Showing papers in "CA: A Cancer Journal for Clinicians in 1975"

Major trends in cancer:25 year survey

Abstract: > The overall incidence of cancer (ex cluding carcinoma in situ of the uterine cervix and non-melanoma skin cancer) has decreased slightly during this period. Cancers of the stomach, esopha gus, rectum, uterus, ovary and blad der (female) have declined, while cancers of the lung, pancreas, colon (male), prostate and bladder (male) have increased. Clearly, significant progress has been made. Twenty-five years ago, one in four patients with cancer survived five years. Today, one in three will be saved, a gain of some 55,000 lives each year.

Carcinoma of the cervix—the wertheim operation

Abstract: vic lymph node dissections in all group C patients treated by radium. The results in our clinics in 12 Taussig operations caused us to decide to try, not his opera tion, but a radical surgical procedure, in which a combined radical surgical re moval of the uterus was attempted, and in addition his method of lymph node dissection was carried out. It has been obvious to the author, after the observation of possibly 2,000 cases of cancer of the cervix, that radiation is not the ideal method of treatment. Radi ation reactions are occasionally very se vere and the morbidity caused by the treatment in a large group of patients is great and depressing. It is not uncom mon to find that in early cases patients fail to respond to treatment when it is obvious that if the patient had been operated upon, success might have fol lowed. The larger the experience with radiation and the longer the follow-up of cases, the more discouraged our staff has become over our results. Patients with advanced cervical cancer occasionally do exceptionally well, and yet if in such a hospital as the Pondville Hospital (Massachusetts Department of Public Health) the absolute curability figures are considered, it is apparent that in only the early and favorable cases are patients cured. Of I ,000 patients of all groups and grades coming to that hospital only This paper represents the personal ex perience of the author in the radical sur gical treatment of cancer of the cervix of the uterus. It is not a plea to others to un dertake such surgery. Frank W. Lynch, Victor Bonney, and (the late) Fred J. Taussig have been used as guides as the work has progressed. Their enthusiasm and their well-done work were inspira tions. Bonney's results, so well known to all of us, were excellent but his mor tality, even in his last two series of 100 cases, is too great. His mortality figures had to be bettered. This might be accom plished by a better selection of cases and perhaps by the use of improved preoperative and postoperative treat ment. Lynch's2'3 proof of the presence of apparently viable cancer cells in cer vices removed after radiation and his en couragement to the author while in San Francisco spurred on this surgical expe rience. Taussig's5'6'7 careful and thorough dissection of the pelvic lymph nodes as an adjunct to radiation of the cervix and pelvic tissues, and the appar ent ability to cure, at least for five years, some patients with positive lymph nodes led to a desire to see his work. The ob servation of his dissections while in St. Louis demonstrated that part of the surgical procedure. Taussig advises pel

CEA, AFP and other potential tumor markers

Abstract: “¿ overt― colon cancer, many of whom had metastases, and by other investiga tors.4'5 In another expanded study, however, patients with earlier disease were included, with a fall in positivity to 72 percent.6 (Table 1.) The positivity rate fell even further to 59 percent in patients seen preopera tively, but rose to 96 percent in those with evidence of metastases following surgery .@†̃ These findings have been widely confirmed. The combined Canadian National Cancer Institute/American Cancer Society Study reported 62 per cent positivity in patients studied preoperatively using the Thomson-Gold assay.8 Thus, CEA levels vary with the stage of disease. In three series of patients tested by three different assays, CEA positivity ranged from a low of 19 to 40 percent in patients with localized disease (Duke's Stage A) to as high as 100 percent in those with widespread metastases, commonly to the liver. It is clear that the CEA assay is a better indicator of widespread disease particularly of metastases to the liver than it is of early colon cancer. A preoperatively negative assay (normal: <2.5 ng./ml.)* does not exclude the diagnosis of cancer, but it does make the diagnosis of metastases less likely. Gold's demonstration of a glycoprotein antigen in human colon cancer in 19651 and Thomson's description four years later of a radioimmunoassay for carcin oembryonic antigen in serum,2 stirred the imagination and interest of both lay and scientific communities. CEA and alpha-fetoprotein especially, as well as other tumor markers, have been exten sively evaluated clinically. The sim plicity of the original concept—that macromolecules immunochemically identical to embryonic antigens are also produced by common human cancers—has been modified by practi cal clinical realities.

