Showing papers in "CA: A Cancer Journal for Clinicians in 1976"

Plasma cell neoplasms

Abstract: Plasma cell neoplasms constitute a group of entities with marked variations in clinical manifestations, extent of dis ease, frequency and severity of compli cations and treatment requirements. These disorders are usually associated with increased production of a homo geneous globulin, recognized as a “¿ peak― on serum or urine electro phoresis. Multiple myeloma is the most common plasma cell neoplasm, and must be distinguished from other closely related disorders such as localized plas macytoma, asymptomatic and indolent myeloma, idiopathic “¿ peaks― and mac roglobulinemic lymphomas. Plasma cell dyscrasias may be classified in the fol lowing manner: Localized Plasmacytoma About five percent of patients with plasma cell neoplasms have evidence of only one or two plasmacytomas, without the major complications frequently as sociated with multiple myeloma. In these patients, myeloma proteins are low or absent and the serum concentra tion of nonmyeloma immunoglobulins is generally normal. Local radiotherapy to about 4,000 rads is usually effective. Such therapy may reduce the level of any myeloma protein present and ele vate the serum concentrations of non myeloma immunoglobulins to supranor mal levels, indicating that a large frac tion of tumor has been eliminated.' This elevation of normal immunoglobulins also suggests that a small number of ma lignant cells may have inhibited normal immunoglobulin production by means of a humoral mechanism.2 Clinical sta bility may be sustained for many years. However, some patients thought to have localized plasmacytomas soon de velop rising myeloma proteins, pointing to an incorrect disease classification at diagnosis and the need for chemo therapeutic management. The median survival for a group of patients with no

Carcinoma of the penis

Abstract: Most premalignant penile lesions should be completely locally excised. Giant condyloma frequently cannot be distinguished from fungating carcinoma and usually requires limited penectomy. Cancers other than epidermoid carcinomas are very rare and, except for basal cell carcinoma, have a generally poor prognosis. Prognosis of squamous cell carcinoma, however, depends on the stage of disease as determined by both local invasion and by involvement of inguinal nodes. The three-year survival rates for 55 patients were: stage I, 95 percent; stage II, 67 percent; stage III, 29 percent; and stage IV, zero percent. Most primary lesions were treated by partial penectomy, and no patient developed local recurrence. There is a significant discrepancy between initial clinical and histologic staging, due to the difficulty of determining lymph node metastases. Current methods of radiation therapy indicate that it has a role for management of primary penile cancer, especially in young men with small lesions. The management of inguinal lymph nodes is still debated. Although the reliability of the sentinel node biopsy has not been established, it may be appropriate in patients with noninvasive primary lesions and no detectable inguinal metastases. The need for immediate or prophylactic lymph node dissection in patients with invasive primary tumors is controversial. Successful management depends on careful and frequent follow-up examinations, with early intervention for suspicious adenopathy. In view of the poor prognosis for advanced lymph node metastases, we prefer to use early lymph node dissection when the primary lesion is deeply invasive. Limited bilateral pelvic lymph node dissection is associated with minimal morbidity and seems to be an appropriate prelude to groin dissection. Extensive pelvic metastases are a sign of incurability and abrogate the need for groin dissection. We prefer to perform the inguinal dissection at the time of lymph node dissection through a separate curve groin incision.

Cigarette smoking among physicians and other health professionals, 1959‐1972

Abstract: The subject of smoking among physi cians and other health professionals has been of special interest as the evidence thatcigarette smokingisa majorhealth threat continues to mount. A 1967 report based on questionnaire replies from over 5,000 physicians in 25 states indicated that29 percentwere still smokingciga rettes in 1965, a decrease of 10 percent from those currently smoking cigarettes in 1959.1 Results from another question naire completed in 1972 indicated that only 19.5 percent of physicians were still smokingcigarettes a ofthattime. These data were obtained from the American Cancer Society's long-range follow-up epidemiologic study, in whichonemillionmen andwomen over 30 years old and from 25 states were enrolled by American Cancer Society volunteers in the Fall of 1959 and asked to complete detailed questionnaires about themselves. The results of this study have been described else where.2'3'4 Among those enrolled were 5,604 physicians, 5,407 males and †̃¿ 197 females. At the start of the study in 1959, 65.7 percent of the male physicians reported that they had smoked cigarettes at some time and 39.5 percent were still smok ers. The subjects were asked to complete short supplemental questionnaires on fouroccasionsaftertheoriginal enroll ment: in 1961, 1963, 1965 and 1972. They supplied additional information, including details of their current ciga rette smoking habit. During the course of the 13-year fol low-up study, 18 percent of the physi cians died. In 1972, 2,899 answered the questionnaire and reported on their smokingbehavior;2,426had answered all four supplemental questionnaires. Among those who answered all ques tionnaires, the percentage of cigarette smokers had dropped from 38.6 percent in1959to37.7percentin1961,to31.8 percentin1963,to28.3percentin1965 and to 19.5 percent in 1972. Of those who were current smokers in 1959,41.4 percenthad given up all forms of smoking by 1972, 13.8 percent switched to pipes or cigars and 44.8 per cent were still smoking cigarettes. Light smokers were able to give up cigarettes more easilythanheavysmok ers: 75.3 percent of those smoking less than one-half pack a day in 1959 quit by 1972; 61.7 percent of the one-half to one pack a day smokers, 51.1 percent of the one to two pack a day smokers and only 38.0 percent of the two or more pack a day smokers quit cigarettes in 1972. The vast majority of those who re Mr. Garfinkel is Assistant Vice President for Epi demiology and Statistics, the American Cancer Society, New York, New York. Presented at the Science Writers' Seminar, St. Pe tersburg, Florida, March 30, 1976.

