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THE lack of agreement in recent reports concerning the incidence of carcinoma in cases of nodular goiter and the current tendency to minimize the incidence of malignant change in multiple nodular goiter led us to review the association of cancer and nodular goiter in cases observed at the Mayo Clinic. All cases of malignant lesions of the thyroid gland seen at the clinic from 1907 to 1937, inclusive, have been reviewed previously and reported by one of us (Pemberton (1)). The present study, consequently, was limited to cases of malignant lesions of the thyroid gland seen during the decade from 1938 to 1947, inclusive. The findings, in general, with the exception of an unexplained change in the incidence of the different types of carcinoma, were in keeping with those in the earlier series. The findings also supported the belief long held by us and by others, that clinically unrecognizable carcinoma occurs sufficiently often in nodular goiter to warrant thyroidectomy in the great majority of such cases.

c HEMODECTOMAS (nonchromaffrn paragangliomas) arise in the sites of distribution of the chemoreceptor system. The chemoreceptor system consists of scattered structures composed of neura1, epitheIia1 and vascuIar eIements that, under stimuIation, act to increase the rate, depth and minute voIume of respiration. These structures are located in we11 defined anatomic sites. The Iong-recognized carotid body Iies on the media1 aspect of the common carotid artery at its bifurcation. The jugular body, or glomus jugmare, is found in the dome of the juguIar buIb in cIose association with the tympanic branch of the gIossopharyngeal nerve and the auricuIar branch and jugular ganglion of the vagus nerve. The glomus intravagaIe, or vagal body, Iies within the perineurium of the vagus nerve, usuahy just beneath the juguIar foramen at or near the nodose ganghon. The aortic body may be Iocated near the bifurcation of the innominate artery, at the puImonary end of the ductus arteriosus, or on the anterolatera1 aspect of the aortic arch. The ciIiary body is SO designated because of its Iocation within the orbit in proximity to the cihary gangtion. With the recent report of Korn and associates [I] concerning the occurrence throughout the Iung tissue of minute structures resembhng the carotid body, it shouId be admitted that, as yet, unrecognized sites of chemoreceptor tissue may exist.

FOR MANY YEARS, surgical thyroidectomy was the only effective form of therapy in the treatment of exophthalmic goiter or Graves' disease. Since strong iodine solution (Lugol's Solution) has been used in preoperative preparation, the procedure has been very safe, and the mortality has been low (less than 0.1% in many series). The operation has been effective in at least 95% of the cases. Unfortunately, the operation results in morbidity of some medical significance in a few cases, the complications being primarily occasional vocal cord paralysis, tetany due to hypoparathyroidism, and myxedema.1-3Although these complications occur infrequently and can be managed satisfactorily, they are contraindications to further surgical treatment in this disease. This is especially so now that radioactive iodine(131I) has been established as an effective modality in the management of Graves' disease and is less true when iodine or the antithyroid drugs such as propylthiouracil or methimazole

In the past, the recurrence rate of tumors of the parotid gland has been exceedingly high. This fact is surprising, since approximately 80% of parotid tumors are considered to be benign. Kirklin and associates, 1 reviewing all parotid tumors treated at the Mayo Clinic from 1907 through 1944, found a recurrence rate of 32% in 30 years. Malignant lesions of this gland represent 20% to 35% of all parotid tumors. 1-3 The poor results in the treatment of parotid tumors stem largely from inadequate removal of the primary lesion. The two most important reasons for this are fear of injuring the facial nerve and lack of knowledge of the technique in dissecting the nerve from parotid tissue. 4,5 Therefore, about eight years ago, we instituted a more aggressive approach to the treatment of lesions of the parotid gland. Most benign tumors since 1951 have been removed by subtotal (superficial) parotidectomy

In this study an attempt is made to describe the type of thyroid gland in which cancer is found. Sixty-five per cent of the 256 cancers studied occurred in otherwise non-nodular glands. The cancers were grouped in 5 categories: papillary, follicular, solid and anaplastic carcinomas and malignant lymphomas. Eight glands contained malignant lymphomas. About 90 per cent of the carcinomas in the series occurred in glands with no or minimal lymphocytic infiltration of the parenchyma. The incidence of struma lymphomatosa was less than 1 per cent and the incidence of moderate to marked lymphocytic infiltration was about 10 per cent. Nodularity and lymphocytic infiltration occurred in the portion of the glands exclusive of the cancers with about the same frequency as in glands obtained at necropsy and reported in other papers. Most of the 256 cancers occurred in otherwise essentially normal glands. Lymph-node metastasis was found to occur more frequently from those papillary carcinomas that were found in...