Management of disseminated neuroblastoma

Abstract: Very few children with disseminated neuroblastoma are cured, and sponta neous regressions are rare. This poor prognosis has not improved despite the combined use of surgery, radiotherapy and multiple chemotherapy alone or in combination. It should be emphasized, however, that only surgery and radio therapy have been employed to their maximum potential. While chemo therapy has proven equally disappoint ing, it has been used at what may be considered sub-optimal time intervals and dosages. The relatively good prognosis for in fants under one year of age has biased the approach of some investigative on cologists who doggedly extrapolate suc cessful treatment methods in the infant to the older child. By the time the tumor is diagnosed in the older child, it has survived a vicissitude of structural, bio chemical and immune insults and, by selection, has become imbued with all the characteristics essential to its growth in a hostile environment. It may as well have managed to alter and thereby co habit within its host. One cannot expect that neuroblastoma in an older child will disappear entirely simply by removing or radiating bits of tumor. Only by af fecting each tumor cell can we hope to cure the patient. A more aggressive ap proach is thus required, involving maxi mum but safe utilization of chemo therapeutic agents and supportive meas ures for ending cytotoxicity. Recently, this approach has been pursued in the management of the child with neuro blastoma.

Single agent versus combination chemotherapy.

Abstract: Dr.DeVita: Not entirely. Certain types of tumors have demonstrated remark able responsiveness to single agents. The success of methotrexate in the treatment of choriocarcinoma is well known. Over 70 percent of women can be cured, even if the disease is widely disseminated. Choriocarcinoma's exquisite responsiveness to single agent ther apy may be related, in part, to its rapid proliferation and the host's ability to mount an effective immune response to what may be allo geneic residual disease. To no small extent, therapy has been aided by the presence of a marker. chorionic gonadotrophin. Another tumor that is responsive enough to single agent chemo therapy to warrant the word “¿ cure― is Burkitt's lymphoma@ 20 per cent of Burkitt's original patients achieved long-term remission using minimal amounts of cyclophosphamide alone. In a random ized trial of single or multiple high doses of cyclophosphamide conducted by the National Cancer Institute's unit in Uganda, 10 of 11 patients with localized disease (Stages I or II) have sustained long remissions. Multiple doses of cyclophosphamide were no more effective than single doses in patients with localized disease, but it must be emphasized that multiple doses of this potent immuno suppressive agent failed to do any harm. Relapses were no more

Natural history and staging of renal cell carcinoma

Abstract: Renal cell carcinoma intrigues both clinician and investigator by its often roguish way of presenting itself. Subtle symptoms, misleading physical and lab oratory findings challenge the clinician by mimicking other disorders, rivaling the notoriety of tuberculosis and syphi lis. In 30-45 percent of patients, no pre senting symptoms are directly related to the primary tumor. The toxic and endo crine effects provide topics for labora tory investigation, while the phenome non of spontaneous regression or late recurrence demands better understand ing of host immune mechanisms. Our task is to highlight seemingly unrelated clues which, when taken to gether, will lead to proper diagnosis and earlier treatment of renal cancer. To plan such proper management requires an un derstanding of the patterns of growth and recurrence. Staging initial extent of tumor helps determine prognosis and most valuable treatment.

Proctosigmoidoscopy--age criteria for examination in the asymptomatic patient.

Abstract: clearly related to early detection and treatment The average five-year sur vival rate after treatment of colorectal cancer is approximately 50 percent; if cancer has not extended beyond the bowel wall (Duke's Stage A), the sur vival rate is nearly 100 percent' Unfortunately, diagnosis early in the manifestation of symptoms is not neces sarily diagnosis early in the course of disease A number of investigators ad vocate routine proctosigmoidoscopy for early diagnosis ,29 but others question the need for this procedure on an annual basis'°12 The American Cancer Society encourages physicians to search for co lorectal cancer before the onset of symp toms and recommends annual proctosig moidoscopic examination for all pa tients 40 years and older With approxi mately 80 million such persons in the United States, this is indeed an awe some task Is it necessary to screen so large a population? At the Lahey Clinic, proctosigmoido scopy is considered an essential compo nent of the complete physical examina tion, and more than 15,000 are per formed annually A prospective study was undertaken to assess the value of this procedure in screening for colorec tal cancer

