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Background: The purpose of this study was to assess the occurrence of various morphologic types of leukemia and myeloma within patient demographic groups and to correlate findings with data-reporting periods and other variables, such as 5-year relative survival., Methods: Data from 31,850 cases of multiple subgroups of acute and chronic leukemia, 12,237 cases of myeloma, and 321 cases of "other" lymphoreticular neoplasms were collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. The data were examined by age, sex, race, age-specific and age-adjusted incidence rate, and patient 5-year relative survival during three reporting periods: 1973-1977, 1978-1982, and 1983-1987., Results: The age-adjusted incidence rate for all categories of leukemia combined has been constant, but there has been an increase in the relative frequency (percentage) of acute lymphoid leukemia (ALL) in the general population and a rising incidence rate of myeloid leukemia in the black population. The increase of ALL is offset by a decline of acute myeloid leukemias (AMLs) and acute leukemia, not otherwise specified. The age-adjusted rate of ALL in whites, 1.5 per 100,000 per year, is twice that of blacks, 0.8. The rates for each of the major categories of leukemia are considerably higher in males than in females. Five-year survival rates changed very little for leukemias over the 15 years of the study except for ALL, in which there was a marked improvement between the first (1973-1977) (39.1%) and second (1978-1982) (51.3%) reporting period. The SEER data confirm that multiple myeloma is predominantly a disease of late adulthood and occurs more frequently in blacks and males. The incidence rate of multiple myeloma has not changed during the 15 years surveyed. The 5-year relative survival rate has remained nearly constant for multiple myeloma. There is a marked difference in 5-year relative survival rates for patients with plasmacytoma of bone marrow (45.7%), multiple myeloma (25.9%), and plasma cell leukemia (13.0%)., Conclusions: Shifts in the relative frequencies of leukemia types may have been affected by changes in classification criteria, changes in the use of histologic terms over time, and the expanded use of immunophenotyping and other technology to characterize acute leukemias. Incidence rates and 5-year relative survival rates for myeloma have remained stable.

Fifty-five percent of human cancer occurs in individuals 65 years of age and older; the most common sites are the stomach, colon, rectum, prostate, and breast. Patient delay in seeking care for symptoms may result in diagnosis at a more advanced stage than that seen in younger individuals. Treatment decisions may be impacted by comorbid illness and by physician reluctance to treat the elderly patient as they do the younger. Age alone never should be the factor that modifies a cancer treatment plan. Clinical trials rarely are available to the elderly; it is time that such treatment bias ceased. Adequate informed consent is as important in the elderly as it is in other age groups. Quality of life after cancer treatment is most important to the elderly cancer patient. Surgery and/or radiotherapy may be used for cancer treatment in the elderly when comorbid conditions are treated appropriately. Chemotherapy schedules may need modification when renal or hepatic function is impaired. Compliance with treatment is usually good if transportation is available. Pain management is important in this age group and requires individualization. Home health care is of great benefit to the elderly patient with cancer. Oncologic nursing for the elderly requires multiple skills. The literature on cancer treatment for the elderly is limited and, at times, negative. Cancer treatment in the elderly is remarkably safe when the comorbid conditions also are treated. Treatment choices are just as important to the elderly as they are to all cancer patients. Quality-of-life issues are critical in selecting treatment choices. Cancer follow-up is performed most appropriately by the oncologist.

