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The differentiation of cancer tissue
Society AMERICAN
ASSOCIATION OF OBSTETRICIANS, GISTS AND ABDOMINAL SURGEONS THIRTY-EIGHTH
HOT
SPRINGS,
?‘A.,
ANNUAL SEPTEMBER
GYNECOLO-
MEETING 16, 17 AND
18, 1965
DR. ASA B. DAVIS, OF NEW YORK, PRESIDING (Concluded
In a Symposium
on Malignancy,
from
May)
the following
papers were read:
&room& of the Stomach, by DR. CEO. F. CHANDLER, (See page 101.)
Metastasis in Breast Cancer, by DR. WM. A.
KINasToN,
N. Y.
COVENTRY, DULUTH,
MINN.
(See page 113.)
The DiScentiation MICH.
of Cancer Tissue, by DR. JAMEF, E.
DAVIS, DETROIT,
(See page 29.) DISCUSSION
DR. HENRY SCXKMITZ, CHICAGO, ILL.-To correctly evaluate the treatment, the cases should be grouped as we group the cases of carcinoma of the cervix, namely, Group 1, the clearly localized cases; Group 2, comprises cases in which there ia doubt about localization to primary seat of invasion; Group 3, contains the cases with invasion of the contiguous tissues and organs without fixation, and Group 4, those with a fixation and extensive invasion. The same classifioation could be applied to the breast cases. The indications for the various methods of treatment are placed on this grouping. In Group 1 the treatment indicated is radical excision, including the pectoralis muscles. There is no necessity of applying the x-ray or radium because all the cancer cells can be removed and the patient should remain well. In Group 2 there is a tendency of the carcinoma to spread, there is usually a very perceptible growth. Here x-ray should first be applied in a sufllcient dose to cause occlusion of the lymphatic vessels and a degeneration of the cancer cells, so that they are for the time being stunned and rendered harmless. Operation then follows. In Group 8 we should primarily have recourse to radiation and if, after radiation, the carcinoma becomes movable and reduced in size, then we should add a radical excision. In Group 4 no form of treatment will do the patient any good. It is, of course, natural that in the treatment of carcinoma of the breast we should pay particular attention to the mode of spread by metastaaes. We know that the spinal column, the hip bones and the hea&a of the femurs are the places most frequently involved, even after extensive primary treatment. Therefore x-ray pietures should be taken of every case of cancer of the breast before treatment. In recent correspondence I have had with Dr. Bloodgood about the matter we came 122
AM. ASSN. OBST., GYNEC. AND ABD. RIIZG.
12::
to the conclusion that if x-ray treatment can do these patients any good, the* bones of the entire trunk should be included in the treatment to prevent the appear ante of metastasis later on. If we wait until metastases occur, which are usually indicated by indefinite pains in the involved areas, x-ray treatment rarely will Jo the patient any good. I have treated a great many earcinomata of the breast and recorded 150 cases which had been treated more than five years ago. They were divided into two Of all the cases of primary classes, the primary and the recurrent carcinomas. carcinomata, about 28 per cent have passed the five year period free from recur, rence; of the recurrent cases 20 per cent have passed this period. I do not wish to say these cases may not eventually die from carcinoma, but they have passotl the five year period well and free of the disease. It has been stated that the so-called high voltage radiation will give better results than the low voltage, the essayist having used a 100 kilovolt currfant. 1t does not make any difference what kind of radiation one uses so long as the rallia tion is absorbed in the diseased tissue, and the 100 kilovo.it will give as good 1’~ suits as the 200 kilovolt. We use both kinds of apparatus in Chicago ant1 111 carcinoma of the breast we decline to use the 200 kilovolt current because thy results were very inferior to those obtained with the 100 kilovolt. The high voltaalL on account of deeper penetration will cause more damage to the lungs than the 760 kilovolt. If I have any criticism to offer it is that the focus skin distance was too short and therefore the difference in intensity between the surf.ace dose and the dot11 dose at 2 or 3 cm. was so great that the underlying cancer tissue received only a fraction of radiation, which in this instance was probably about 25 per cent. If a greater focus skin distance had been used-say 50 cm. or even 65 to 80 cm.