Malignant brain tumors—a synopsis

Abstract: Brain cancers differ from other neo plasms due to the confines of the closed cranial vault, the comparatively small lethal tumor burden, and the failure of most common brain tumors to metasta size. In addition, different forms of brain cancer have different biologic, kinetic, metabolic and growth characteristics, making it difficult to discuss this field as a single entity. An estimated 8,500 patients will die of brain cancer this year. The male/fe male ratio is 57:43 and the crude inci dence rate, 4.5/100,000.1 Tumors of the brain and central nervous system are the second most common cancer in children of both sexes under the age of 15 years, only surpassed in incidence by leuke mia. The etiology of intracranial tumors is unknown and only a few cases of rela tively rare forms, such as acoustic neurinoma and neurofibroma appear to be hereditary. The incidence of cerebral metastases from a primary neoplasm elsewhere in the body is probably arti factually low, but will become a more significant problem as greater control of the primary disease begins to prolong life. The most common brain cancer is the highly malignant glioblastoma multi forme, which accounts for one-quarter of reported cases.2 (Table 1.) Malignant astrocytomas probably represent a less malignant form of this tumor. Ependy momas, oligodendrogliomas and me dulloblastomas, found in less than two percent of patients, may well be a dif

Germinal tumors of the testes.

Abstract: Testicular tumors are the most com mon solid cancers in patients 15 to 34 years old, accounting for 12 percent of all cancer deaths in this group. The overall incidence rate in the United States is 2.1 per 100,000 males. 1.2Un fortunately, evidence suggests that the mortality rate is increasing here and abroad. For unexplained reasons, testic ular tumors are extremely rare in Amer ican Blacks3 as well as in Africa, Asia and New Zealand.4 While the definitive etiology of testic ular tumors is still unknown, several causal factors have been implicated in cluding cryptorchidism, trauma, pre existing endocrinopathy, atrophy and certain genetic factors. The incidence of testis tumors is high in patients with mal descended or previously atrophic testes, but the exact rate has not been deter mined.5 Approximately one in 80 in guinal and one in 20 abdominal testes will become malignant.6 A number of factors may be responsible for the in creased incidence of testicular tumors in the cryptorchid—gonadal dysgenesis, elevated temperature, interference with blood supply, endocrine disturbances, or perhaps the atrophy itself which is usually present. It is difficult to attach a cause and ef fect relationship between tumor and trauma since the latter is virtually inevi table in a young person engaged in phys ical activities. Genetic factors have been suggested because of the relatively high incidence of testis tumors in twins, brothers and other members of the same family.7 There is also a slightly higher incidence of a second testis tumor devel oping in a patient with a tumor of the op posite gonad.2

Non‐hodgkin's lymphoma an approach to staging and therapy

Abstract: Progress in the management of non Hodgkin's lymphomas (NHL) has been less impressive than the dramatic ad vances in the control and cure of Hodg kin's disease. Unlike Hodgkin's dis ease, it has not yet been documented whether NHL tends to spread along con tiguous lymph nodes. Recent evidence suggests that hepatic and marrow in volvement may frequently be observed at diagnosis in patients with the lympho cytic types of NHL, in contrast to Hodg kin's disease, which is usually limited to the lymph nodes at presentation. Al though disseminated NHL may respond to the same chemotherapeutic regimens as Hodgkin's disease, response has been noted in a smaller percentage of patients and for a shorter duration of time. Despite these limitations, however, ad vances in histologic classifications as well as clinical and pathologic staging have broadened our understanding of the non-Hodgkin's lymphomas, and will hopefully lead to improved survival. The Hodgkin's disease staging sys tem introduced at Ann Arbor can be readily applied to the study of NHL.

Radiology in lung cancer: problems and prospects.

Abstract: As bronchogenic carcinoma continues to be the most insidious of all neoplasms and the most common cancer in males, it is time to reappraise the role of radi ology in diagnosis, staging and follow up. When lung cancer reaches the threshold of visibility on a chest radio graph, 60 to 80 percent of its life span is completed; it will kill the host in over 90 percent of cases. Quite obviously, the conventional chest radiograph has failed as an acceptable screening method in de tecting curable lung cancer. Although not often appreciated, radiographic signs of bronchogenic tumors are many, varied and nonspecific. This article sum marizes the presenting radiographic fea tures of the various histologic types of primary bronchogenic carcinoma and demonstrates how radiographic methods can be applied to pretreatment evalua tion and follow-up. Most bronchogenic tumors are beyond the scope of surgical cure on pre sentation. In a series of I ,000 cases, the disease had extended to the hilar nodes in 54 percent and the mediastinal lym phatics in an additional 35 percent.