An abnormal mammogram often will detect a mass, a cluster of calcifications, or both; these findings are not pathognomonic and require a tissue diagnosis to confirm the presence of invasive cancer, in situ cancer, or a nonmalignant process. Although mammography is very sensitive, its abnormalities may be nonspecific. Ultrasound may help to distinguish a cystic mass from a solid mass. The mammographic report should be concise and not vague and must provide the referring physician with clear information as to whether the test is normal, a biopsy must be performed on the abnormality, or the abnormality will be reviewed with a repeat X-ray examination in 6-month intervals until the nature of the abnormality is determined. A common error is to palpate a breast mass that is not visible on the mammogram (false negative) and assume that the mass is not cancerous. Reasonable interpretation of a mammographic abnormality must differentiate malignant disease from a variety of benign conditions and at the same time minimize the number of biopsies performed on a mammographic abnormality that proves to be benign. Asymptomatic breast cancer may be detected mammographically when screening mammography is used; five to seven cancers should be detected in each 1000 women when initially screened, and this incidence will decrease to 0.8-3.5 cancers per 1000 women screened, depending on their age. In recent reports, the detection of an in situ, or a Stage 0, breast cancer occurred in about 25% of the women screened. The earlier the stage, the better the prognosis and the more conservative the treatment options that may be offered to the patient. Every mammographic practice must be audited for quality control. Modern computer technology may make this effort less tedious and time-consuming than it was in the past.

Although clinical research is essential in cancer control, less than 5% of cancer cases in community hospitals are entered in clinical trials. Phase III studies comprise the bulk of clinical research at our community hospital. Potential research protocols are selected by the Community Clinical Oncology Program Therapeutic Investigations Committee for referral to affiliated institutional review boards. Selection criteria include assessments of the scientific validity, relevance, and importance of the research, the match between the proposed protocol and research interests and experience of the investigators, priorities of the research bases for patient accrual, and resource availability for conduct of the study. There are serious impediments to the performance of clinical trials in the multiethnic, multilingual urban community hospital setting. These include diminution of the potential patient pool for trial entry due to language barriers and other difficulties associated with patient accrual; escalating costs (insurance coverage from some carriers in not available for clinical trial participation, and some therapies may be excluded by third-party payers); underinsurance or lack of insurance in many segments of the potential patient population; declining financial support for clinical research and the variability of payments, with restrictions even for standard or conventional treatments; the widespread belief that investigational studies are too costly or are of unproven value; potential liabilities associated with withholding cancer therapy; the unresolved legal quagmire surrounding cancer care for patients just under 18 years of age; and the potential for scientific misconduct related to the performance of clinical trials.

The cure rate for cancer can be increased from the current 51% to 75% by the year 2000. Two important actions that will make this goal possible are the prevention of cancers that are caused by known carcinogens and the earlier detection of cancer in asymptomatic individuals. Current knowledge about the cause of cancer makes it prudent for persons to change their lifestyles (primary prevention). Tobacco products are the number one culprit in cancer cause and it is estimated that 30% of all cancer deaths in the United States would not occur if tobacco use had been avoided. The sound principles of cancer prevention and early detection need to be applied by primary care physicians and community cancer centers working together. Caution must be advised when recommending a variety of diets and medicines that, as yet, have no proven value in cancer prevention. Cancer control research is needed to expand cancer control applications in a cost effective and acceptable manner.

Fifteen patients developed acute nonlymphocytic leukemia (ANLL) 31 to 182 months following chemotherapy and/or radiotherapy for various malignancies and one non-neoplastic disorder. The ANLL was commonly heralded by a brief preleukemic phase consisting of cytopenias and a variety of morphologic abnormalities. At diagnosis of ANLL, all of the patients had a panmyelosis with variation in the predominant abnormal cell line. Neutrophilic and erythroid abnormalities were most striking in 12 of the patients, megakaryocytic abnormalities predominated in 2 and monocytic abnormalities in 1. Pancytopenia, marked anisopoikilocytosis, normoblastemia, large hypogranular platelets, hypogranular neutrophils, pseudo-Pelger-Huet nuclei, low myeloblast counts and basophilia were the most common abnormalities in the blood. Bone marrows were hypercellular with increased myeloblasts and basophils, abnormal neutrophil precursors, occasional monocytoid blasts, dyserythropoiesis with PAS positive erythroblasts, ring sideroblasts and micromegakaryocytes. All of the 7 patients who had bone marrow chromosome studies exhibited major chromosomal abnormalities. Response to anti-leukemic therapy was poor. The morphologic and clinical findings of these 15 patients appear to define a clinical-pathologic entity.

