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The Treatment of Anilin Tumors of the Urinary Bladder
ANILIN TUMORS OF BLADDER.
155
THE TREATMENT OF ANILIN TUMORS OF THE URINARY BLADDER VICTOR D. WASHBURN Wilmington, Delaware
The purpose of this paper is to discuss the treatment of anilin tumors of the urinary bladder. The cases to be considered are 23 white males, dye workers in this country. Of this number 12, or 52 per cent, presented no signs or symptoms suggestive of tumor of the urinary bladder. Men engaged in industry, without urinary symptoms, regard themselves as being perfectly well and it is but natural that they contemplate the idea of a cystoscopic examination with considerable reluctance and sometimes with actual fear. Since these examinations are made annually, confidence on the part of the men and a spirit of cooperation is of outstanding importance. It is our custom, therefore, to treat these men with profound courtesy and consideration. Vve are careful our manipulation of the instruments so that trauma and discomfort are reduced to a minimum. From this same point of view, we find it desirable to use instruments of a small. caliber. We have found it necessary to be most precise and methodical in our examination. The tumors are sometimes exceedingly small and easily overlooked. therefore) look into the bladder when it is distended, when it is empty and while it is filling. In the beginning of our work in this series we did not do a routine cystoscopic biopsy on all of our cases. All papillary tumors were treated by fulguration with a bipolar current through the cystoscope. Patients with sessile tumors, or those that failed to respond to fulguration, were treated by open operation and implantation of radon seeds. Some of our cases made favorable progress under this treatment. The tumors disappeared and the patients have so far remained clinically well and free from bladder tumor. The method was defective, however, in that in some aspects it was a method "trial and error."
156
SYMPOSIUM
;:-- We learned by experience that in certain cases fulguration alone was insufficient. The tumors disappeared but they sometimes recurred at the original site. New tumors appeared elsewhere in some cases. We also found that they changed in appearance and character; what appeared to be benign tumor originally, proved to be malignant in some of the recurring lesions. The second phase of our work began when we agreed that all cases were to have a routine cystoscopic biopsy confirmed by a second specimen in operative cases; and that treatment was to be based on the grade of the tumor, and the clinical setting. We perform biopsy on all accessible tumors and use a Bransford Lewis rongeur forceps which are introduced through an operating cystoscope. This method has the advantage of being quick and painless. It does not traumatize the bladder nor cause excessive bleeding. The specimen is small, perhaps a third as large as a grain of wheat, and yet it is sufficient for the purposes of the pathologist. TREATMENT
Tumors that were single, small and accessible, and of grades I or II, were to be treated by fulguration through the cystoscope. Those of grades III or IV were to be treated by open operation and the implantation of gold radon seeds. In actual practice we have found it desirabie to modify the first step of this plan . .If a tumor is small and benign in appearance, we do not wait for the report of the pathologist but do a biopsy and fulguration at the same sitting. We consider the implantation of gold radon seeds through an open bladder incision the method of choice in all bladder tumors except those that are small, accessible and of grades I or IL The open incision enables the operator to inspect the bladder and treat adequately the lesions present. We use gold radon seeds representing approximately 1.5 m.c. each and implant them at intervals of 1 cm. Tumors that are sessile or submucocal are treated by implantation only. The papillary forms and the larger tumors that may be necrotic we remove in any manner that is convenient, sometimes with the electric cutting current, and sometimes we twist them off with sponge
ANILIN TUMORS OF BLADDER
157
forceps. The base is then implanted with radon seeds followed by cauterization. It may be said that the implantation of radon seeds through a cystoscope, especially after the patient has been treated by fulguration, is technically rather difficult. If scar tissue is present, the seeds tend to escape from the bladder wall after implantation. We deem it proper to speak of the difficulties inherent in the cystoscopic estimation of the size of tumors, their exact location and even their number. If there is uncertainty as to the actual size and number of the tumors in a given case, there must of necessity be uncertainty as to the number of radon seeds required. An ample supply of these seeds must be at hand if the lesions are to be treated adequately. We have discontinued the use of mushroom catheters or large drainage tubes in this type of work. The bladder wall is sutured snugly around a 22 F . s. r. catheter and a cigarette drain is placed in the pre-vesical space. These are removed not later than the fourth post-operative day. We find that the incision heals more promptly and the patient voids naturally sometimes as early as the seventh post-operative day, and may leave the hospital with a closed incision as early as the twentieth post-operative day. From table 1 it may be seen that there were eleven men with single tumors treated by fulguration through the cystoscope. Case 1 is interesting in that on one occasion fulguration was so extensive as to cause leakage of urine into the peritoneal cavity. The abdomen was opened promptly and the bladder wall invaginated. The patient recovered and is back at work free from bladder tumor. From table 2 it may be seen that there were seven men with multiple bladder tumors treated by fulguration only. Case 14 is interesting in that it is, so far as we known, the first case of bladder tumor in a dye worker treated in the United States. It will be noted that he was first seen in 1929 and treated for multiple tumors which disappeared under fulguration. His bladder was normal for three years. A routine cystoscopy in April, 1933, revealed a small papillary carcinoma grade II, in a new location.