Hypercalcemia and cancer

Abstract: nal medicine, MayoClinic andMayoFoundation, and Associate Professor of Internal Medicine, Mayo Medical School, Rochester, Minnesota.Dr. Smith is aconsultant in nephrology and internal medicine, Mayo Clinic and Mayo Foundation, and Associate Professor of Internal Medicine, Mayo Medical School, Rochester.Dr. Purnell is aconsultant in endocrinology and in ternal medicine, Mayo Clinic and Mayo Foundation, and Assistant Professor of Internal Medicine, Mayo Medical School, Rochester. Dr. Goldsmith is aconsultant in the Russell M.Dr. Riggs is aconsultant in endocrinology and inter nal medicine, Mayo Clinic and Mayo Foundation, and Professorof Internal Medicine, Mayo Medical School, Rochester.Wilder

BCG in the treatment of human cancer

Abstract: of clinicians and researchers, and an example of the unpredictability of science and medicine, that Bacille Cal mette-Guérin (BCG), an anti-tubercu losis vaccine introduced in 1921, should in 1975 be under extensive in vestigation for its possible role in the treatment of human cancer.' The his tory of BCG's use as a potential cancer treatment is worth reviewing. For more than 100 years, the miraculous disap pearance of cancer after severe infec tion has occasionally been reported. Examples of cancer regression subse quent to local infection led Coley to conclude, in the early 1900 s, that bac teria released a toxin that could directly or indirectly cause the death of tumor cells. He therefore began to treat cancer patients with various bacterial toxins but, despite a few promising results, found no consistent therapeutic benefit. Clinical observations, however, con tinued to support the concept that bac terial infections might play a role in the regression of cancer.2 For instance, a number of investigators noted that fol lowing thoracotomy for lung cancer, those patients with postoperative em pyema had a significantly better chance for long-term survival than those who did not have empyema. (Fig. I.) This was a remarkably surprising finding, and one of the few examples I know of where patients benefit from a postoperative complication! Independently, immunobiologists in terested in the nature and control of immune responses to foreign antigens discovered that the simultaneous injec tion of certain bacteria with an antigen, such as bovine serum albumin (BSA), markedly increased the strength of the immune response against BSA. Tu bercle bacilli were found to be among the most effective bacterial adjuvants for immune stimulation. Finally, with increased understanding of the immune system's role in cancer, experimental immunologists began to question whether BCG or other types of “¿ im munoadjuvants― would be of value in stimulating the immune system to de stroy tumor cells in animals or man.

Clustering of cancer.

Abstract: The feline leukemia virus (FeLV) causes cancer in cats and, in some cases, appears to be transmitted from cat to cat much like “¿ ordinary― viruses, with most infected animals immunologically resisting disease, and only the occasional one developing leukemia. 1.2 Although probably un common, the mere existence of this phenomenon in animals makes a similar situation clearly in the realm of possi bility for at least some types of human cancer as well. Attempts to isolate a virus which causes human cancer have not been successful. However, there are a number of candidates such as the Ep stein-Barr and herpes genitalis viruses, and biochemical analysis of tumor ma terial has shown evidence of RNA viruses similar to the oncornaviruses of many animal species.3 This is a very active field and rapid progress can be expected. Concurrent with a purely laboratory approach, epidemiologic studies are searching for a link between various candidate viruses and cancer.3 In addi tion, data are being collected and eval uated on the possibility of person to-person transmission—' †̃¿ contagion' †̃¿ — of both leukemia and Hodgkin's dis ease. One goal of these investigations

Prolactin and breast cancer

Abstract: In the C3H strain of mice, which is infected with mammary tumor virus, mammary cancer develops spontaneously in females from hyperplastic alveolar nodules that arise from apparently normal glandular epithelium. The progression of hyperplastic nodules to mammary cancer is at least partially dependent on prolactin. In rats, both prolactin and estrogen seem to be of primary importance in influencing the growth of breast tumors, which are chemically induced. High doses of estrogen stimulate pituitary secretion of prolactin in rats, yet paradoxically result in tumor regression. prob ably through the peripheral effects on breast tissue. Some of the strongest evidence for the role of prolactin in rodent breast cancer has been obtained by the manipulation of serum levels with L-dopa or the ergot derivatives.

Cellular pathology: Lecture VIII. Blood and lymph.