Nineteen patients whose bone marrow smears showed histiocytic hyperplasia with prominent hemophagocytosis were found to have a clinicopathologic syndrome associated with active viral infection. High fever, constitutional symptoms, liver function, and coagulation abnormalities and peripheral blood cytopenias were characteristic findings. Hepatosplenomegaly, lymphadenopathy, bilateral pulmonary infiltrates, and skin rash were often present. Fourteen of the patients were immunosuppressed. Active infection by herpes group viruses was documented in 14 patients and by adenovirus in 1. The bone marrow of most patients also showed decreased granulopoiesis and erythropoiesis with normal to increased numbers of megakaryocytes. Treatment generally consisted of supportive therapy and withdrawal of immunosuppressive drugs. Thirteen patients recovered. Lymph node biopsy and autopsy material showed generalized histiocytic hyperplasia with hemophagocytosis. The relationship of this disorder to familial hemophagocytic reticulosis, familial erythrophagocytic lymphohistiocytosis, histiocytic medullary reticulosis, and malignant histiocytosis is discussed. Immunosuppressive and cytotoxic therapy may be contraindicated in the treatment of this virus-associated syndrome.

Twenty-four patients with proven primary and/or metastatic cancer received single intravenous injections of phospholipid vesicles containing 0.5 mCi of Indium-111. Gamma camera scintigraphy 1 to 72 hours later visualized tumors in 22 patients (92%), including carcinomas of breast, lung, colon, prostate, kidney, cervix, thyroid, and soft tissue sarcoma, lymphoma, and melanoma. Tumor sites that were identified included soft tissues, bone, lung, liver, lymph node, and spinal cord. There were only two false-positive images in metastatic sites and four false-negative images in metastatic sites. Overall sensitivity for tumors in 97 individual sites was 85%, whereas specificity was 96%. Unsuspected areas of malignancy were seen in the lumbar subdural space, pleura, liver, thyroid, and lung. Besides tumor accumulations, homogeneous uptake was observed in normal liver and spleen. Radiation doses to these two organs were 2.2 and 2.9 cGy/0.5 mCi In-111, respectively. Whole body radiation dose was 0.3 cGy/0.5 mCi. The use of Indium-111-labeled vesicles permits a wide variety of human tumors in primary and metastatic sites to be imaged without toxicity and with radiation doses comparable to other radionuclide scanning techniques.

Acute nonlymphocytic leukemia (ANLL) developed in four patients 66 to 157 months following the diagnosis of nodular poorly differentiated lymphocytic lymphoma (PDL-N). The ANLL was signalled by increasing anemia and thrombocytopenia. A characteristic cytologic pattern of the leukemia was found. In each patient, a panmyelosis was present with striking morphologic abnormalities in leukocytes, erythrocytes and megakaryocytes. Marrow cytogenetic studies demonstrated abnormalities in all three patients studied. One of three patients treated with intensive chemotherapy obtained a complete remission. When long term survivors with PDL-N develop increasing anemia and thrombocytopenia, morphologic and cytogenetic marrow examinations are indicated to distinguish progressive lymphoma from therapy-induced myelosuppression or ANLL.

A surgical oncologist should teach at the undergraduate or postgraduate level, play a leadership role in oncology in either the community hospital or in an academic institution, encourage or participate in basic or clinical oncologic research, and foster interdisciplinary cooperation with the other oncologic specialists. The surgical oncologist should take an active role in educating the general surgical community through programs of the American College of Surgeons Commission on Cancer. Professional recognition of Surgical Oncology should be secured through the examination of surgical oncologists. The privilege of being a surgical oncologist carries with it the responsibility of recognition, certification, increased research effort and team involvement for optimal cancer care.