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TABLE 1 Single, small bladder tumors treated by fulguration only NAME
AGE
TYPE
GRADE
LOCATION
FIRST
SUBSEQU ENT
TREAT-
TREATMENT
RECU RRENCE
8 times to 2-33
Yes, new sit e, 2- 32
CYSTOTOMY
RESULT
MENT
Yes, 6--32; per- At work, bladder free, 9-33 !oration following fulguration
IV?
Posterior wall
12-31
Papillomatous
I
Posterior wall, left ureteral ridge
10-33
Papillomatous
I
Near right ureter
8-33
Too recent Too recent
0
c:1
1. H.B.
37
Subsessile
2. H. 0 . E.
44
3. F. Q .
49
Too recent u:,
10-33
~'ti
4. A . E . D.
50
Papillomatous
II
Near right ureter
8-33
w. K.
50
Papillomatous
I
Near right ureter
8-33
Too recent
6. F . W.
57
Papillomatous
I
Near right ureter
8-33
Too recent
Bladder free, 10-33
5.
7. W. H.
57
Papillomatous
I
Nearleft ureter
8-32
1-33
8. E.G.
37
Papillomatous
Not done
Base
2-33
None
9. A. E.
39
Papillomatous
Unsatisfactory
Left lateral
2-32
3-32 4-32 6-32 6-32
10, H.J.
47
P apillomatous
Not done
Near left ureter
8-11-32
I I. J.P.
48
Papillomatous
Not done
Posterior wall
8- 32
8-31-32 10- 32
~
s::
Bladder free, 10-33 8-33 No bladder gested
neoplasm, wall con-
Bladder free, 8-33 Bladder free, 5- 33
TABLE 2 Multiple tumors of the bladder treated by fulguration only FIRST
NAME
AGE
TYPE
GRADE
LOCATION
TREATMENT
SUBSEQUENT TREAT-
RECURRENCE
RESULT
MENT
12. P. L.
39
Papillomatous
Near each ureter al meat us
3-32
4-32 6-32 7-32
13. H. M.
40
Papillomatous
Near each ureteral meatus
14. H. N. T.
40
Papillomatous
Left lateral and base
6-32 12-29
t-<
Yes, 10-33, anterior wall new site
7-32 12-20-29 1-10-30 1-24-30 2- 7-30 2-28-30 3-31-30
Too recent
Yes, 4-26-33, new site near right ureter grade II
Bladder free, 6-7-33
q
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0
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43
Papil!omatous
I II
Right lateral, left lateral
10-11-33
Too recent
16. W. L. M.
45
Papillomatous
I II
Right lateral posterior wall above right ureter
10-17-33
Too recent
17. V. P.
47
Papillomatous
Posterior wall, right lateral
10-17-33
Too recent
18. H. ill.
56
Papillomatous
Base posterior wall
7-32 8-32 9-32 2-33
z >-3
Bladder free, 8-10-33
15. H.B.
6-22-32
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Bladder free of tumor 8-33; bladder hemorrhagic
f-'
01
I-'
8
TABLE 3 Bladder tumors treated by open operation and implantation of radon seeds NUMBER
AGE
TYPE
GRADE
LOCATION
FIRST TREATMENT
S UBS EQUENT
RECURREN CE
OPERATION
RESULT
TREATMENT
19. J. H . B .
35
Papillomatous
III
Posterior wall, right lateral
6--32
Several fulguraYes, old site t ions and 3 separat e cystoscopic implant ations of Radon seeds
Yes, 4-29-33, 12 seeds, 18.3 m .c.