Abstract: proportion of colourless corpuscles in the blood appears to be dependent upon an affection of the lymphatic glands, I have designated by the name of Leuco cytosis. Now you know that another matter has long been the subject of my studies, the affection named by me Leu kaemia, and our next business must be to determine how far genuine leukaemia differs from these leucocytotical condi tions. In the very first cases of leukaemia which came before me, a very essential property was discovered to exist, namely, that there was no essential vari ation in the proportion of fibrine in the blood. Afterwards it was found out that the proportion of the fibrine might, ac cording to the particular circumstances of the case, be greater or less than, or the same as usual, but that a continually augmenting increase of the colourless blood-corpuscles invariably took place; and that the coincidence of this increase with a diminution in the number of the coloured (red) corpuscles became more and more marked, so that as a final result a condition was attained, in which the number of the colourless corpuscles was almost equal to that of the red ones, and striking phenomena were displayed, even when the coarser modes of obser vation were employed. Whilst in ordi nary blood we can seldom count more than one colourless corpuscle to about 300 coloured ones, there are cases of leukaemia in which the increase of the colourless ones reaches such a height, that to every three red corpuscles there is one colourless one, or even two; or in which indeed the greater numbers are in favor of the colourless corpuscles. In dead bodies the increase in the col ourless corpuscles generally appears more considerable than it really is; for these corpuscles possess extraordinary adhesiveness and accumulate in consid erable masses wherever there is a retar dation in the stream of blood so that in the dead body the greatest number is always found in the right heart. Once, before I left Berlin, this singular case oc curred to me, that, when I punctured the right auricle, the physician who had treated the case cried out, astonished, “¿ Why, there's an abscess there!― So like pus did the blood appear. This pun form condition of the blood does not in deed pervade the entire circulating stream; the whole of the blood never looks like pus, because a comparatively large number of red corpuscles always continues to exist; still it sometimes hap pens that blood flowing from a vein even during life exhibits whitish streaks, and that, when the fibrine has been removed by stirring, and the defibrinated blood is allowed to stand, a voluntary separation at once takes place, the whole of the blood corpuscles, red and colourless, gradually sinking to the bottom of the vessel, and there forming a double sedi ment, a lower red stratum, covered by an upper, white and puriform one. This is explained by the difference in the spe cific gravity of the two kinds of cor puscles and the time they take to sink. In this way too we are enabled very readily to distinguish leukaemic from chylous Reprinted from: Virchow, Rudolf. CellularPathol ogy. Translated by Frank Chance, New York: Dover Publications, Inc., 1971.

Do viruses cause cancer in man

Abstract: Many factors are involved in the in duction of animal and human cancer: ionizing radiation, chemical carcino gens, age, hormone balance and genetic constitution of the host. In addition, viruses are known to cause tumors in animals such as frogs, fowl, rodents, cats, cows and monkeys, and it is im probable that cancer in man has a fun damentally different etiology. However, it is unlikely that evidence of the viral etiology of human cancer will ever fully satisfy Koch's postu lates. These include that: (I) the micro-organism must be observed in most cases of the disease; (2) it must be isolated and grown in pure culture; (3) the pure culture must, when inocu lated into a susceptible animal, repro duce the disease; and (4) the micro organism must be observed in, and recovered from, the experimentally diseased animal. Thus, supporting evi dence that viruses cause several human cancers is largely circumstantial and hasbeengatheredinseveralways.One line of attack is to search for virus particles, viral precursors in the form of antigens, and virus-specific nucleic acids in human tumor biopsy samples and cultured tumor cells. Passenger and contaminant viruses should be rig orously eliminated before any agent can

Rights of the cancer patient.

Abstract: What cancer means to the patient is different, frequently, from what cancer means to a doctor or health care worker. It is much within our education, of course, to look upon the processes which dislodge people from normality as being diseases, those things indeed which take them away from any normal stance, and which our education prepares us to correct. So, we spend much of our energy processing thoughts which have to do with the biologic na ture of disease. But frequently the pa tient's concerns are quite different. To a sick person having a disease is part of something larger. With long-term, chronic, and especially fatal disease, there is a search for meaning: Why am I sick, what is my life now to me and to others? What does it mean now to be becoming unto death? For that cancer patient who is not cured, the thought is constantly there as to what this all means, as he must now live his life .through becoming unto death. It.is one of the great paradoxes of modern Ameri can medicine that we offer a patient many ways to extend his living, but at the same time, we extend his dying. The imposi tion of both phenomena simultaneously presents the sick individual and his.f am ily with a confusing signal. Physicians appear to act as if only treatments for life are permissible and.that helping people

Hodgkin's disease: current recommendations for management.