Bone marrow trephine biopsies were performed on 107 previously untreated patients with Hodgkin's disease (HD). Fifteen patients (14%) exhibited bone marrow involvement. These consisted of two of three patients (67%) with lymphocyte depletion, six of 27 patients (22%) with mixed cellularity, five of 64 patients (8%) with nodular sclerosis, and two who were unclassified. Twelve patients manifested a diffuse pattern of involvement; three, a focal pattern. In eight patients more than 70% of the marrow biopsy was replaced by Hodgkin's tissue, in one patient 50% of the marrow biopsy was replaced, and in six patients less than 30% of the marrow biopsy was replaced. Typical Reed-Sternberg (RS) cells were found in the trephine biopsies in 13 of the 15 patients and mononuclear RS variants in two. Bone marrow involvement was the only evidence of stage IV disease in 10 of the 15 patients. In addition to the 15 patients with initial involvement with HD, 11 patients without marrow involvement exhibited granulomas (six) and benign lymphocytic aggregates (five) in their trephine sections. Hematological parameters were studied in all pretreatment patients. Only in the nodular sclerosis group were these parameters useful in differentiating patients with and without Hodgkin's involvement of the marrow. Seventeen additional patients who had been previously treated at the time HD was demonstrated in their bone marrow were also studied. Large areas of necrosis were frequently seen in previously treated patients and one patient demonstrated cryptococcosis in the bone marrow.

Thirteen patients with a malignant lymphoma exhibiting the cytologic characteristics of Burkitt's lymphoma manifested marrow involvement at the time of initial diagnosis (11 patients) or later in the course of the disease (two patients). Eleven patients were 16 years of age or younger. Eight had evidence of abdominal disease, five in the ileocecal area. Despite extensive marrow involvement in most of these patients, frankly leukemic blood pictures were uncommon. Platelet counts and absolute neutrophil counts were frequently normal. Membrane surface markers were studied in four patients. The malignant cells from three exhibited mulambda surface immunoglobulin; the cells from the other manifested muk surface immunoglobulin. All of the patients had a rapid clinical course in spite of intensive chemotherapy. The median survival from detection of marrow involvement was 2.5 months.

Leukemic cells from 13 patients with therapy-related acute nonlymphocytic leukemia (ANLL) were studied by electron microscopy. All of the patients had radiotherapy, and/or alkylating agent chemotherapy for other neoplastic disease 25 to 182 months prior to the diagnosis of ANLL. All cases manifested ultrastructural evidence of a panmyelopathy. All marrow cell lines exhibited nuclear--cytoplasmic asynchrony and abnormalities of cell size. Developing granulocytes exhibited decreased primary and/or secondary granule formation and abnormal granules characterized by irregular shape, large size and internal membranous lamellae. Monocytes showed perinuclear bundles of microfilaments. In some cases, the predominant leukemic blasts showed evidence of early basophil granule development which was not appreciated in light microscopy. Abnormalities in erythroid cells included abundant intracristal mitochondrial iron, large vacuoles, infoldings of redundant membrane and membrane-bound nuclear blebs and intranuclear clefts. Megakaryocytes manifested decreased numbers of granules and demarcation membranes. Excessively large platelets with decreased or abnormal granules were identified; giant compound granules with irregular contour and variable electron density were present. Several of the changes in the developing hematopoietic cells were similar to those described in preleukemia and in certain nonneoplastic disorders. The consistent panmyelosis in therapy-related ANLL together with several uniform clinical features defines a specific clinicopathologic entity.

The morphology, ultrastructure, and acid phosphatase activity of the leukemic cells of 11 cases of T-cell acute lymphoblastic leukemia (T-ALL) were studied. Distinctive small cells with markedly hyperchromatic convoluted nuclei comprised from 2 to 25% of the leukemic cells in the blood and bone marrow smears of 10 of the 11 patients. Similar cells were found in only four of 47 cases on non-T, non-B-ALL. Many of these small leukemic cells exhibited ultrastructurally nuclear membrane reduplication and nuclear blebs and splits. The presence of these small leukemic cells with markedly hyperchromatic convoluted nuclei in ALL is strongly suggestive of T-ALL. This cytomorphologic finding, when combined with the presence of strong focal acid phosphatase activity, lends even greater predictability of a T-cell process.