--and a 100 kilovoltage, I believe the results from the x-ray radiation would havt, been better. It was stated that some of these patients had received x-ray treatments at frequent intervals, as often as at twelve different times. Normal tissues will recover from the damage caused by x-rays after one application, and probably also after a second application. But if the application is continuously repeated we will eausc a degeneration of healthy tissue, such as indurations and ulcers, which behave lilrr a malignant disease. Therefore, we should make it a rule not to subject the patient to repeated x-ray treatments. If results are not obtained by one or two correctly applied radiations then the canc.er is refractory ard further applicat,ions are useless and dangerous. The microscopic study by Dr. Davis is a very valuablo contribution. If we apply his teaching method we will materially contribute to the correct diagnosis of cancer. The work done by Alter, Martzloff, Schottlaender and Broders in the study of the cell type of cervical carcinomata has greatly advanced our knowledge of the malignancy of cancer. Such typing should be madc the fouudation for treatmeni. A fat spindle cell, unripe carcinoma is much more malignant and resists treatment much more than the prickle cell or squamous cell cancer. The latter shows a higher percentage of five year healing after operation and also radiation than the fat spindle cell type. DR. WM. TV. BAHCCCK, PHIIADEWHIA, PA----I speak with hesitation about a treatment we have used in apparently hopeless oases of malignancy during the past eighteen months. The principle is not new, is ba,sod upon the work of Dr. Hodenpyl and consists in injecting intravenously as&tic fluid from patients with cancer of the peritoneum. We have used very large injections-250 to 2,000 c.c.-and have found the fresh peritoneal fluid from other patients with carcinoma very well tolerated. Almost eighty injections have been given; the total number of patients being about forty. In two patients surprising improvement has follow4 the treatment.
124
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
A man found on an exploratory operation to have an apparently inoperable carcinoma of the stomach and considered hopeless, was given one injection and sent home to die. He soon gained 27 pounds, lost all symptoms and now has been back at work for a year and seems to be in good health. The ,second case is that of a woman who was operated upon last year for advanced cancer of the uterus and then treated for recurrence by radium. The disease progressed, she developed a large fistula in the bladder and last Spring was finally confined to her bed under opiat.es. The condition was such that further treatment by radium was refused. After several injections, she showed surprising improvement both locally and generally. Recently, she reported at the office, having the fistula but with little induration and no odor or bleeding. The other patients treated have for the most part died. The fluids have been from various types of carcinoma involving the peritoneum with ascites. Here is a method of giving richIy albuminous fluids in large amounts to replenish the tissues of the debilitated patients with carcinoma. To avoid reaction we have found blood and fluid typing less important than the use of fresh ascitic fluid. DR. WM. SEAMAN BAINBRIDGE, NEW YORK CITY.-YOU may recall a report, previously made, of a series of cases of malignancy (a large number of which were in animals and a lesser number in humans) where hypodermic and intravenous injections of fluid were administered. There were about two dozen, not counting about twenty-five controls, in which we used hypodermics of saline, albumin, and various other fluids. As is true in many cases of advanced cancer, which may get better and then worse, regardless of the type of treatment used, we had temporary improvement in many of these cases. In some instances, we used ascitic fluid, while in others we used quite different fluids, and about as many patients showed this temporary improvement under the injection of the one fluid as under the other. All of the cases, however, eventually died, the course of their disease being unaffected by the treatment. Our experience with the Hodenpyl serum and its usefulness has been published. DR. MILES F. PORTER? FORT WAYNE, IND.-I should like to ask the author of the paper on sarcoma of the stomach to tell us what these patients died of who lived from two to seven years’% I would like to ask also regarding the metastasis to the liver by way of the lymph glands. Sarcoma does not usually metastasize in that way. What is the explanation4 A word regarding radiation in the attempt to cure cancer. I can recall three individuals who have died as a result of fibrosis of the lungs consequent upon, in my humble opinion, the use of the x-ray in extensive doses in the attempt to prevent metastasis from a carcinoma of the breast. I should like to ask also how the diagnosis of the cancer, cured temporarily at least by the injection of the peritoneal fluid, was made7 I at one time reported five consecutive cases of cancer of the thyroid. This diagnosis was made in the laboratory and the cases were cured by subtotal thyroidectomy. The explanation is that the diagnosis was wrong. DR. CHANDLER (closing).-1 cannot answer Dr. Porter’s question because in all the literature there is nothing I can find on the subject. I am watching this woman and if I live long enough I will know what causes her death eventually. I have had a number of my colleagues look over these cases and there seems to be nothing that states what the patients die of. All the pathologists say that the metastasis in carcinoma of the stomach is through the lymphatics into the liver. I cannot explain it.