At work , comfortable
20. A. K.
39
Papillomatous
IV
Anterior wall surrounding vesicle neck
6--32
Yes, old site
9-25-32, 15 glass seeds,
31 Radon seeds, 56 m .c., comfortable
Base, right lateral
4-32
21. F. H.
50
Papillomatous
22. P. T.
60
Sessile carcinoma
23. W. H .
44
Papillomatous
II
Left lateral wall and base
Not Left lateral done
7.5 m.c.; recurrence,
4-8-33
5-32 7-32 8-32 10-32
3-33, old site, biopsy, not done at operation
10-7-33, implanted 13 seeds
Too recent
,-.·
~J.
Died 1-5-33
2-32
3-32
No
5- 12-32, 24 seeds R adon, 66 m .c. 8- 30-32, resection 9-30-32, 24 seeds, 72.3 m .c.
3-32
4- 32
Yes, 4-33, new site posterior wall grade II
4-29-33, 11.24 m.c. Radon At work
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ANILIN TUMORS OF BLADDER
161
In table 3 are grouped five men all of whom have been subjected to one or more cystotomies. Case 20, the youngest patient in the entire series, after numerous fulgurations and the implantation of radon seeds, through the cystoscope finally came to operation in April, 1933. Case 21 is especially interesting in that when first treated in June 1932 he had an extensive papillary mass surrounding the internal vesical orifice, anteriorly. By September 20 he had complete urinary obstruction. At open operation an electrothermic cutting current was used to remove a large papillary mass. For the purpose of utilizing the caustic alpha and beta rays, 16 glass radon seeds of ½m.c. each were implanted. Seven months later it was found that the tumor had recurred, although not as extensively as when first seen. In April 1933 his bladder was reopened, 11 grams of tumor tissue were removed and 31 gold radon seeds of 1.8 m.c. each implanted. At the second operation it was observed that certain areas of the bladder, which had been definitely neoplastic at the first operation, were now smooth, soft and normal in appearance. Had we been able to estimate more accurately the size of the tumor and had at hand a sufficient number of radon seeds to implant the case adequately, it is quite possible that the tumor might not have recurred. It will be noted that case 22 was our only fatality. When first seen he was in the sixth decade of life with an extensive infiltrating carcinoma. He did not respond to open operation and the implantation of 24 gold radon seeds. He later developed an acute urinary retention which was partially relieved by a transurethral prostatic resection. A second open operation, with the implantation of 24 gold radon seeds, was performed in September 1932. He developed a recto-vesical fistula on January 3, 1933, and succumbed on January 5, 1933. It is to be noted that case 23 had a new tumor one year after his last treatment. It was a papillary carcinoma, grade III in a new location. He was treated by open operation and is back at work.
162
SYMPOSIUM SUMMARY
1. It may be said that 23 men, all engaged in the manufacture of dye stuffs in the United States, have been treated for tumor of the urinary bladder. 2. Eleven cases had single tumors which were treated through the cystoscope by fulguration with the bipolar current. 3. Seven cases had multiple tumors which were treated in the same manner. Of this group, 2 cases have had new lesions in a different location. 4. Five cases came to open operation. Of this group 2 had a single tumor, grades III or IV. The remaining 3 were multiple, 2 of them grades III or IV and 1 clinically malignant but unfavorable for biopsy. 5. There has been one death in our series. 6. No conclusions are drawn as to the results of treatment. BIBLIOGRAPHY (1) REHN, L. : Tumors of the bladder among fuchsin workers. Arch. klin. Chir., 1895, 1, 588-600. (2) LEUENBERGER, S. C .: Tumor formation as observed under the influence of the synthetic dye industry. Beitr. z. klin. Chir., 1912, lxxx, 208. (3) PosNER, C.: Significance of urogenital cancer with respect to the cancer problem. Ztschr. f . Krebsforsch, 1904, i, 4. (4) OPPENHEIMER, R . : Diseases of the urinary apparatus as observed in chemical plant workers. Ztschr. f. Urol. u. Chir., 1926, xxi, 336-70. (5) ScHAR, W. : Experimental cancer of the bladder caused by inhaling naphthylamine. Le Cancer, 1930, vii, 205. (6) PERLMAN, S., AND STAEHLER, W.: Artificially Produced Growths of the Bladder. Klin. Wchnschr., 1932, xi, 1-4. (7) GRoss (personal communication). (8) REHN, L .: Bladder diseases among anilin workers. Verh. deut. Ges. Chir., 1906, xxxiii, 313-314. (9) CuRSCHMANN: Statist ical data on bladder tumors in workmen in the chemical industry. Zentral. f. Gewerbehyg., 1920, viii, 145-9, 169-176. (10) HENRY, S. A., KENN AWAY, N . M., AND KENNAWAY, E. L .: The incidence of cancer of the bladder and prostate in certain occupations. Jour. Hygiene, 1931, xxxi, 125. (11) JosEPH, E. : Treatment of bladder tumors. Ztschr. f. Urol., 1925, xix, 118. (12) HAAGENSEN, C. D . : Occupational neoplastic disease. Am . Jour. Cancer, 1931, xv, 641-703. (13) HOFFMAN, F. L.: San Francisco Cancer Survey, 1931, p. 176. (14) SIMON, L .: Prognosis and treatment of so-called anilin tumors of the bladder. Arch. klin. Chir., 1932, clxxiii, 708-711.
