George Crile

Fistulas of lactiferous ducts

T HE purpose of this paper is to present the probIem of chronic draining sinuses near the areoIa in the breasts of women, to discuss the probabIe pathogenesis of this condition and to suggest an effective method of treatment. There is a large group of diseases of the breast characterized by diIatation of the Iarger ducts, stasis of secretion and periducta1 inffammation. These diseases have been variousIy termed “obIiterative mastitis,“9 “dilated ducts beneath the nippIe” and “varicoceIe tumor of the breast, “l “comedomastitis,“2~3~*o-12 “pIasma ceI1 mastitis,“6 “periducta1 mastitis,“6 and “secretory cystic disease.“’ AIthough the Iesions of comedomastitis are we11 known, the presence of sinus tract formation complicating this Iesion appears to be infrequent. Thus Tice et a1.l’ describe onIy one case of draining sinus in their 172 cases of comedomastitis. Deaver4 describes sinuses and fistuIas of the femaIe breast as compIications of improperIy drained acute pyogenic abscesses. He noted that abscesses appeared during pregnancy or lactation. Incision and drainage of these abscesses resuIted in persistent draining sinuses which incited suspicion of underIying tubercuIous infection. In nonpregnant women the cause was attributed to an “ancient” Iactation abscess or mastitis. Dean Lewis8 mentions occasiona sinuses foIIowing “chronic pyogenic mastitis” and suggests that inadequate incision of an abscess may be the cause. The treatment advocated up to now is adequate drainage, suIfonamides and peniciIIin IocaIIy and parenteraIIy, IocaI excision of the sinus and even simpIe mastectomy when a11 therapeutic procedures faiIed to effect a cure. Reports of five patients with comedomastitis in whom fistuIas of Iactiferous ducts deveIoped foIIow: CASE REPORTS

The advantages of subtotal thyroidectomy and suppression of TSH in the primary treatment of papillary carcinoma of the thyroid

Patients between the ages of 6 and 45 years with distant metastases from papillary carcinoma of the thyroid can be treated as effectively by subtotal thyroidectomy and suppressive doses of thyroid hormone as by total thyroidectomy followed by treatment with iodine 131 (131I). Moreover, distant metastases can be treated by either 131I or suppression as effectively after they are apparent on x‐ray as they can be when treated in a subclinical stage. Therefore, in patients younger than 45 years old it is rarely necessary to perform a total thyroidectomy or to do frequent postoperative scans. In patients older than 44 or younger than 7 who have distant metastases or extensive involvement of both lobes, total or almost total thyroidectomy is justified if it can be done with minimal morbidity. In patients of this age group whose tumors fail to respond to suppressive doses of thyroid, 131I should be used. In view of the importance of diagnostic related groups (DRG) to the economy of hospitals, we note that the cost of total thyroidectomy, ablation by 131I, and intermittent body scans is at least three times that of less radical procedures which, in conjunction with suppression by thyroid feeding, give the same survival with less morbidity.

Special uses of the Silverman biopsy needle in office practice and at operation.

Abstract 1. 1. The Silverman biopsy needle can be used in the office to obtain tissue from superficially located tumors and organs. 2. 2. The needle is particularly useful in obtaining biopsies of the thyroid in suspected cases of thyroiditis. 3. 3. The needle can be used to obtain biopsies of the liver during peritoneoscopy. During laparotomy it is of special value in obtaining satisfactory biopsies of the pancreas. 4. 4. Since needle biopsy is capable of implanting tumor tissue, biopsies of operable tumors should not be taken unless the surgeon is prepared to proceed immediately with excision of the tumor and the tract through which the needle was inserted.

Treatment of breast cancer by local excision

Summary o 1. The five year survival rate of a group of twenty patients with cancer of the breast treated by local excision of the tumors was as high (65 per cent) as that of a much larger group treated by complete mastectomy with or without axillary dissection or radiation. The patients were selected for local excision because of the peripheral location of their tumors. The lesions did not differ significantly in size, stage, or histology from the series with which they were compared. 2. There are several series of cases reported in the literature in which local excisions of breast lesions with or without radiation have yielded as high or higher proportions of five year survivals as did more radical operations. 3. It is not recommended that breast tumors be treated routinely, or even commonly by local excision; however, in special situations when there are important emotional or professional factors to consider, it is possible to select peripherally located lesions that can be excised locally with confidence that the rate of survival will be as high as is commonly seen after radical operations.