Abstract: Since 1962, we have conducted a series of controlled clinical trials at Stanford University Medical Center aimed at op timizing the treatment of Hodgkin's dis ease. Design, eligibility criteria and in terim results have been previously re ported. 1-3These and other clinical stud ies will undoubtedly continue to provide substantial additional information as more cases are accrued and observed for longer follow-up periods. However, the fact that certain aspects of treatment are in a state of flux creates difficulties for the practicing physician called on to manage a patient with Hodgkin's dis ease. This article sets forth a distillation of our current views concerning optimal management in relation to site(s) and stage of disease, constitutional symp toms and histopathology, both for the previously untreated patient and also for the previously treated, relapsing patient who poses a much more difficult prob lem. In most instances, recom

Introducing cancer into the curriculum

Abstract: Is undergraduate medical training in oncology adequate? Those of us who have an interest in oncology have always maintained that it is not, but we have only documented the deficiencies anec dotally, such as the limited number of specific courses in oncology, and the lack of emphasis on cancer in national certifying and licensing examinations. It is my belief that the eventual attainment of “¿ adequate― cancer education will depend on oncologists joining forces with other medical specialists to identify and develop a balanced and realistic set of specific expectations—a body of re quired knowledge—so that the †̃¿ undif ferentiated― medical student is prepared to begin postgraduate training in any clinical field at the time of his or her graduation -

Measuring improved survival of cancer patients

Abstract: Group of the National Cancer Institute have shown significant improvement in 54 percent of all incident cancer cases from 1950 to 1971. Recent comments on progress in cancer research, as reflected by prolonged survival and reduced mor tality, must be put in proper perspective. This involves the accurate dissemination of the latest available data, a profound understanding of how past accomplish ments have effected cancer treatment, and a clear description of the time-lag between the development of a new treat ment and its ultimate reflection in gen eral survival statistics.

The Author's Reply: Feedback

Abstract: Dr. Sheldon Sommers, Director of Pathology at Lenox Hill Hospital, has adopted the World Health Organi zation's recommendation of the histo logic typing of ovarian tumors that was published in a 1973 monograph, edited by Drs. Sirov, Scully and Sobin. This is a very complete breakdown of not only the common epithelial tumors but the gonadal stromal tumors, germ cell tumors, metastatic tumors as well as un classified tumors. In addition to the usual three classifications of benign, borderline and malignant, it goes further and differentiates them according to whether the adenomatous or fibrous ele ment is dominant. Surface papillomas are included as a separate entity because there is increas ing evidence to suggest that they may be more prone to spread than the com pletely encapsulated tumor, even though they are in the same clinical stage. The decision of whether serous tumors in vade the stroma is usually not difficult. Although diagnosis is usually made without difficulty in clear cell or endo metrioid cancers, it is not as straightfor ward as for serous cancers. Benign, bor derline and malignant forms of any of these neoplasms may coexist in any one tumor. This has been confirmed in stud ies using the electron microscope and may explain the importance of exam in ing many sections of the tumor before reporting the karyotype. Mucinous tumors are commonly multilocular and who tend to be younger than the usual patient with ovarian carcinoma, are ex cellent candidates for conservative ther apy. In any event, they certainly should be considered separately.in studies of the effects of various treatments on ovarian tumors.

Ovarian cancer in children--guide for a difficult decision.

Abstract: cancer in a child is surpassed only by confusion over treatment. Although the ovary is the most common site of gyne cologic tumors in children, fortunately. only one in 10 is malignant. Ovarian neoplasms may occur at any time in childhood or adolescence, but tend to be more frequent between the ages of 10 and 14 years. This finding suggests that release of a control mecha nism or pituitary stimulation of a latent factor may trigger tumor development. Ovarian cancer poses certain prob lems in children that are not as signifi cant in adults: it is associated with in creased cachexia and ascites; larger tumors cause relatively greater pressure symptoms and dyspnea: evolution is more rapid, due to the limited space for tumor expansion; tumors generally have a higher degree of virulence as a result of the child's less effective immunologic defenses. Of course, the effects of ther apy on a child's future development must always be considered.