ANILIN TUMORS OF BLADDER
163
(15) SIMON, L.: Precancerous conditions in the bladder. Deutsch. Ztschr. f. Chir., 1930, xxvii, 539-543. (16) JANSSEN: Chirugie der Harnblase, 1920, p. 884-5. (17) BAYLE, G. L.: Traite des maladies cancereuses. Paris, 1833, i, 564. (18) WALDEYER: Quoted by J. Wolff, Volkmann's Sammlung, xxxiii, 1873. (19) v. BRUNN, A.: Arch. f. Mikro. Anat., xli, 294. (20) RAUENBUScH, L.: Virch. Arch., 1905, clxxxii, 132. (21) EHRICH, E.: Bruns Beitrage, 1901, xxx, 581. (22) GoEBEL, C.: Ztsch. f. Krebsforschung, 1905, iii. (23) LuBARSCH: Festschrift zu Virchow's 80 Geburtstage. Wiesbaden, 1901, p. 205 and 231. (24) GRANDHOMME: An extract from "Die Theerfarben Fabriken der Aktiengesellschaft Farbwerke Form. Meiste Lucius und Bruning Zu Hochst A. M. In Sanitarer und Socialer Beziehung" Inter. Lab. Office Rep., 1921, p. 22-28. (25) ENGELHARDT: Quoted by Rehn (1). (26) SCHWERIN: Bladder tumors in chemical plant workers. Zentralbl. f. Gewer-behygiene, 1920, viii, 64-69. (27) ADLER, 0.: The action and fate of benzidine in the bodies of animals. Arch. exp. Pathol. u. Pharmokol., 1907-08, lviii, 167-197. (28) ENGEL, H.: Fate of beta-naphthylamine in the body of the dog. Zentralbl. · f. Gewerbehygiene, 1920, viii, 81-86. (29) KENNAWAY (Personal Communication). (30) FENWICK, E. H.: Trans. Path. Soc. London, 1888, p. 183. (31) JANEWAY, H. H.: Ztschr. f. Krebsforschung, 1910, viii. (32) LEICHTENSTERN, 0.: Deut. med. Woch., 1898, xxiv, 709. (33) SCHEDLER: Dissertation. Basle. 1905. (Quoted in Internat. Lab. Office Report, 1921.) (34) SEYBERTH: Munch. med. Woch., 1907, liv, 1573. (35) BERENBLUM, I.: The Cancer Review, 1932, August, p. 337-353. (36) NASSAUER, M.: Ztschr. f. Pathol., 1919, xxii, 353. (37) SCHEELE, K.: Verh. d. deut. Ges. f. Urol., 1926, VII Congr., Vienna, p. 343. (38) MUELLER, ACHILLES: Experiences in the treatment of anilin carcinoma of the bladder. Munch. med. Wochen., 1920, lxxvii, II, 1387. (39) SIEBEN, H.: Med. Klin., 1931, xxvii, 587.