Primary cutaneous melanoma: a report from the Queensland melanoma project.

Abstract: generally regarded as a particularly viru lent and usually fatal disease, a reputa tion no longer deserved. If individuals are instructed to report any change in a mole, and if physicians are alert to the possibility of melanoma,* the diag nosis can be made at an early biologi cal and potentially curable stage. In Queensland, Australia, there are few major cancers that have as hopeful a prognosis. From 1963 through 1968, all cases of malignant melanoma occurring in Queensland were registered at the Re search Unit of the Princess Alexandra Hospital in Brisbane as part of the Queensland Melanoma Project.' Mi croscopic diagnoses were reviewed by a panel of pathologists, whose agree ment was required before the case was considered proven. More than 1,500 patients with malignant melanoma have been recorded, and form the basis of this article. In Queensland, the average annual incidence rate per 100,000 population was 14 for males and 17 for females, an average annual rate of 16 new pa tients per 100,000 population.2 This is the highest reported incidence in the world. No aborigines have been treated for melanoma in Queensland since the study began. No marked predilection was found in persons with a fair com plexion, blue eyes, blond or red hair.2 Unlike squamous cell carcinoma, no particular concentration of melanoma on exposed sites was noted.2 An environmental factor is probably responsible for the high incidence of malignant melanoma in Queensland; sunlight is the most likely etiologic agent, and possibly exerts both a direct and an indirect effect on the develop ment of this skin cancer.3

Cancer statistics, 1976 a comparison of white and black populations.

Abstract: Comparisons of cancer statistics in the white and black populations reveal large differences between the two groups. Some of these differences may be due to artifacts of case finding and some to true biologic variations, but the majority must be attributed to environmental and socioeconomic factors. (There is a gene tic basis for the much greater incidence of non-melanoma skin cancer among whites than blacks. However, these cancers are generally not life-threat ening and, as is customary nowadays, they are not included in the data which follow. Similarly excluded are all in situ carcinomas.) The following article compares white and black populations in regard to: •¿ the probability of developing and dying of cancer; •¿ trends in cancer incidence and mortal ity over the last several decades; •¿ stage of disease at diagnosis; •¿ survival following diagnosis.

Ewing's sarcoma

Abstract: There are no known external causes of Ewing’ sarcoma, a form of bone cancer, although a small number of cases are linked to genetic abnormalities. This malignancy occurs with remarkable consistency in registry populations across Europe and the United States, including Los Angeles County. Few cases of it occur after age 30. Although African-Americans and Asian-Americans are at a substantially lower risk than whites or Latinos, there is still a slight tendency toward higher risk among males of lower social class. Despite the racial/ethnic disparity, no systematic pattern of geographical occurrence is apparent, and therefore no local source of causation can be proposed.

Combination radiation therapy and chemotherapy: A logical basis for their clinical use

Abstract: estimated the failure rate of advanced cancers at specific sites that are not read ily eradicable:' cancers of the oral cav ity, oropharynx and nasopharynx (T3, T4, N2, N3); gynecologic cancers of the cervix (Stages III, IV), ovary (Stage IIB) and vulva: large advanced geni tourinary cancers of the bladder (Stage B2C) and prostate (Stage C). (Table 1.) Gastrointestinal tumors frequently begin insidiously and can reach advanced stages in the stomach, colon and inac cessible sites, such as the pancreas. Soft tissue sarcomas are often locally recur rent and invasive prior to metastasizing. Malignant brain tumors, for example, glioblastoma multiforme, medulloblas toma and mixed gliomas, which are lo cally invasive and rarely disseminate outside the central nervous system, il lustrate the problem clearly.

