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I am indeed pleased and honored to have been invited to give the James Ewing lecture this year, and to be among those who have previously done so. To review the list of previous James Ewing lecturers makes one humble to recognize his peers, teachers, and associates from whom he has learned so much. Although I did not personally know Dr Ewing, name recognition and respect for his great contribution to the field of oncology came as a medical student more than 50 years ago when I bought and studied the fourth edition of his book, Neoplastic Diseases , 1 a classic contribution to the knowledge of cancer in his day. One could spend considerable time relating how this man has contributed to the professional life of each of us. Rather than relate what has been so eloquently stated by LaSalle Leffall 2 in his James Ewing lecture in 1987, I

One hundred thirty-nine surgically treated patients with medullary carcinoma of the thyroid gland (MTC) were seen in our institution between January, 1926 and December, 1973. The incidence of this tumor among all thyroid cancers was 8%. Twenty-nine patients had the familial form of MTC; they were subclassified, on the basis of the phenotype, into a group of 15 patients with Sipple syndrome (or multiple endocrine neoplasia (MEN) Type 2A) and a group of 14 patients with mucosal-neuroma phenotype (or MEN type 2B). Better survivorship was seen in the younger patients, in those with bilateral tumors, in familial MTC, and in patients whose tumor was confined to the thyroid gland at the initial surgery. The incidence of tumor recurrence was 34%. However, in those with adequate surgical treatment, the recurrence was only 23%. The 5- and 10-year survivorships were 80% and 67%, respectively. The best chance of cure lies in early diagnosis through the use of immunoreactive calcitonin measurement in family members at risk, and an aggressive surgical attack on the primary tumor and any cervical metastases.

The surgical anatomy of the thyroid and parathyroid glands is reviewed and a detailed description of the techniques of thyroidectomy and parathyroidectomy is given, knowledge of which remains essential to any general surgeon’s armamentarium.

Carcinoma of the anus represents about 2% of cancers of the large bowel. From 1950 to 1970, 20 patients were treated for this condition. Included were 113 patients with squamous cell carcinoma (31 perianal), 64 with basalid squamous carcinoma, 8 with Paget's disease of the anus, 7 with melanoma, 6 with basal cell carcinoma, and 6 with adenocarcinoma. Combined abdomino-perineal resection was the treatment of choice except for perianal lesions; for these, local excision was used most frequently. Inguinal node dissection was used infrequently, and it is not possible to draw meaningful conclusions from the data. Overall survival rates for patients having anal squamous cell carcinoma are similar except when lymphatic invasion is present; then basaloid lesions have a significantly better prognosis. For rare anal carcinomas, histopathologic findings dictate the end results-- the better the findings and more satisfactory the results.

If a cancer of the upper or lower colon can be treated by segmental resection or anterior resection with re-establishment of intestinal continuity, then conservative treatment by fulguration or cryosurgery has little place in the management of the lesion. On the other hand, if combined abdominal resection is required for the treatment of tumor, because of its location in the lower rectum or other anatomical or technical problems, and a permanent colostomy is necessary, then local treatment must be considered. It is unfortunate to have established a permanent colonic stoma if the radical operation has not contributed to the future well-being of the patient. If lesions are carefully selected for fulguration when a colostomy would otherwise be required, the survival rate compares favorably or is better than when radical surgery is used. The theoretical advantage of radical surgery is offset by the mortality of the procedure. For recurrence of cancer after conservative treatment, combined abdominal resection can almost always be done. Selection of cases for local treatment is based on several factors: lesion is well differentiated (Broders' Grade 1 or 2); lesion is localized (Dukes “A or early Dukes” B); lesion is small and not circumferential; lesion is not on the anterior wall of the rectum in female patients; and increased risk of surgery in patients with complicating medical conditions.

The possibility of urinary tract injury should always be considered in the course of anterior resection or combined abdominoperineal resection of the lower colon and rectum. Controlled studies of ureteral and other injuries and fistulas cannot be made; but fortunately, unanticipated damage to the lower urinary tract does not occur often. The surgeon operating in the pelvis should be aware of the problems rarely encountered and should be capable of their management. If a urologic surgeon is available, consultation often is desirable. Prompt intraoperative recognition is most important so remedial procedures can be carried out immediately. Delay in recognition and treatment jeopardizes the patient's course and the function of the urinary tract. Postoperative urinary tract infections should be diagnosed early so prompt treatment can be instituted.

Reoperation for persistent or recurrent hyperparathyroidism is more hazardous than is primary cervical exploration and is also much less likely to result in cure of the disease. Only 21 of 34 reoperations (62%) were successful during the period 1970 through 1972 at the Mayo Clinic, compared with success in 312 of 327 primary operations (95%). In 9 patients who had their initial exploration at this institution, the most common cause of failure at the first operation was inadequate treatment of multiglandular disease; in 25 patients who were first operated on elsewhere, missed adenomas were far more common.

