Carotid body tumors.

A review of seven carotid body tumors less than 5 cm in diameter confirms the thesis of other recent reports that such tumors can be resected with minimal morbidity. In two of our cases, initial exploration and biopsy were performed not suspecting the nature of the neck mass; in one of these, hypoglossal and facial nerve deficits resulted. Angiography was diagnostic in six of our seven cases and should be used to establish the diagnosis preoperatively in any neck mass of doubtful origin where carotid body tumor is a part of the differential diagnosis.

Individualization of treatment for hilar bile duct cancers.

Two cases of hilar bile duct cancer are presented, 1 treated with the preferred technique of left intrahepatic anastomosis, the other with tube drainage. The many factors to be considered before choosing the most appropriate procedure are stressed. A critique of several techniques is offered, with a discussion of the nuances in decision making. The surgeon who embarks upon treatment of such tumors should be thoroughly familiar with the wide range of procedures available; better selection should improve palliation.

A new table-fixed retractor.

In summary, the goal of lowering operating room costs by reducing the number of persons needed for safe performance of operations is an important stimulus to the improvement and refinement of table-fixed retractor systems. Far more important in my view, however, is the need for a convenient system that can reliably replace extra help in emergency situations when a surgical procedure must be performed under less than optimal conditions. As teachers of surgeons, we should introduce table-fixed retractor systems into training programs so that surgeons can be familiar enough with them to use them effectively when necessary. This will not be accomplished unless table-fixed retractors are simple and convenient to set up and readjust.

Changing clinical, pathologic, therapeutic, and survival patterns in differentiated thyroid carcinoma.

Records of 792 patients with differentiated thyroid carcinoma seen at the Lahey Clinic Foundation over a 40-year period were analyzed; 631 patients had a minimum followup period of 15 years. Differentiated types currently constitute nearly 90% of thyroid carcinomas. The clinical presentation has improved substantially through the years, and the results of treatment generally have improved. The per cent of patients with primarily incurable and locally unresectable disease or distant metastases has decreased from 7% before 1950 to 1% currently, and this group resulted in almost one third of the total fatalities and one half of fatalities within the first 5 years after treatment. Clear relationships were demonstrated between older age, men, extraglandular extension, blood vessel invasion, major capsular involvement, multifocal disease, and higher mortality rates. Lymph node metastases were found to exert a protective effect in all categories of disease analyzed, and this effect was directly related to the number of lymph node metastases present such that no deaths occurred in those patients who had more than 10 node metastases. Surgical treatment recommended is subtotal thyroidectomy for patients at high risk of death from disease as defined by combinations of age, sex, and extraglandular extension. Patients at low risk or with small carcinomas can be treated satisfactorily by lobectomy. Lymph node resections should be of a limited type or a modified neck dissection and should be performed only therapeutically. No improvement, as judged by mortality or recurrence rates, could be demonstrated by the use of radio therapy after surgery, and its use should be discouraged. Thyroid hormone administered for suppression of endogenous thyroid-stimulating hormone production improved mortality rates significantly in patients with papillary and mixed forms of carcinoma in all age groups but did not affect survival in patients with follicular carcinoma of the thyroid.20