John deJ. Pemberton

Functional parathyroid tumors and hyperparathyroidism

Abstract There have been many reports of non-functioning malignant parathyroid tumors and of functioning parathyroid adenomas. However, there have been only seven previous reports of functioning malignant parathyroid tumors producing hyperparathyroidism. In this paper fourteen cases of clinical hyperparathyroidism, proved to be due to functioning parathyroid tumors, are presented. In two cases the termination was fatal while in twelve, the results of operative treatment were excellent. Stress has been laid on the widely divergent clinical pictures which patients who have hyperparathyroidism may present. It has been shown that any one symptom or sign—clinical, laboratory or roentgenologic—should not be regarded as decisive. Single findings of concentrations of calcium less than 12.5 mg. per 100 cc. of serum were encountered in 30.8 per cent of cases of proved hyperparathyroidism. Attention has been drawn to the importance of bearing in mind the relation between the serum protein level and the serum calcium level. Depression of the value for serum phosphorus, measured as inorganic phosphate, is the rule in those cases without gross impairment of renal function. The serum alkaline phosphatase level is elevated in proportion to the degree of involvement of bone. The Sulkowitch test provides a rough estimate of the presence or absence of excess urinary excretion of calcium. Considered alone, it is not diagnostic of hyperparathyroidism. The changes of bone in hyperparathyroidism appear to be an index more of the duration of the disease than of its severity. According to our experience the incidence of renal lithiasis in hyperparathyroidism is about 60 per cent. In thirteen (92.8 per cent) of the fourteen cases here presented the tumor showed cytologic evidence of malignancy. Two of these latter cases have been reported previously. No correlation was found to exist between the weight of the tumor and the degree of hyperparathyroidism as measured by the concentration of calcium in the serum before operation. The average weight of the tumors was 18.2 Gm. They were encapsulated and usually were brown. Four (28.6 per cent) were in the mediastinum, three being in the posterior mediastinum and one in the anterior mediastinum. Cytologic evidence of malignancy was seen in chief cells, oxyphil cells and wasserhelle cells. Such evidence included irregularity of the size and staining power of the nuclei, a densely staining chromatin network, giant nuclei, mitotic figures, pathologic mitoses, prominent nucleoli, irregular cellular arrangement and invasion of the capsule and blood vessels by tumor cells. The type of cell predominating in the tumor did not appear to affect the clinical picture. Stress has been placed on the necessity for complete operative removal of parathyroid tumors.

Submucous lipomas of colon and rectum

Abstract A review of the literature revealed 113 cases of submucous lipoma of the colon and rectum; in 94 of these cases the tumor produced symptoms. Three cases in which the condition was treated successfully with operation have been added. Submucous lipomas of the colon and rectum chiefly affect women who are between forty and sixty years of age. The tumors are found in the cecum, ascending colon, and sigmoid flexure, in the order named. The condition rarely is diagnosed preoperatively; the most common diagnosis is carcinoma and acute appendicitis. The symptoms are those of intestinal obstruction, and the average duration of symptoms is 41.5 months. The treatment is surgical removal in one stage, if possible, or by means of graded procedures.