From 1950 through 1974, a total of 108 cases of primary intestinal leiomyosarcoma were seen at the Mayo Clinic. Most of these uncommon tumors occurred in the fifth and sixth decades of life, and more of them in men than in women (2.6:1). There were 73% in the small bowel, 25% in the large bowel, and 2% in the anus. Gastrointestinal bleeding and pain were the two most common signs at presentation, and they led to surgical exploration in all cases where they appeared. By the time surgery was performed, only 48% of the tumors could be resected with hope of cure. Within that group of cases, 50% of the patients survived 5 years, but only 35% survived 10 years, late recurrence being common. The histologic grade of the tumor affected survival strongly. Lack of recognition of the high late recurrence rate probably led to erroneous early optimism in prognosis.

It is fortunate today that several alternatives are available for reconstruction of the intestinal tract when proctocolectomy is required in the management of inflammatory diseases of the colon or multiple neoplastic diseases. The Brooke ileostomy proves to be very satisfactory and is acceptable to the majority of patients but does require the continual wearing of an appliance. For patients with chronic ulcerative colitis and a poorly functioning anal sphincter or one that is diseased, a continent ileostomy is the preferred procedure. However, in patients with a normally functioning anal sphincter, an ileoanal anastomosis, most often with a "J" pouch, is the first alternative procedure to be considered because evacuation following this operation is through the normal route and requires no equipment. For patients with granulomatous colitis (Crohn's disease), it seems best to consider only the Brooke type of ileostomy because of the risk of recurrent inflammatory disease involving the ileum. However, for colonic ulcerative colitis and familial polyposis, either the continent ileostomy or the ileoanal anastomosis is the preferred procedure to be considered. Dozois has reviewed in detail the technical aspects of the various surgical procedures, the indications for their use, the results that can be expected, and the comments of many of the contributors to the advances in the management of patients requiring proctocolectomy and one method or another of re-establishing a means for bowel evacuation. With the various alternatives that are available today and the excellent results that can be expected when patients are properly selected, more patients with diseases of the colon and rectum requiring proctocolectomy can be offered the benefits of surgical treatment, returning them to society and improving their quality of life.

The series included 52 patients with acute bleeding stress ulcers of the stomach and duodenum seen at the Mayo Clinic during a 25-year period. All patients underwent operation for control of massive bleeding that was unresponsive to intensive medical therapy. All ulcers were superficial and occurred during clinically stressful circumstances. No patient had a history or findings suggestive of pre-existing peptic ulcer disease or imbibation of ulcerogenic substances. Overall operative mortality was 54%, and this rate seemed to be related to multiple factors acting together; patients with multiple predisposing stress factors and those requiring large transfusion volumes (greater than 17 total units) were at greatest risk of death. Fifty-two patients underwent 60 operative procedures for control of hemorrhage. Of the 60 procedures, 23 (38%) failed to prevent rebleeding. Of the 28 patients who died, six (21%) died of hemorrhage and five (18%) died of hemorrhage as one of many contributing factors. Of eight different procedures performed, near-total to total gastrectomy was the single procedure that was most effective in controlling hemorrhage. The authors support the selection of rapid intervention and generous extirpative surgery once intensive medical measures fail to control hemorrhage.

Complications after construction of a continent ileostomy may require reoperation to restore continence. Although most patients accept another operation, a few refuse further operative intervention. In such patients we have employed an indwelling ileostomy valve device. A Silastic tube with a circumferential balloon to provide a leakproof seal functionally replaces the nipple valve that has failed. In 14 patients, the valve device has maintained continuous and voluntary control over evacuation without untoward local or systemic effects. If further investigation continues to support this approach to maintaining continence, use of an indwelling ileostomy valve device might be preferable to continued creation of the nipple valve.

The clinical presentation, pathology, and appropriate surgical management of cysts of the liver were analyzed in a review of 150 cases of hepatic cystic disease encountered surgically at the Mayo Clinic from Jan. 1, 1954, through Dec. 31, 1971. The incidence of this disease was 17 per 10,000 abdominal explorations. The series included 82 solitary cysts, of which 15 produced symptoms; 49 multiple cysts, of which 7 were symptomatic; 13 hydatid cysts, of which 12 were symptomatic; 3 traumatic cysts, of which 2 were symptomatic; and 3 inflammatory cysts, of which 1 was symptomatic. Symptoms, when present, comprised (in order of frequency) the presence of an abdominal mass, abdominal pain, and hepatomegaly. Congenital and hydatid cysts were located most often in the right lobe of the liver. The smallest cysts were the multiple cysts (average diameter, 4.3 cm) and the largest were the hydatid cysts (average diameter, 10.5 cm). Histologically, the lining of the congenital cysts most often was of cuboidal epithelium. The treatment of congenital cysts included simple biopsy, aspiration, and excision. In cases of hydatid cysts, preliminary sterilization was found to be essential prior to aspiration. Hydatid cysts may be excised or opened, evacuated, and the cavity obliterated. In certain cases hepatic resection may be warranted in order to remove all of the hydatid disease.

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.