The various complications of thyroid surgery have long been known to surgeons embarking on the surgical treatment of goiter. These complications may be severe enough to jeopardize the life of the patient or to create a physical or physiologic incapacity which will limit his normal activities. Because of the severity of these complications it becomes necessary that their incidence be reduced to an absolute minimum in this age of modern surgery. Moreover, if surgery is to continue to play a dominant role in the treatment of thyroid disease, the complications of this form of treatment must be less than those of other equally effective forms of treatment.

A clinicopathologic study has been made of 605 cases of thyroiditis of the “Hashimoto” type seen during a 27-year period at the Mayo Clinic. The lesions were divided on a morphologic basis into diffuse thyroiditis (188 cases), thyroiditis with “hyperplastic” epithelium (57 cases) and focal thyroiditis (360 cases). Four histologic subgroups of diffuse thyroiditis were observed, namely, those with extensive epithelial destruction (29 cases), those with oxyphilic epithelium (36 cases), those with varied epithelial changes (106 cases) and those with severe lymphoid infiltration or associated lymphosarcoma (17 cases). These subgroups, as a whole, represent an advanced stage of the disease process. Clinical and laboratory data are provided for these arbitrarily chosen groups, as well as results of thyroidal function studies in a limited number of cases in each category. These 605 cases included 18 cases of associated carcinoma and 12 cases of associated lymphosarcoma. All the carcinomas, both large and...

A total of 253 children less than 15 years of age who had exophthalmic goiter have been seen at the Mayo Clinic during the 48-year period, 1908 through 1955. There were 217 girls and 36 boys, a ratio of about 6:1. Observations in this series indicate that the disease in children does not appear to differ significantly from that in adults, although there is less tendency for children to have severe exophthalmos. Exophthalmos that occurs during childhood may persist for years after thyrotoxicosis has been relieved. Diabetes mellitus is observed more frequently among children with exophthalmic goiter than would be expected as a chance occurrence. Exophthalmic goiter during childhood, if adequately treated, does not alter adolescent development. Subtotal thyroidectomy is a satisfactory and safe method of treating exophthalmic goiter in children. There were only 4 hospital deaths among 196 children treated by this means. No surgical death has occurred since 1933 among children treated by this method. ...

Cancer of the cervical part of the esophagus and postcricoid region of the hypopharynx is commonly a silent lesion until it is far advanced with wide local extension and metastasis to regional lymph nodes. Neither radiation therapy nor radical surgery has saved more than a few of these patients from an end which is often painful and miserable, with stench from necrotic tumor, inanition, and hemorrhage from major vessels of the head and neck. This paper reports experience with six patients with cancer of the cervical part of the esophagus and postcricoid region of the hypopharynx who recently were treated by transposition of colon. Lesions of the pyriform sinus are usually found in men of about 60 years of age who have been heavy drinkers or smokers or both. 4 The so-called postcricoid cancer is usually found in women more than 50 years old. Results of a recent and exhaustive

Two hundred fifty radical neck dissections performed in 208 patients from January 1960 through December 1964 are reviewed. The spinal accessory nerve was sacrificed in the course of the dissection in 161 and was preserved in 89. Five patients died in the immediate postoperative period. The incidence and sites of recurrences in the remaining 245 dissections were analyzed. When lymph nodes of the cervical region were found histologically to be involved by tumor, recurrences developed on the side of dissection in 36 per cent of cases when the spinal accessory nerve was sacrificed and in 17 per cent when the nerve was preserved. In the latter group, there were no recurrences in the posterior cervical triangle or along the course of the nerve. In both groups, local recurrence on the side of dissection was associated with recurrence of the primary tumor in more than a third of the cases and with distant metastasis in approximately a half. When the cervical lymph nodes were not involved, the incidence of recurrent lesions in the neck was 12 per cent in the first group and 4 per cent in the second. Again a high proportion of cervical recurrences were accompanied by recurrence of the primary tumor. No patient in whom one or both spinal accessory nerves were preserved died as a result of local recurrence in the neck alone. Modification in the classical technic of radical neck dissection in order to preserve the spinal accessory nerve appears to be safe and justifiable in selected cases.