DISCUSSION Dr. EDWIN BEER: listening to tr-is interesting and valuable series of papers on bladder tumors arising in workers in dye factories, there is little that one can add to the presentations. I personally have never seen or recognized such a case, and all my information has been obtained from a study of the medical literature, beginning with the publication of Rehn of Frankfort. There is apparently a direct connection between the irritations in the bladder-whether evidenced by cystitis, hemorrhages, or
155
THE TREATMENT OF ANILIN TUMORS OF THE URINARY BLADDER VICTOR D. WASHBURN Wilmington, Delaware
The purpose of this paper is to discuss the treatment of anilin tumors of the urinary bladder. The cases to be considered are 23 white males, dye workers in this country. Of this number 12, or 52 per cent, presented no signs or symptoms suggestive of tumor of the urinary bladder. Men engaged in industry, without urinary symptoms, regard themselves as being perfectly well and it is but natural that they contemplate the idea of a cystoscopic examination with considerable reluctance and sometimes with actual fear. Since these examinations are made annually, confidence on the part of the men and a spirit of cooperation is of outstanding importance. It is our custom, therefore, to treat these men with profound courtesy and consideration. Vve are careful our manipulation of the instruments so that trauma and discomfort are reduced to a minimum. From this same point of view, we find it desirable to use instruments of a small. caliber. We have found it necessary to be most precise and methodical in our examination. The tumors are sometimes exceedingly small and easily overlooked. therefore) look into the bladder when it is distended, when it is empty and while it is filling. In the beginning of our work in this series we did not do a routine cystoscopic biopsy on all of our cases. All papillary tumors were treated by fulguration with a bipolar current through the cystoscope. Patients with sessile tumors, or those that failed to respond to fulguration, were treated by open operation and implantation of radon seeds. Some of our cases made favorable progress under this treatment. The tumors disappeared and the patients have so far remained clinically well and free from bladder tumor. The method was defective, however, in that in some aspects it was a method "trial and error."
156
SYMPOSIUM
;:-- We learned by experience that in certain cases fulguration alone was insufficient. The tumors disappeared but they sometimes recurred at the original site. New tumors appeared elsewhere in some cases. We also found that they changed in appearance and character; what appeared to be benign tumor originally, proved to be malignant in some of the recurring lesions. The second phase of our work began when we agreed that all cases were to have a routine cystoscopic biopsy confirmed by a second specimen in operative cases; and that treatment was to be based on the grade of the tumor, and the clinical setting. We perform biopsy on all accessible tumors and use a Bransford Lewis rongeur forceps which are introduced through an operating cystoscope. This method has the advantage of being quick and painless. It does not traumatize the bladder nor cause excessive bleeding. The specimen is small, perhaps a third as large as a grain of wheat, and yet it is sufficient for the purposes of the pathologist. TREATMENT
Tumors that were single, small and accessible, and of grades I or II, were to be treated by fulguration through the cystoscope. Those of grades III or IV were to be treated by open operation and the implantation of gold radon seeds. In actual practice we have found it desirabie to modify the first step of this plan . .If a tumor is small and benign in appearance, we do not wait for the report of the pathologist but do a biopsy and fulguration at the same sitting. We consider the implantation of gold radon seeds through an open bladder incision the method of choice in all bladder tumors except those that are small, accessible and of grades I or IL The open incision enables the operator to inspect the bladder and treat adequately the lesions present. We use gold radon seeds representing approximately 1.5 m.c. each and implant them at intervals of 1 cm. Tumors that are sessile or submucocal are treated by implantation only. The papillary forms and the larger tumors that may be necrotic we remove in any manner that is convenient, sometimes with the electric cutting current, and sometimes we twist them off with sponge
ANILIN TUMORS OF BLADDER
157
forceps. The base is then implanted with radon seeds followed by cauterization. It may be said that the implantation of radon seeds through a cystoscope, especially after the patient has been treated by fulguration, is technically rather difficult. If scar tissue is present, the seeds tend to escape from the bladder wall after implantation. We deem it proper to speak of the difficulties inherent in the cystoscopic estimation of the size of tumors, their exact location and even their number. If there is uncertainty as to the actual size and number of the tumors in a given case, there must of necessity be uncertainty as to the number of radon seeds required. An ample supply of these seeds must be at hand if the lesions are to be treated adequately. We have discontinued the use of mushroom catheters or large drainage tubes in this type of work. The bladder wall is sutured snugly around a 22 F . s. r. catheter and a cigarette drain is placed in the pre-vesical space. These are removed not later than the fourth post-operative day. We find that the incision heals more promptly and the patient voids naturally sometimes as early as the seventh post-operative day, and may leave the hospital with a closed incision as early as the twentieth post-operative day. From table 1 it may be seen that there were eleven men with single tumors treated by fulguration through the cystoscope. Case 1 is interesting in that on one occasion fulguration was so extensive as to cause leakage of urine into the peritoneal cavity. The abdomen was opened promptly and the bladder wall invaginated. The patient recovered and is back at work free from bladder tumor. From table 2 it may be seen that there were seven men with multiple bladder tumors treated by fulguration only. Case 14 is interesting in that it is, so far as we known, the first case of bladder tumor in a dye worker treated in the United States. It will be noted that he was first seen in 1929 and treated for multiple tumors which disappeared under fulguration. His bladder was normal for three years. A routine cystoscopy in April, 1933, revealed a small papillary carcinoma grade II, in a new location.