Study of the tumor cell-lymphocyte interaction in patients with breast cancer

The role of regional axillary node lymphocytes in the immune response to tumor cells in patients with breast cancer was studied in a tissue culture system in which the interaction between the tumor cells and lymphocytes was measured in terms of clumping of lymphocytes around tumor cells, their cytotoxic effect, and the blast transformation of lymphocytes; all these parameters were considered as evidence for cellular immune response to the tumor. Of the 17 patients studied in this manner, 10 who had no nodal or other metastatic involvement showed a significant tumor cell‐lymphocyte interaction, four who had extensive involvement of the axillary nodes showed no interaction, and, of the remaining three patients, in whom only one node appeared to be involved, two had a significant response whereas one showed no interaction. In six patients with no nodal involvement, both the nodal lymphocytes and the peripheral lymphocytes were available for studying the interaction with tumor cells, and, in all of these, the former showed a greater degree of reaction than the latter. The quantitative significance of this observation is not clear at the present time.

Role of preoperative irradiation in prolonging concomitant immunity and preventing metastasis in mice

As long as a primary allogeneic tumor was present on a mouses foot it sustained the concomitant immunity of the host and suppressed the growth of implants of the same tumor. A mouses immunity to reimplantation of the tumor waned perceptibly within 4 days of the time the tumor was removed, and by the seventh day was barely demonstrable. When the primary tumor was treated by a single large dose of irradiation, its cells, though doomed to die, either released large amounts of sensitizing antigens or continued for from 2 to 3 weeks to produce antigens and sustain the hosts immunity against reimplantations of the tumor. In an isogeneic tumor system, the incidence of pulmonary metastasis was much less after destruction of a tumor‐bearing foot by irradiation than when the foot was amputated. This suggests that even an isogeneic tumor confers some immunity on the host, and that the rapid waning of this immunity after amputation of the tumor‐bearing foot renders the host more susceptible to the development of metastases than it is following its destruction by irradiation.

Tumors of the carotid body.

Abstract 1. 1. Removal of tumors of the carotid body is difficult and is associated with high morbidity and mortality. 2. 2. The carotid artery should not be sacrificed unless its ligation is necessitated by uncontrollable hemorrhage. 3. 3. If patience and care are used, most carotid body tumors can be removed without damaging the carotid artery. 4. 4. Irradiation therapy is not often effective in arresting the growth of carotid body tumors. 5. 5. Five cases of carotid body tumor are reported. 6. 6. In one of these cases the tumor metastasized to bones.

Hyperinsulinism due to islet-cell tumors simulating sarcoma: a report of two cases of large tumors composed of round and spindle cells associated with hypoglycemia.

Functioning islet-cell tumors are usually composed of nests, cords, or sheets of cells, resembling beta cells and associated with varying amounts of intercellular stroma. Such tumors are usually small. In contrast, we have observed two very large neoplasms which caused hypoglycemia and were composed predominantly of spindleshaped cells with cytoplasmic processes. Associated with these spindle cells in both of the tumors were round cells without cytoplasmic processes. The purpose of this paper h to describe the clinical features and pathologic findings of these two cases in order to substantiate the thesis that these tumors are actually functioning isletcell neoplasms.

Possible role of uninvolved regional nodes in preventing metastasis from breast cancer

The importance of the regional nodes in the immunologic resistance of the body to cancer is discussed. Late in the course of the disease, or when the nodes contain metastases, the nodes are no longer important to systemic immunity and can be removed without lowering resistance. Early in the disease, when the primary tumor is small and the nodes are not affected, it appears that removal of nodes increases the incidence of metastasis.

Carcinoma of the uterus

Abstract Our own standpoint at the present moment may be summarized as follows: 1. 1. In any cases of abnormality in uterine function within the child-bearing period, meticulous care to determine the cause of the abnormality. 2. 2. In the case of any abnormal discharge after the menopause, immediate vaginal hysterectomy followed by the application of radium. 3. 3. Radium and x-ray therapy in the treatment of all cases of carcinoma of the cervix, final judgment as to the abandonment of surgery in these cases being reserved. 4. 4. Individualization of each patient; that is, certain cases of carcinoma of the fundus which are apparently inoperable may become operable after a period of rest and the application of selected therapeutic measures. 5. 5. Extensive correlation of the experience of individual observers is essential to the establishment of a correct basis of judgment as to the relative merits of surgery, radium and of the x-ray in the treatment of carcinoma of the uterus—whether of the fundus or of the cervix.