Cancer centers--origins and purpose. The James Ewing lecture.

Cancer centers in the United States date back to the beginning of this century, although there were few until the late 1950s and 1960s. The National Cancer Act of 1971 introduced a new era in serving as a major stimulus to the development of comprehensive cancer centers. Research scientists and physicians in centers have contributed significantly to the new knowledge of normal and abnormal regulation of cell growth and differentiation and to the advances in the diagnosis and treatment of cancer. The future for cancer centers is very bright. They will continue to play a major role in the advancement of knowledge about cancer. However, centers must be reevaluated at intervals to correct any deficiencies and to stimulate new and innovative approaches. Surgical oncologists should become more involved in cancer center research. Comprehensive cancer centers should develop more effective regional cancer control and prevention programs. Reevaluation of centers by the National Cancer Institute, Bethesda, Md, and its advisory body, the National Cancer Advisory Board, along with cancer center leaders, should result in a consensus concerning changes to enhance their contribution to a solution to the cancer problem.

Breast carcinoma: an overview.

Breast cancer incidence in the United States is increasing, and the role of the gynecologist is becoming increasingly important in early detection of this common tumor of women. This article presents basic information on the anatomy and physiology of the female breast and their relationship to benign and malignant conditions commonly seen in clinical practice. An overview of detection screening, diagnosis, and treatment of breast carcinoma is also provided.

Surgical oncology in university departments of surgery in the United States.

Data on surgical oncology and multidisciplinary cancer program activity were obtained from 124 of 126 university surgery departments in the United States. Most of these institutions have American College of Surgeons-approved cancer programs (84%) as well as divisions of medical (95%), radiation (94%), pediatric (76%), and gynecologic (79%) oncology. Only 47 departments (38%) have formal divisions of surgical oncology. There are no major staffing or activity differences in surgical departments with or without such divisions, but multidisciplinary cancer program activity is greater in those institutions with a surgical oncology focus. Peer-reviewed cancer research grants are more frequent in departments of surgery with a surgical oncology division (68% vs 47%). The activities of the existing 47 divisions of surgical oncology are mainly operative, with breast cancer, melanoma, and soft-tissue sarcomas being the major clinical responsibilities. Chemotherapy is also frequent (81%). Cancer education for undergraduate and postgraduate surgical trainees is a major responsibility of most divisions, but only a small proportion (28%) have postresidency surgical oncology training programs. In contrast to the growth of some oncologic specialties, the establishment of surgical oncology within university departments has been slow, and the manpower needs appear modest.

An ultrastructural analysis of breast carcinoma presenting as isolated axillary adenopathy.

Metastatic adenocarcinoma in the axillary lymph nodes of a female patient often originates from a primary tumor in the ipsilateral breast. Mastectomy may be recommended if adenocarcinoma is found in the axillary nodes even when the primary tumor is not clinically detectable. In these circumstances, the recommendation for mastectomy should be based on the firm histologic diagnosis of adenocarcinoma. In the present report, five female patients are discussed who presented with axillary lymphadenopathy without clinically evident breast masses or mammographic evidence of malignancy. Axillary lymph node biopsies, performed in each patient, were inconclusive after conventional light microscopic examination. Electron microscopy established the diagnosis of adenocarcinoma. These findings were complemented by sex steroid analyses of the tumors where possible. Each patient underwent ipsilateral mastectomy, and in each specimen an occult breast carcinoma was found. The necessity of making a precise tissue diagnosis in all cases of metastatic cancer from an unknown primary is stressed, and special techniques to accomplish this must be considered preoperatively. This is particularly important in the female patient with metastatic breast carcinoma in an isolated axillary lymph node, since ipsilateral mastectomy may be curative.

Ethical considerations in the treatment of breast cancer.