1--'
~
00
TABLE 1 Single, small bladder tumors treated by fulguration only NAME
AGE
TYPE
GRADE
LOCATION
FIRST
SUBSEQU ENT
TREAT-
TREATMENT
RECU RRENCE
8 times to 2-33
Yes, new sit e, 2- 32
CYSTOTOMY
RESULT
MENT
Yes, 6--32; per- At work, bladder free, 9-33 !oration following fulguration
IV?
Posterior wall
12-31
Papillomatous
I
Posterior wall, left ureteral ridge
10-33
Papillomatous
I
Near right ureter
8-33
Too recent Too recent
0
c:1
1. H.B.
37
Subsessile
2. H. 0 . E.
44
3. F. Q .
49
Too recent u:,
10-33
~'ti
4. A . E . D.
50
Papillomatous
II
Near right ureter
8-33
w. K.
50
Papillomatous
I
Near right ureter
8-33
Too recent
6. F . W.
57
Papillomatous
I
Near right ureter
8-33
Too recent
Bladder free, 10-33
5.
7. W. H.
57
Papillomatous
I
Nearleft ureter
8-32
1-33
8. E.G.
37
Papillomatous
Not done
Base
2-33
None
9. A. E.
39
Papillomatous
Unsatisfactory
Left lateral
2-32
3-32 4-32 6-32 6-32
10, H.J.
47
P apillomatous
Not done
Near left ureter
8-11-32
I I. J.P.
48
Papillomatous
Not done
Posterior wall
8- 32
8-31-32 10- 32
~
s::
Bladder free, 10-33 8-33 No bladder gested
neoplasm, wall con-
Bladder free, 8-33 Bladder free, 5- 33
TABLE 2 Multiple tumors of the bladder treated by fulguration only FIRST
NAME
AGE
TYPE
GRADE
LOCATION
TREATMENT
SUBSEQUENT TREAT-
RECURRENCE
RESULT
MENT
12. P. L.
39
Papillomatous
Near each ureter al meat us
3-32
4-32 6-32 7-32
13. H. M.
40
Papillomatous
Near each ureteral meatus
14. H. N. T.
40
Papillomatous
Left lateral and base
6-32 12-29
t-<
Yes, 10-33, anterior wall new site
7-32 12-20-29 1-10-30 1-24-30 2- 7-30 2-28-30 3-31-30
Too recent
Yes, 4-26-33, new site near right ureter grade II
Bladder free, 6-7-33
q
~ 0
[:d [12
0
'zj
43
Papil!omatous
I II
Right lateral, left lateral
10-11-33
Too recent
16. W. L. M.
45
Papillomatous
I II
Right lateral posterior wall above right ureter
10-17-33
Too recent
17. V. P.
47
Papillomatous
Posterior wall, right lateral
10-17-33
Too recent
18. H. ill.
56
Papillomatous
Base posterior wall
7-32 8-32 9-32 2-33
z >-3
Bladder free, 8-10-33
15. H.B.
6-22-32
~ t-'
i:d t-'
~
t::J t<1
[:d
Bladder free of tumor 8-33; bladder hemorrhagic
f-'
01
I-'
8
TABLE 3 Bladder tumors treated by open operation and implantation of radon seeds NUMBER
AGE
TYPE
GRADE
LOCATION
FIRST TREATMENT
S UBS EQUENT
RECURREN CE
OPERATION
RESULT
TREATMENT
19. J. H . B .
35
Papillomatous
III
Posterior wall, right lateral
6--32
Several fulguraYes, old site t ions and 3 separat e cystoscopic implant ations of Radon seeds
Yes, 4-29-33, 12 seeds, 18.3 m .c.