Morphological and clinical features of 39 patients with nodular lymphoma were studied with particular reference to bone marrow and blood involvement. Twenty-one patients (54%) were found to have bone marrow involvement at the time of initial diagnosis. Thirteen (33%) also had peripheral blood involvement. A specific cell type, the small nodular lymphoma cell, was found in the bone marrow smears of 19 and the 21 patients with bone marrow involvement and in the peripheral blood smears of all patients with blood involvement. When large cells predominated in the lymph node or bone marrow sections, the bone marrow smears and the imprints of the lymph node and trephine biopsy demonstrated these large cells to have morphological qualities of lymphocytes rather than histiocytes.

The incidence, pattern, extent, and morphology of bone marrow involvement in 176 cases of non-Hodgkin's lymphoma (NHL) were studied in relationship to the Lukes--Collins classification. Ninety percent of the cases were B-cell lymphomas; 10% were T-cell lymphomas. In 53% of cases there was bone marrow involvement by lymphoma at diagnosis. Marrow involvement was most frequently found in the small lymphocyte (B), small cleaved follicular center cell (FCC), and convoluted lymphocyte lymphomas. Frequently, the extent of bone marrow biopsy replacement by lymphoma was less than 30%; the pattern of infiltration was predominantly focal (70%). Cytologic agreement between lymph node and bone marrow specimens was always present in small lymphocyte (B), small noncleaved FCC, convoluted lymphocyte, and lymphoepithelioid cell lymphomas. Cytologic diversity between lymph node and marrow was noted in 20% of small cleaved FCC, 40% (2/5) of large cleaved FCC, and 38% (3/8) of large noncleaved FCC lymphomas. In 79% of all involved cases, both bone marrow biopsy sections and aspirate smears were diagnostic of NHL; only biopsy sections were positive in 18%, and only smears were positive in 3%. The Lukes--Collins classification predicts a high incidence of bone marrow involvement for small lymphocyte (B), small cleaved FCC, and convoluted lymphocyte lymphomas.

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.

The clinical and pathologic findings of four patients with Chediak-Higashi syndrome in the accelerated phase were studied in order to clarify the nature of this enigmatic process. Fever, lymphadenopathy, hepatosplenomegaly, and cytopenias were present in every patient. All cases demonstrated extensive parenchymal infiltrates in many organs composed of benign-appearing histiocytes manifesting hemophagocytosis accompanied by lymphocytes and plasma cells. Studies in one patient suggested a viral etiology with the findings of a low blood lymphocyte OKT4 to OKT8 ratio, acquired loss of lymphocyte response to mitogens, the presence of Epstein-Barr virus genome in the mononuclear cells of lymph node, blood, and bone marrow, and possible clinical responses to acyclovir. It is concluded that the accelerated phase of Chediak-Higashi syndrome may be the clinicopathologic expression of the virus-associated hemophagocytic syndrome.

In 1982, more than 125,000 cancer cases in the United States should be preventable. Every physician should advise all patients to eliminate all tobacco use, moderate alcohol use, avoid the use of drugs which are carcinogenic, minimize sun and x-ray exposure, maintain an ideal weight, and follow a "prudent" diet. Secondary prevention efforts would include the American Cancer Society recommendations for the early detection of cancer in asymptomatic persons. Worldwide epidemiologic studies suggest that over 80% of human cancer is due to factors in the environment such as diet, life style, and synthetic chemical contaminants, and perhaps a complex interaction of factors including genetic susceptibility. Current research into the mechanisms of carcinogenesis and in the role of diet in cancer cause, are underway. Chemoprevention of cancer may someday be possible using retinoids, vaccines, and diet alteration.