sought;_ and such reports as heaIed tubercuIosis, mrhary tubercuIosis, pIeura1 adhesions, pneumoconiosis and pIeura1 effusions shouId be received with reserve and examinations shouId be made at sufficient intervaIs to determine whether these signs remain constant. Primary carcinoma of the Iung is particuIarIy prone to metastasize to brain, meninges, and bones of the spine. A roentgenogram of the head seIdom gives evidence of secondary tumors in the brain aIthough the skuI1 is quite often invaded by metastatic tumors, notabIy by hypernephroma. Suspicious signs in the bones of the chest or skuI1, themseIves not diagnostic shouId Iead to further study of the osseous system for more positive data. Carcinoma of the nasopharynx often invades the skuI1, and its first cIinica1 symptoms may be ocuIar paIsy, chiasma1 signs or invoIvement of the fifth and other crania1 nerves. For instance, in hypernephroma when the tumor is smaI1 or Iocated peripherarly it may exhibit no signs or symptoms and the various examinations may be negative. A primary tumor with metastasis in the brain may be entireIy missed. Roentgenograms of the chest and skuI1 shouId be taken as soon as symptoms suggesting brain tumor appear both for their immediate value and for comparison with Iater studies. Two iIIustrative cases are cited in detai1. In addition there are tabuIated three groups of metastatic tumors of the brain. Group I, consisting of IO cases? includes latent maIignant disease, the inrtia1 symptoms of which were due to cerebra1 metastases. The importance of the roentgen examination of the chest in these cases is emphasized. Group II in&ides 6 cases of maIignant disease which were symptomless? but demonstrable on exammatron. The inrtia1 symptoms in these were cerebraI. In this group are incIuded three cases of carcinoma of the nasopharynx and 2 cases of carcinoma of the thyroid. Group III incIudes 8 cases in which the mahgnant tumors were removed surgicaIIy, and the cerebral symptoms were the first evidence of recurrence. Three of the cases deveIoped folIowing removaI of breast carcinoma and one each from carcinoma of the sigmoid, hypernephroma, sarcoma of the testis, mahgnant more and tumor of the parotid gIand. There is stiI1 another group of
NEW SUUES
VOL.II, ho.
6
Progress
mahgnant disease which during its cIinica1 course metastasizes to the nervous system with or without the production of definite symptoms. SIMPSON, FRANK E., and FLESHER, ROY E. Radon (radium emanation) as a pahiative agent in the treatment of intra-oral cancer. J. Am. M. Ass., Aug. 28, 1926, Ixxxvii, 655-657. The usua1 technique empIoyed by the authors is as foI1ow-s: If onIy surface irradiation is to be given, approximateIy IOOO mc. screened with 2 mm. siIver and z mm. rubber is appIied to an area 4 to 6 sq. cm. for fifteen minutes. Great care must be taken not to rub or traumatize the Iesion. Sometimes a Iesion is of such irreguIar contour that severa appIications are necessary,: and in these cases due regard must be paid to overIapping. If intratumoraI treatment is also indicated a preIiminary surface irradiation is given with IOOO mc. in order to minimize the danger of metastasis. This procedure is regarded as very important. Then bare g&s tubes are implanted under IocaI anesthesia, each tube containing 0.5 to 1.0 mc. of radon, the tubes being distributed I cm. apart, evenIy throughout the Iesion. These are alIon_ed to remain since the tubes either become encysted or sIough out during healing. A smal1 piece of tissue for microscopic examination is removed with a smal1 sharp punch immediateIy after the first powerfu1 irradiation. To guard against loca1 effects on the fingers the radon tubes are handled with rubber covered forceps 12 inches Iong. The operator during the appIication of the radon is shieIded from the patient by movabIe Iead angIe pIates each weighing about 300 pounds. The Iymphatic gIands of the neck of the patient frequentIy require irradiation, and the radon is applied by means of wooden carriers 4 X 4 X 4 cm. For the protection of the patient a heavy movabIe lead shieId is empIoyed which fits around the wooden bIock carrymg the radon and is suspended above the tabIe on which the patient lies. Between 1919 and 1922 the above radon treatment was employed in 56 unseIected cases of intraora1 squamous ceI1 cancer, none of the cases being favorabIe for operation. The cIinica1 diagnosis was confirmed microscopicaIIy in all of these. There were 52 men and 4 women. The average duration of the disease was 5.3 months. The Iesion was on the tongue in 9 cases, on the floor of the mouth in 3, and bucca1 mucous membrane in 17, the superior maxiIIa in 8, the inferior maxiIIa in 7 and the paIate and tonsi in 12. In 29 cases there were paIpabIe Iymph nodes in the neck; in 23 the submaxiIIary nodes were apparently affected
in Surgery
American Journal of Surgery
633
and in 4 the cervica1 nodes. One case had paIpabIe submaxiIIary and submental nodes; in another there were palpable submental and cervical nodes. In 27 cases no definite nodes couId be detected. Thirty-nine of the 56 cases have been carefuIIy traced. Of these 21 had definitely paIpable lymph nodes when treated. Of these 2 are Iiving, one having been we11 for over five years and the other for over four. years. The remainder died but the majority showed definite improvement for a time. The duration of life after treatment varied from four months to three years, average 16.4 months. Of the 18 patients without nodes 14 are Iiving, 4 for more than five years, 5 for more than four years, and 5 for more than three years. Four of the patients are dead. Three of the latter Iived for more than three years after treatment but a11 died eventuaIIy of recurrence. Of the 9 patients with tongue cancer 6 had paIpabIe nodes in the neck, and 2 of these are living. Of the 3 patients without nodes, 2 are Iiving. The 4 Living patients with tongue cancer have been we11 for five years, four years, three and a haIf years and three years respectively. Assuming that the 17 untraced patients are dead, the tota mortality in this group of 56 unseIected patients is 63.3 per cent. The remainder have been we11 for periods of three to five years, the average duration of freedom from symptoms of cancer being three years and nine months up to the time of this report. SUTHERLAND, CHARLES G. PoIypoid tumors in the pyloric end of the stomach: Reports of three cases. Radiology, June, 1926, vi, 520-522. The first case occurred in a woman aged sixty compIaining of “stomach troubIe” of one year’s duration. Examination revealed a movable, tender mass in the right fIank supposed to be a kidney. A roentgenogram reveaIed a large shadow in the area of the right kidney at the IeveI of the fourth Iumhar vertebra, and cystoscopic examination showed the function of the right kidney to be greatIy impaired. Roentgenoscopy ehcited a narrowing of the antrum of the stomach, pre-pyloric spasm so frequentIy associated with gastric uIcer, and the fiIms presented a saucer shaped defect in the duodenal cap. At operation a soft movable tumor about 6 cm. in diameter was founc1 at the pyIoric end of the stomach. This tumor couId be invaginated into the duodenum. The patient aIso had a gastric uIcer on the Iesser curvature, about 7.5 cm. above the pylorus. The right kidney was resected at a Iater operation when a pyonephrosis with stone was found.