ASSOCIATION OF OBSTETRICIANS, GISTS AND ABDOMINAL SURGEONS THIRTY-EIGHTH
HOT
SPRINGS,
?‘A.,
ANNUAL SEPTEMBER
GYNECOLO-
MEETING 16, 17 AND
18, 1965
DR. ASA B. DAVIS, OF NEW YORK, PRESIDING (Concluded
In a Symposium
on Malignancy,
from
May)
the following
papers were read:
&room& of the Stomach, by DR. CEO. F. CHANDLER, (See page 101.)
Metastasis in Breast Cancer, by DR. WM. A.
KINasToN,
N. Y.
COVENTRY, DULUTH,
MINN.
(See page 113.)
The DiScentiation MICH.
of Cancer Tissue, by DR. JAMEF, E.
DAVIS, DETROIT,
(See page 29.) DISCUSSION
DR. HENRY SCXKMITZ, CHICAGO, ILL.-To correctly evaluate the treatment, the cases should be grouped as we group the cases of carcinoma of the cervix, namely, Group 1, the clearly localized cases; Group 2, comprises cases in which there ia doubt about localization to primary seat of invasion; Group 3, contains the cases with invasion of the contiguous tissues and organs without fixation, and Group 4, those with a fixation and extensive invasion. The same classifioation could be applied to the breast cases. The indications for the various methods of treatment are placed on this grouping. In Group 1 the treatment indicated is radical excision, including the pectoralis muscles. There is no necessity of applying the x-ray or radium because all the cancer cells can be removed and the patient should remain well. In Group 2 there is a tendency of the carcinoma to spread, there is usually a very perceptible growth. Here x-ray should first be applied in a sufllcient dose to cause occlusion of the lymphatic vessels and a degeneration of the cancer cells, so that they are for the time being stunned and rendered harmless. Operation then follows. In Group 8 we should primarily have recourse to radiation and if, after radiation, the carcinoma becomes movable and reduced in size, then we should add a radical excision. In Group 4 no form of treatment will do the patient any good. It is, of course, natural that in the treatment of carcinoma of the breast we should pay particular attention to the mode of spread by metastaaes. We know that the spinal column, the hip bones and the hea&a of the femurs are the places most frequently involved, even after extensive primary treatment. Therefore x-ray pietures should be taken of every case of cancer of the breast before treatment. In recent correspondence I have had with Dr. Bloodgood about the matter we came 122
AM. ASSN. OBST., GYNEC. AND ABD. RIIZG.
12::
to the conclusion that if x-ray treatment can do these patients any good, the* bones of the entire trunk should be included in the treatment to prevent the appear ante of metastasis later on. If we wait until metastases occur, which are usually indicated by indefinite pains in the involved areas, x-ray treatment rarely will Jo the patient any good. I have treated a great many earcinomata of the breast and recorded 150 cases which had been treated more than five years ago. They were divided into two Of all the cases of primary classes, the primary and the recurrent carcinomas. carcinomata, about 28 per cent have passed the five year period free from recur, rence; of the recurrent cases 20 per cent have passed this period. I do not wish to say these cases may not eventually die from carcinoma, but they have passotl the five year period well and free of the disease. It has been stated that the so-called high voltage radiation will give better results than the low voltage, the essayist having used a 100 kilovolt currfant. 1t does not make any difference what kind of radiation one uses so long as the rallia tion is absorbed in the diseased tissue, and the 100 kilovo.it will give as good 1’~ suits as the 200 kilovolt. We use both kinds of apparatus in Chicago ant1 111 carcinoma of the breast we decline to use the 200 kilovolt current because thy results were very inferior to those obtained with the 100 kilovolt. The high voltaalL on account of deeper penetration will cause more damage to the lungs than the 760 kilovolt. If I have any criticism to offer it is that the focus skin distance was too short and therefore the difference in intensity between the surf.ace dose and the dot11 dose at 2 or 3 cm. was so great that the underlying cancer tissue received only a fraction of radiation, which in this instance was probably about 25 per cent. If a greater focus skin distance had been used-say 50 cm. or even 65 to 80 cm.