At work , comfortable
20. A. K.
39
Papillomatous
IV
Anterior wall surrounding vesicle neck
6--32
Yes, old site
9-25-32, 15 glass seeds,
31 Radon seeds, 56 m .c., comfortable
Base, right lateral
4-32
21. F. H.
50
Papillomatous
22. P. T.
60
Sessile carcinoma
23. W. H .
44
Papillomatous
II
Left lateral wall and base
Not Left lateral done
7.5 m.c.; recurrence,
4-8-33
5-32 7-32 8-32 10-32
3-33, old site, biopsy, not done at operation
10-7-33, implanted 13 seeds
Too recent
,-.·
~J.
Died 1-5-33
2-32
3-32
No
5- 12-32, 24 seeds R adon, 66 m .c. 8- 30-32, resection 9-30-32, 24 seeds, 72.3 m .c.
3-32
4- 32
Yes, 4-33, new site posterior wall grade II
4-29-33, 11.24 m.c. Radon At work
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ANILIN TUMORS OF BLADDER
161
In table 3 are grouped five men all of whom have been subjected to one or more cystotomies. Case 20, the youngest patient in the entire series, after numerous fulgurations and the implantation of radon seeds, through the cystoscope finally came to operation in April, 1933. Case 21 is especially interesting in that when first treated in June 1932 he had an extensive papillary mass surrounding the internal vesical orifice, anteriorly. By September 20 he had complete urinary obstruction. At open operation an electrothermic cutting current was used to remove a large papillary mass. For the purpose of utilizing the caustic alpha and beta rays, 16 glass radon seeds of ½m.c. each were implanted. Seven months later it was found that the tumor had recurred, although not as extensively as when first seen. In April 1933 his bladder was reopened, 11 grams of tumor tissue were removed and 31 gold radon seeds of 1.8 m.c. each implanted. At the second operation it was observed that certain areas of the bladder, which had been definitely neoplastic at the first operation, were now smooth, soft and normal in appearance. Had we been able to estimate more accurately the size of the tumor and had at hand a sufficient number of radon seeds to implant the case adequately, it is quite possible that the tumor might not have recurred. It will be noted that case 22 was our only fatality. When first seen he was in the sixth decade of life with an extensive infiltrating carcinoma. He did not respond to open operation and the implantation of 24 gold radon seeds. He later developed an acute urinary retention which was partially relieved by a transurethral prostatic resection. A second open operation, with the implantation of 24 gold radon seeds, was performed in September 1932. He developed a recto-vesical fistula on January 3, 1933, and succumbed on January 5, 1933. It is to be noted that case 23 had a new tumor one year after his last treatment. It was a papillary carcinoma, grade III in a new location. He was treated by open operation and is back at work.
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SYMPOSIUM SUMMARY
1. It may be said that 23 men, all engaged in the manufacture of dye stuffs in the United States, have been treated for tumor of the urinary bladder. 2. Eleven cases had single tumors which were treated through the cystoscope by fulguration with the bipolar current. 3. Seven cases had multiple tumors which were treated in the same manner. Of this group, 2 cases have had new lesions in a different location. 4. Five cases came to open operation. Of this group 2 had a single tumor, grades III or IV. The remaining 3 were multiple, 2 of them grades III or IV and 1 clinically malignant but unfavorable for biopsy. 5. There has been one death in our series. 6. No conclusions are drawn as to the results of treatment. BIBLIOGRAPHY (1) REHN, L. : Tumors of the bladder among fuchsin workers. Arch. klin. Chir., 1895, 1, 588-600. (2) LEUENBERGER, S. C .: Tumor formation as observed under the influence of the synthetic dye industry. Beitr. z. klin. Chir., 1912, lxxx, 208. (3) PosNER, C.: Significance of urogenital cancer with respect to the cancer problem. Ztschr. f . Krebsforsch, 1904, i, 4. (4) OPPENHEIMER, R . : Diseases of the urinary apparatus as observed in chemical plant workers. Ztschr. f. Urol. u. Chir., 1926, xxi, 336-70. (5) ScHAR, W. : Experimental cancer of the bladder caused by inhaling naphthylamine. Le Cancer, 1930, vii, 205. (6) PERLMAN, S., AND STAEHLER, W.: Artificially Produced Growths of the Bladder. Klin. Wchnschr., 1932, xi, 1-4. (7) GRoss (personal communication). (8) REHN, L .: Bladder diseases among anilin workers. Verh. deut. Ges. Chir., 1906, xxxiii, 313-314. (9) CuRSCHMANN: Statist ical data on bladder tumors in workmen in the chemical industry. Zentral. f. Gewerbehyg., 1920, viii, 145-9, 169-176. (10) HENRY, S. A., KENN AWAY, N . M., AND KENNAWAY, E. L .: The incidence of cancer of the bladder and prostate in certain occupations. Jour. Hygiene, 1931, xxxi, 125. (11) JosEPH, E. : Treatment of bladder tumors. Ztschr. f. Urol., 1925, xix, 118. (12) HAAGENSEN, C. D . : Occupational neoplastic disease. Am . Jour. Cancer, 1931, xv, 641-703. (13) HOFFMAN, F. L.: San Francisco Cancer Survey, 1931, p. 176. (14) SIMON, L .: Prognosis and treatment of so-called anilin tumors of the bladder. Arch. klin. Chir., 1932, clxxiii, 708-711.