Summary One hundred and seven cases of mucoepidermoid carcinoma of major salivary glands (91 per cent in the parotid gland) encountered at the Mayo Clinic from 1907 through 1963 have been reviewed. Approximately two thirds of the patients were females and the age of patients ranged from five to eighty-one years. Tumors were divided on a histopathologic basis into three groups (grades 1, 2, and 3), representing different levels of histologic activity. In the earlier part of the period, excision of the tumor was the most common treatment; later subtotal or total removal of the gland was most frequently the treatment of choice. The recurrence rate for all tumors was 25 per cent, being 10 per cent for the well differentiated tumors (grades 1 and 2) and 71.4 per cent for the grade 3 lesions. The survival rate is excellent for patients with grade 1 and grade 2 lesions, but poor for those with grade 3 tumors. Total parotidectomy with preservation of the facial nerve in most cases is the treatment of choice for mucoepidermoid carcinoma in the parotid gland, and total removal of the gland when the lesion is located in the submaxillary or sublingual gland.

A series of twenty-nine cases is presented in which thirty parotidectomies were performed for recurrent chronic sialadenitis. The results during the follow-up period have been excellent, except in one case in which subtotal parotidectomy had been performed and a recurrence developed five months later. Based on the experience in this series it is recommended that when symptoms of chronic or recurrent parotitis are of sufficient severity and duration and do not respond to conservative measures, subtotal or total conservative parotidectomy should be performed. With proper technic these procedures can be performed without danger of injury to the facial nerve and with complete relief of symptoms.

MALIGNANT lymphomas can involve the colon primarily as a localized entity or secondarily as a manifestation of generalized lymphoma. In either event, such tumors in this location are not commonly encountered by the surgeon. A correct diagnosis was rarely made before operation in the past because of the varying gross configurations of the lesions with different roentgenographic appearances. The roentgenographic features of this disease are now recognizable in many instances, but they are essentially the same whether the involvement is primary or secondary. Multiple tumors are occasionally found in the colon. However, a localized malignant lymphoma may be found in another organ when the colonic tumor is recognized. Involvement of multiple organs is encountered when obvious generalized lymphoma is present, but there are instances in which the malignant process seems to be confined to two or three regions only. We decided to review all surgical cases in which a colonic

Although an ileostomy as established today (Brooke type) is a satisfactory exchange for the disease being treated and is compatible with normal activities in 90 per cent of patients, it is inconvenient because of the necessity of wearing an appliance constantly and because skin problems develop in 25 per cent of the patients. Kock has proposed the creation of an intra-abdominal reservoir, which has a capacity of approximately 500 ml after six months and can be intubated periodically to evacuate the ileal content, thereby eliminating the necessity of wearing an ileostomy appliance in 90 per cent of cases. This report presents our experience to date with seven patients in whom pouches were established successfully and were observed for periods varying up to six months.

THERE is considerable diversity of opinion regarding the treatment of the region of the cervical lymph nodes in the presence of labial and intraoral malignant lesions. As Wilson 1 pointed out, the lymphatic spread of cancer may vary according to the primary site and therefore the results should be studied in terms of the origin of the metastatic lesions. In this paper we shall present only the results of treatment of the neck in squamous cell epithelioma of the lower lip. The trend in the treatment of cervical nodes, as Duffy 2 has pointed out, has progressed from radical surgical procedures, pioneered by Kocher, Cheattle, Bloodgood and Crile, through extensive use of radiation at some centers to a consideration of the two methods separately or in combination. It is felt that metastatic lesions develop by lymphatic emboli rather than by direct extension. 3 Therefore, the treatment of the secondary lesion can be considered to be separate from