--and a 100 kilovoltage, I believe the results from the x-ray radiation would havt, been better. It was stated that some of these patients had received x-ray treatments at frequent intervals, as often as at twelve different times. Normal tissues will recover from the damage caused by x-rays after one application, and probably also after a second application. But if the application is continuously repeated we will eausc a degeneration of healthy tissue, such as indurations and ulcers, which behave lilrr a malignant disease. Therefore, we should make it a rule not to subject the patient to repeated x-ray treatments. If results are not obtained by one or two correctly applied radiations then the canc.er is refractory ard further applicat,ions are useless and dangerous. The microscopic study by Dr. Davis is a very valuablo contribution. If we apply his teaching method we will materially contribute to the correct diagnosis of cancer. The work done by Alter, Martzloff, Schottlaender and Broders in the study of the cell type of cervical carcinomata has greatly advanced our knowledge of the malignancy of cancer. Such typing should be madc the fouudation for treatmeni. A fat spindle cell, unripe carcinoma is much more malignant and resists treatment much more than the prickle cell or squamous cell cancer. The latter shows a higher percentage of five year healing after operation and also radiation than the fat spindle cell type. DR. WM. TV. BAHCCCK, PHIIADEWHIA, PA----I speak with hesitation about a treatment we have used in apparently hopeless oases of malignancy during the past eighteen months. The principle is not new, is ba,sod upon the work of Dr. Hodenpyl and consists in injecting intravenously as&tic fluid from patients with cancer of the peritoneum. We have used very large injections-250 to 2,000 c.c.-and have found the fresh peritoneal fluid from other patients with carcinoma very well tolerated. Almost eighty injections have been given; the total number of patients being about forty. In two patients surprising improvement has follow4 the treatment.
124
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
A man found on an exploratory operation to have an apparently inoperable carcinoma of the stomach and considered hopeless, was given one injection and sent home to die. He soon gained 27 pounds, lost all symptoms and now has been back at work for a year and seems to be in good health. The ,second case is that of a woman who was operated upon last year for advanced cancer of the uterus and then treated for recurrence by radium. The disease progressed, she developed a large fistula in the bladder and last Spring was finally confined to her bed under opiat.es. The condition was such that further treatment by radium was refused. After several injections, she showed surprising improvement both locally and generally. Recently, she reported at the office, having the fistula but with little induration and no odor or bleeding. The other patients treated have for the most part died. The fluids have been from various types of carcinoma involving the peritoneum with ascites. Here is a method of giving richIy albuminous fluids in large amounts to replenish the tissues of the debilitated patients with carcinoma. To avoid reaction we have found blood and fluid typing less important than the use of fresh ascitic fluid. DR. WM. SEAMAN BAINBRIDGE, NEW YORK CITY.-YOU may recall a report, previously made, of a series of cases of malignancy (a large number of which were in animals and a lesser number in humans) where hypodermic and intravenous injections of fluid were administered. There were about two dozen, not counting about twenty-five controls, in which we used hypodermics of saline, albumin, and various other fluids. As is true in many cases of advanced cancer, which may get better and then worse, regardless of the type of treatment used, we had temporary improvement in many of these cases. In some instances, we used ascitic fluid, while in others we used quite different fluids, and about as many patients showed this temporary improvement under the injection of the one fluid as under the other. All of the cases, however, eventually died, the course of their disease being unaffected by the treatment. Our experience with the Hodenpyl serum and its usefulness has been published. DR. MILES F. PORTER? FORT WAYNE, IND.-I should like to ask the author of the paper on sarcoma of the stomach to tell us what these patients died of who lived from two to seven years’% I would like to ask also regarding the metastasis to the liver by way of the lymph glands. Sarcoma does not usually metastasize in that way. What is the explanation4 A word regarding radiation in the attempt to cure cancer. I can recall three individuals who have died as a result of fibrosis of the lungs consequent upon, in my humble opinion, the use of the x-ray in extensive doses in the attempt to prevent metastasis from a carcinoma of the breast. I should like to ask also how the diagnosis of the cancer, cured temporarily at least by the injection of the peritoneal fluid, was made7 I at one time reported five consecutive cases of cancer of the thyroid. This diagnosis was made in the laboratory and the cases were cured by subtotal thyroidectomy. The explanation is that the diagnosis was wrong. DR. CHANDLER (closing).-1 cannot answer Dr. Porter’s question because in all the literature there is nothing I can find on the subject. I am watching this woman and if I live long enough I will know what causes her death eventually. I have had a number of my colleagues look over these cases and there seems to be nothing that states what the patients die of. All the pathologists say that the metastasis in carcinoma of the stomach is through the lymphatics into the liver. I cannot explain it.