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(15) SIMON, L.: Precancerous conditions in the bladder. Deutsch. Ztschr. f. Chir., 1930, xxvii, 539-543. (16) JANSSEN: Chirugie der Harnblase, 1920, p. 884-5. (17) BAYLE, G. L.: Traite des maladies cancereuses. Paris, 1833, i, 564. (18) WALDEYER: Quoted by J. Wolff, Volkmann's Sammlung, xxxiii, 1873. (19) v. BRUNN, A.: Arch. f. Mikro. Anat., xli, 294. (20) RAUENBUScH, L.: Virch. Arch., 1905, clxxxii, 132. (21) EHRICH, E.: Bruns Beitrage, 1901, xxx, 581. (22) GoEBEL, C.: Ztsch. f. Krebsforschung, 1905, iii. (23) LuBARSCH: Festschrift zu Virchow's 80 Geburtstage. Wiesbaden, 1901, p. 205 and 231. (24) GRANDHOMME: An extract from "Die Theerfarben Fabriken der Aktiengesellschaft Farbwerke Form. Meiste Lucius und Bruning Zu Hochst A. M. In Sanitarer und Socialer Beziehung" Inter. Lab. Office Rep., 1921, p. 22-28. (25) ENGELHARDT: Quoted by Rehn (1). (26) SCHWERIN: Bladder tumors in chemical plant workers. Zentralbl. f. Gewer-behygiene, 1920, viii, 64-69. (27) ADLER, 0.: The action and fate of benzidine in the bodies of animals. Arch. exp. Pathol. u. Pharmokol., 1907-08, lviii, 167-197. (28) ENGEL, H.: Fate of beta-naphthylamine in the body of the dog. Zentralbl. · f. Gewerbehygiene, 1920, viii, 81-86. (29) KENNAWAY (Personal Communication). (30) FENWICK, E. H.: Trans. Path. Soc. London, 1888, p. 183. (31) JANEWAY, H. H.: Ztschr. f. Krebsforschung, 1910, viii. (32) LEICHTENSTERN, 0.: Deut. med. Woch., 1898, xxiv, 709. (33) SCHEDLER: Dissertation. Basle. 1905. (Quoted in Internat. Lab. Office Report, 1921.) (34) SEYBERTH: Munch. med. Woch., 1907, liv, 1573. (35) BERENBLUM, I.: The Cancer Review, 1932, August, p. 337-353. (36) NASSAUER, M.: Ztschr. f. Pathol., 1919, xxii, 353. (37) SCHEELE, K.: Verh. d. deut. Ges. f. Urol., 1926, VII Congr., Vienna, p. 343. (38) MUELLER, ACHILLES: Experiences in the treatment of anilin carcinoma of the bladder. Munch. med. Wochen., 1920, lxxvii, II, 1387. (39) SIEBEN, H.: Med. Klin., 1931, xxvii, 587.
DISCUSSION Dr. EDWIN BEER: listening to tr-is interesting and valuable series of papers on bladder tumors arising in workers in dye factories, there is little that one can add to the presentations. I personally have never seen or recognized such a case, and all my information has been obtained from a study of the medical literature, beginning with the publication of Rehn of Frankfort. There is apparently a direct connection between the irritations in the bladder-whether evidenced by cystitis, hemorrhages, or