• The excision of small parts of the parotid gland is liable to result in damage to the facial nerve, which runs through the substance of the gland. Such damage is hard to avoid if the nerve is not well exposed, and the surgeon has to choose between the danger of facial paralysis and the danger of incomplete performance of the intended extirpation. A good exposure makes it possible to choose between removal of the superficial portion of the gland and total removal of both superficial and deep portions by careful dissection. If there is a malignant tumor in the gland, excision must be total and the nerve must be sacrificed. Nerve grafting, using a section from the greater auricular nerve, was successful in preventing permanent facial paralysis in a case of this kind here described.

Three to four decades ago the mortality associated with colon and rectal surgery was 20% or greater and the morbidity was high. This experience earlier had led to the development of multiple-staged operations for the management of neoplastic and inflammatory diseases of the large bowel and rectum. With the introduction of chemotherapeutic agents (the sulfonamides, which were poorly absorbed in the gastrointestinal tract)1in the late 1930's, the mortality for colon surgery promptly began to fall; and over the next decade it was reduced to approximately 5% in most reports. Shortly after the sulfonamides, antibiotics came into use and aided further the management of patients having colon surgery. Poth2,3advocated the combined use of phthalylsulfathiazole (Sulfathalidine) and neomycin as the best prophylactic drugs for suppressing the widest number and variety of intestinal microorganisms. This combination of drugs or some modification of it has been used and recommended by

In the current literature most authors agree that no completely satisfactory method exists for the preoperative diagnosis of parotid tumor. Blady and Hocker state that on sialography most malignant tumors show "infiltration" of the ducts, which they feel is diagnostic. The present study was undertaken to see whether such infiltrating lesions shed malignant cells which might be collected in the saliva and studied in the same manner as are bronchial washings. I t was felt that if positive results could be obtained with Papanicolaou smears, surgeons might be encouraged to adopt more radical initial surgical measures in the hope of improving the present discouraging results in the treatment of malignant lesions of the parotid gland. We have found no such study recorded in the English literature. This investigation was made on 33 patients who underwent surgical treatment of parotid tumors at the Mayo Clinic from July 1 to December 5, 1953. A total of 45 patients underwent such treatment during this period, but because of the nature of the previous operations and other factors, the remaining 12 were not considered suitable for study. On the night before operation, a specimen was collected from each parotid gland, the normal side thus serving as a control. In the first patients studied, Stensen's duct was cannulated, but in the remaining patients the simple but efficient device of Curby was used. Salivary flow was stimulated by unsweetened lemon juice. From 2 to 5 ml. of secretion was obtained in all cases, which was stained by a method previously described for bronchial washings. Three slides were made from each specimen. After the tumor was removed, fresh imprints were made in most cases and these were fixed and stained in the same manner as the secretions; these slides showed the appearance of known tumor cells stained by the same technic and served as further controls. All frozen-section diagnoses were confirmed by paraffin sections. Table 1 lists the diagnoses made on the basis of the tumors removed. All the smears showed a few scattered normal-appearing squamous cells and occasional columnar cells. No cells characteristic of the various benign tumors, as seen on the fresh imprints, were found. In the 7 cases in which the tumor was malignant, the slides made from the secretion in 1 of the cases of muco-epidermoid tumor were suggestive of malignancy, while those made in 1 of the cases of adenocarcinoma and in the case of undifferentiated carcinoma showed a few

Nodular goiter occurs in such a high percentage of the population that surgical treatment in all cases is not practical. Thus, only those patients in whom the risk of complication is greater than average are selected for surgery.Thyroidectomy is considered a safe procedure and is associated with low morbidity and mortality.Over-all figures indicate that cancer is present in approximately 5 per cent of nodular goiters. The type of cancer determines the correct surgical procedure. Good results can be expected in most cases.