There is a growing awareness by the medical profession and the public of the increasing complexity of medical ethics. Advances in medical technology have raised new ethical problems. The scope of medical ethics needs to be broadened to provide guidance for new problems encountered by physicians in the rapidly developing science of medicine. Major bioethical principles have been suggested-beneficience, nonmaleficence, justice, equity, veracity, and autonomy. These are all issues debated in the general field of ethics. Society can gain greatest benefit by having these issues debated and discussed by physicians, philosophers, theologians, lawyers, and laymen. General ethical principles involved in the doctor-patient relationship have been discussed, and applications of these principles in some areas of decision making related to breast cancer management have been presented.

Results of a prospective randomized study of hepatic artery infusion with 5-fluorouracil versus intravenous 5-fluorouracil in patients with hepatic metastases from colorectal cancer: A Central Oncology Group study.

In a controlled, prospectively randomized trial, 74 patients with hepatic metastases from colorectal cancer were randomized to either intra-arterial hepatic artery infusion with 5-fluorouracil (5-FU) or systemic chemotherapy with 5-FU. In 61 acceptable patients, there was no significant difference in terms of response rate, time to progression, duration of the response, and survival rate. Though the response rate for the intra-arterial infusion arm was slightly higher than for the systemic arm, the difference was not significant, and the intra-arterial infusion arm was associated with a greater incidence of nausea, vomiting, diarrhea, in addition to complications of femoral-arterial thrombosis, bleeding, and infection at the catheter site not seen in patients treated by systemic chemotherapy. Patients with an objective response to chemotherapy on either treatment arm survived twice as long as the nonresponders. Long-term survival in one patient, 77 months, can occasionally be achieved in patients with hepatic metastases.

The relationship between biliary tract infections and postoperative complications.

The hospital records of 870 consecutive patients undergoing elective biliary tract operations during an eight year period were reviewed. Bacteriologic cultures of the biliary tract obtained on 451 patients were correlated with specific biliary tract abnormalities and with postoperative complications. The incidence of positive biliary tract cultures was higher in patients with common duct disease than in those with chronic gallbladder disease without common duct disease. Choledocholithiasis and partial obstruction of the common duct are viewed as important factors in causing a high incidence of postive biliary tract cultures. Eighty-eight per cent of patients who had undergone previous biliary tract decompression procedures had positive cultures. There was no difference in the yield of postive cultures taken from the gallbladder wall and the gallbladder bile. Forty-nine per cent of patients with common bile duct disease and positive biliary tract cultures had no history of clinical cholangitis. Postoperative wound infections were more common in patients with common duct disease. The microorganism responsible for postoperative cholangitis and septicemia can usually be cultured from the biliary tract at operation. Antibiotics significantly decreased the incidence of postoperative cholangitis and septicemia.

Management of recurrent melanoma of the extremity.

Two forms of therapy employed for treatment of patients with recurrent melanoma limited to the extremity, and carried out during different intervals of time, are presented. Perfusion of the involved extremity with phenylalanine mustard has resulted in a 5-year survival rate of 28% of 43 patients. A second group of 25 patients has been treated by a four-stage immunotherapy program consisting of sensitization with intradermal BCG, followed in 6 weeks by intra tumor injection of BCG. A third stage involved the activation of the patients's lymphocytes, after removal by a blood cell separator, incubated in vitro with irradiated neuraminidase-treated melanoma cells and reintroduced into the patient either by subcutaneous or intratumor injection. The fourth stage of immunotherapy involves injection of an inoculum of irradiated neuraminidase-treated autochothonous tumor cells plus BCG injected intratumorally or subcutaneously. Sixteen of 24 patients receiving immunotherapy treatment program have experienced arrest of their disease lasting from 5 to 42 months.

Intralesional BCG, intravenous immune lymphocytes, and immunization with neuraminidase-treated tumor cells to manage melanoma; A clinical assessment.

An attempt was made to produce tumor immunity in 193 patients who had melanoma, 160 of whom had metastases and 33 of whom did not. Four stages of treatment are outlined. The patients whose disease was confined to the skin, subcutaneous tissues, and lymph nodes seemed to benefit most. The treatment was of no benefit to patients whose disease had progressed to the visceral, skeletal, or central nervous systems.