Although there may be some controversy regarding the recommendations for staging of cancer of the head and neck by the American Joint Committee for Cancer Staging and End Results Reporting, it is hoped that the system will be used as recommended or modified very little.

The basic methods described here may be applied to any situation encountered in surgical treatment of the parotid gland, whether its solution entails biopsy, superficial parotidectomy, or total parotidectomy, with or without preservation of the facial nerve.

All residents of Rochester, Minn., with a diagnosis of cancer of the colon or rectum during the 30-year period, 1940 through 1969, were identified from the records of the Mayo Clinic and the other resources in the Rochester epidemiologic central file. The medical records and microscopic slides on these patients were reviewed, and 439 met the necessary residency and diagnostic criteria. Adjusted average annual incidence rates per 100,000 for the entire time period for cancer of the colon were 33.0 for males and 24.6 for females and for rectal cancer, 16.3 for males and 13.7 for females. Age-specific incidence rates increase progressively with age for cancer in both sites. Age-adjusted rates for both colon and rectal cancer were consistently higher for males than for females in the three decades studied. However, for both sites, the male predominance appeared only in those patients more than 60 years of age. In this study, we were unable to demonstrate significant increases in incidence rates in either sex for cancer of the colon or rectum over the 30-year period.

Thyroid disease (goiter) occurring in pediatric patients over a five year period involved 209 patients (42 male and 167 female patients). Of these, sixty-one had diffuse goiter (colloid, iodine, or primary myxedema), seventy-one had toxic diffuse goiter with hyperthyroidism, and seventy-seven had nodular goiter (thyroiditis, adenoma, and carcinoma). Sixty-five of the 209 patients were treated surgically at the Mayo Clinic: forty-seven of these for Graves' disease, nine for benign nodular goiter, and nine for carcinoma. The other patients were treated by medical measures or were observed. In general, surgical treatment is recommended for Graves' disease and nodular goiter (adenoma, cancer, or lesions suspected of being cancerous). Of patients with nodular goiter who were operated on, 61 per cent had cancer.

The results of treatment of 129 malignant tumors of the parotid gland are reviewed. Tumors with a low to moderate degree of malignancy comprised 67 per cent of the group; the five year recurrence rate was 27 per cent and the survival rate 92 per cent. Tumors with a high degree of malignancy comprised 33 per cent of the group; the five year recurrence rate was 35 per cent and the survival rate 60 per cent. The treatment of the former group should most often be parotidectomy, occasionally with preservation of the facial nerve, while that of the latter should be parotidectomy, with sacrifice of the nerve, and radical neck dissection.

DURING the past decade the "malignant carcinid syndrome" has been a favored subject in the medical literature because of the dramatic nature of its acute and chronic clinical manifestations and of its as yet unresolved challenges to the physiologist and therapist. Still more fascinating are recent reports that the syndrome has been produced by noncarcinoid tumors. To date, 7 such unusual cases have been adequately documented and recorded1 2 3 4 5 6 7: in 3, the primary carcinoma had its origin in the pancreas1 2 3; in 3, the primary lesion was an oat-cell carcinoma of the lung; and in 1, it was a highly . . .

Early diagnosis is most important in the prognosis in colorectal cancer because the cause of cancer is unknown and an effective and practical large-scale screening test, easily and cheaply carried out, is unavailable. If the diagnosis is made early, when the patient is asymptomatic, and prior to development of complications or when the lesion is precancerous, the disease almost always is localized and adequate treatment gives excellent results. However, if symptoms have been present for months or complications have developed prior to establishing the diagnosis (because of patient neglect in seeking advice or physician lack of tenacity in evaluating the patient's condition), or if surgical treatment has been inadequate, the prognosis is poor. Education of physicians and the public remains most important in improving results further. New knowledge or new modalities of treatment should result in improved prognosis not only in colorectal cancer but also in cancer of other anatomic sites.

Forty-six cases of primary malignant lymphoma of the thyroid gland diagnosed and treated at the Mayo Clinic through 1964 have been classified into two groups based on the presence or absence of extension beyond the thyroid capsule. In the twenty cases marked by invasive spread or by involvement of local lymph nodes, the treatment was surgical resection (incomplete in eleven) followed by irradiation. Four of these patients survive (three probably cured) and sixteen are dead, of whom fifteen are believed to have died of lymphoma. Ten patients underwent biopsy of invasive inoperable malignant lymphoma and were treated by irradiation. Of these, six are dead of lymphoma and four are living and well twelve to forty-six months after therapy. Sixteen patients whose malignant lymphoma was confined within the capsule of the thyroid were treated by surgical resection (usually complete) with subsequent irradiation in all but one case. Of these, generalized fatal malignant lymphoma is known to have developed in only one. In five cases of Hashimoto's thyroiditis, lymphoid variant, the therapy was subtotal resection without subsequent irradiation. Over a long period of observation, malignant lymphoma or recurrence has not developed in any patient. The presence or absence of locally invasive tendencies appears to be of major importance in the prognosis of primary thyroidal lymphoma.