The records of 150 patients treated with combined operations for intraoral cancers were reviewed with emphasis on correlation between prognosis and age, presence or absence of histologically positive nodes, grade of neoplasm, and previous treatment. The three year survival rate was 48 per cent and the five year survival rate was 40 per cent. Of those patients succumbing with uncontrolled local disease, 89 per cent died in less than three years after operation. The close agreement of the three year and five year survival rates, together with the high percentage of deaths from the disease within three years, suggests that three year survival rates are as reliable as five year survival rates in this disease. Survival rates were significantly less than the over-all average for patients in the following categories: patients less than fifty years of age, patients having histologically proved metastatic involvement of lymph nodes, patients having higher grade tumors, and patients who had had previous roentgen therapy to the primary lesion. Mortality and morbidity were not excessive and deformity was surprisingly minimal. If, in the future, the surgeon can proceed with radical surgery at an earlier stage in the disease, even more promising survival rates may be attained.

A brief historical review of chemodectoma of the carotid and aortic bodies is given. The anatomic location, embryologic development, and physiology of aortic bodies are described. A case of a chemodectoma of the aortic body presenting in the neck and successfully removed is reported. The patient is well and without recurrence five years later.

IT IS well known that there is a marked difference in the rate of growth and clinical behavior of the various histologic types of thyroid carcinoma. The largest histologic group, namely papillary carcinomas, consists of slowly growing neoplasms whose natural history is now well understood. The role of the surgeon in the treatment of this form of carcinoma is well established. Extensive local surgical procedures may be combined with dissection of cervical lymph nodes, or even with radical dissection of mediastinal lymph nodes. Additional histologic types of thyroid carcinoma, more malignant than the papillary form but of relatively slow growth, include the more or less circumscribed or encapsulated carcinoma variously called “malignant adenoma” or follicular and alveolar carcinoma. In this group, metastasis may occur by lymphatics to regional nodes or by the blood stream, particularly to bone. Hurthle-cell carcinomas, frequently encapsulated, make up a fairly well recognized histologic group, as do solid a...

THE OF chemotherapeutic agents as adjuvants in palliative treatment for malignant tumors in other parts of the body suggested that perhaps beneficial effects could be obtained in lesions involving the head and neck. Although the specificity of these various compounds for certain types of cancer has already been demonstrated in leukemia, lymphoma, and certain epithelial tumors, the variable response of the more common forms of cancer to these agents does not necessarily rule out their use as a last resort. The amenability of tumors in regions of the head and neck to treatment with chemotherapeutic drugs by perfusion and infusion is determined to some extent by the source of the blood supply of the tumors. The blood must be almost entirely supplied by the external carotid artery or its branches. The initial reports on the use of chemotherapeutic drugs for inoperable cancer of the head and neck as a palliative

In the past, cancers of the lower most portion of the alimentary tract have required radical surgery to offer the patient a chance of cure. Unfortunately, for those lesions of the anus, a combined abdominal perineal resection was almost always necessary to remove the malignant neoplasm. This resulted in a permanent colostomy, which altered the patient’s anatomy and function of the bowel as far as evacuation was concerned. If this proved to be a necessary operation, then a colostomy was an acceptable procedure. It is unfortunate, however, when a colostomy has been performed that the pathologic findings are such that would indicate that a lesser operation or other treatment might have successfully and satisfactorily treated the cancer. For many years, squamous carcinomas of the perirectal region, that is, the area of skin from the anal verge to approximately 5 cm beyond the verge, have been identified early because they are on the exposed surface. These lesions have been treated by local excision and by radiation with excellent results. A 5-year survival rate in the range of 90% is usual. Squamous cell carcinoma and basaloid cell ‘carcinoma, both having about the same prognosis, more often were treated by radical resection because these lesions frequently were more advanced and there was always the risk of interference with sphincteric function by using a conservative procedure. This meant that the patient potentially would be incontinent, an unfortunate complication of local treatment. This, too, mea.nt that a combined abdominal perineal resection was preferred in many instances rather than the lesser procedure. Overall, when a squamous cell carcinoma was treated by a radical procedure, the survival rate was about 60% at 5 years and 40% at 10 years. When positive nodes were present, the 5-year survival rate dropped to 32%. Similar survival rates were anticipated in the management of basaloid squamous carcinoma. If either type of lesion was superficially invaded and if local treatment was judged satisfactory, the survival rate was in the range of 80 to 90%. The above figures represent the experience of the past. Today, with improved knowledge regarding the use of radiation therapy in many anatomic areas (in this instance to the anal area), and the availability of chemotherapy, it is becoming apparent that through these combined modalities, the neoplasm can be satisfactorily eliminated in many instances, without the necessity of carrying out a radical surgical procedure that leaves the patient with a colostomy. The success of combined modalities in the management of squamous cell cancer of the anus and also adenocarcinoma of the lower portion of the rectum is well demonstrated in the report by Doctor Sischy.’ The proof of the effectiveness of this approach to the problem is nicely demonstrated by the four patients in whom a subsequent combined abdominal perineal resection was carried out and no residual tumor was found in the surgical specimen. Even though this high success rate might not prove to be true in all cases, it does illustrate that this approach to the treatment of these lesions is successful and eliminates the need for a colostomy. If the approach to the problem should not prove successful in some cases, the lesions most likely will be reduced in size or kept under control during a period of time. If it is apparent that the lesion is not being totally destroyed by the combination therapy, then the radical surgical procedure can be carried out. It is unfortunate, however, that some of these lesions have spread distantly before diagnosis and the beginning of therapy; this is unfortunate because in time the distant metastasis most often will cause death of the patient. Although it does seem reasonable to consider procedures less radical than a combined abdominal perineal resection, it should be remembered that there is an error rate in the accurate staging of cancers at this anatomic site. For that reason, selection of treatment should be conservative for patients in whom there is some question as to whether the lesion might be more extensive than clinically evident.

Of 300 women who had mastectomy for breast carcinoma, 278 (93 percent) responded to a questionnaire about how well they accepted loss of a breast. Of those responding, 73 percent stated that they had no appreciable adverse reaction to the extent of the operation. Twenty patients (7 percent) cited major work, social or sexual problems resulting from mastectomy. Among the 20, sexual problems —cited by 85 percent—predominated. Four (1 percent) of the 278 patients expressed major dissatisfaction with the cosmetic result of an external prosthesis. Two of these patients and four others had surgical reconstruction of the breast, which was satisfactory in five.

A summary statement for the Workshop on Late Effects of Irradiation to the Head and Neck in Infancy and Childhood is presented. The Workshop, conducted by the National Cancer Institute with the cooperation of several other organizations, was convened to determine the present status of knowledge about thyroid disease related to irradiation of the head and neck and to develop guidelines with respect to detection, diagnosis, treatment, and followup. It was decided that surgical exploration should be considered for all palpable thyroid nodules, particularly those that are firm and clearly demarcated and appear as a "cold" area on the scan. Persons at risk because of prior irradiation to the head or neck should have regular reexaminations every one to two years.

Retrospective review was undertaken of 137 patients with occult papillary carcinoma of the thyroid (lesions less than or equal to 1.5 cm in diameter) who were operated on at the Mayo Clinic, Rochester, Minn, between 1926 and 1955. Mean follow-up period was 25.3 years. Operations were conservative. No patient underwent bilateral total lobectomy. For 55 patients with lymph node involvement, lymphadenectomy generally involved selective node excision or modified neck dissection. Subsequent surgery was required in 12 patients; modified radical neck dissection was necessary in only four. No operative deaths occurred. Long-term follow-up showed that all patients were alive and without disease or were dead without proof of thyroid-related disease. Thus, occult papillary thyroid carcinoma with or without nodal metastasis is a nonlethal and curable disease when treated by conservative surgical means. Radical surgical or medical extirpation of all thyroid tissue is unnecessary in the treatment of this disease.

Summary Factors influencing mortality and morbidity rates accompanying head and neck surgery are discussed. The complications encountered in 574 thyroidectomies, 100 radical dissections of the neck, and 234 parotidectomies are reviewed. There was only one postoperative death in 908 cases; it was caused by obstruction of the airway after radical dissection of the neck.