Endocrine treatment of breast cancer

Abstract: palliation for about 40 percent of women with recurrent or metastatic breast cancer. Extensive studies over the past 30 years have shown that various endo crine alterations can induce objective re gression of breast carcinomas lasting a few months or several years. The mech anisms by which various endocrine therapies induce regression of human breast cancer are not fully understood. A working hypothesis maintains that the growth of some malignant tumor cells depends on hormonal function in the host, which is not unusual in kind or exaggerated in rate. Therefore, depriva tion of essential hormones or inter ference with their action would cause growth cessation and eventual elimina tion of some of the cells, in the same manner that an endocrine target organ atrophies after removal of its essential hormone. Figures 1, 2 and 3 illustrate the extent of tumor regression that can be obtained with successful endocrine treatment. The table summarizes the results of various modalities of endocrine therapy. It is apparent that ablative procedures,

A technique for localizing occult breast lesions.

Abstract: mographic techniques has led to the de tection of many nonpalpable breast masses and areas of calcification, which are suspicious of carcinoma. As a result, the number of breast biopsies performed to evaluate these occult lesions has markedly increased. Unfortunately, specimen radiography has often failed to show the lesion in the first biopsy speci men and subsequent extension of the biopsy in these problem cases frequently results in prolonged anesthesia time and undesirable breast deformity. To help find these lesions, we have devised a preoperative needle localiza tion technique that provides a recog nizable dye marker at the lesion site and also establishes a visible tract for the sur geon to follow. This procedure is used

Hyperparathyroidism and cancer

Abstract: Hyperparathyroidism is not uncommon. Recently available multichannel autoan alyzers (SMA-12) for routine biochem ical scanning, combined with progres sively accurate radioimmune assays of parathyroid hormone now reveal that the incidence of parathyroid tumors may be as high as one in two thousand adults.'-5 Disease presentations are protean, pro ducing a wide range of clinical and bio chemical abnormalities. Renal lithiasis, hypertension, gout, peptic ulcer, pan creatitis, osteoporosis, psychiatric dis orders, myopathy, neonatal tetany, fa milial and multiple endocrinopathy, pheochromocytoma, thyroid carcinoma especially medullary carcinoma, acute hypercalcemic crisis and, rarely, nor mocalcemic occult hyperparathyroidism are gradually being recognized as com plications or manifestations of the dis ease.6'7 The coincidence of hyperparathy roidism and cancer poses a critical problem in the differential diagnosis of hypercalcemia. Interest in this associa tion is more than academic. Although hypercalcemia commonly results from metastases eroding bone, it may also be produced by those rare cancers elaborat ing parathyroid hormone, without de monstrable bone metastases; in the lat ter case, hypercalcemia can be reversed by treatment of the cancer. The dif ferentiation of “¿ cancer― hypercalce mia, ectopic hyperparathyroidism and primary hyperparathyroidism can be difficult but the sequelae of an incor rect diagnosis, grave. Moreover, pri mary hyperparathyroidism may co-exist with or mimic cancer. That a poten tially curable disease may simulate a disseminated cancer has obvious thera peutic and prognostic significance.18-23

Part I Cancer of the larynx: Selecting optimum treatment

Abstract: What treatment modality when em ployed initially produces the highest cure rate, the lowest mortality and mor bidity, the best functional result and the least expenditure of the patient's time and money? This is the central question concerning the management of patients with cancer of the larynx, and one which the authors attempt to answer in the fol lowing three-part series. Pan I considers factors influencing the selection of ap propriate treatment. Part II focuses on surgical approaches, and Part III exam ines the role of radiation therapy. Of course, close cooperation and interac tion between the surgeon and the radia tion therapist are essential to ensure the patient the best chance for cure. Laryngeal cancer is a highly curable disease, if detected and treated at an early stage. The overall cure rate for cancer of the laryngopharynx is approxi mately 57 percent. When cancer is local ized to the larynx, the five-year survival rate is 76 percent.' When the tumor is limited to the mid-third of a mobile true

Part III Cancer of the larynx: Radiation therapy

Abstract: Radiation therapy is the treatment of choice for a T1 and T2 tumor with normal cord mobility and/or an exophytic lesion. It not only provides excellent control of the disease, but also preserves a good, useful voice in approximately 90 percent of the irradiated patients. For a T2 lesion with impaired cord mobility and/or moderate ulceration, a trial course of radiotherapy is initially given. If the tumor shows good regression and/or a return of normal cord mobility after a dose of 4000 rads, radiation therapy may be continued to a curative dose level, about 6500 rads. Surgery is reserved for treating residual disease six to eight weeks after radiation therapy or for recurrence. A T3 lesion with complete cord fixation and/or deep ulceration with nodes does not respond favorably to radiation therapy, and a planned combination of irradiation and laryngectomy is advised. Disease that extends beyond the larynx, T4, is rarely curable by radiation therapy alone. If the lesion is still operable, a combined approach of radiation and surgery is preferred; if not, palliative radiation therapy is given. Lymph node metastases from laryngeal carcinoma indicate advanced disease and is managed by preoperative irradiation and radical neck dissection. Under a programmore » of therapeutic individualization, two-thirds to three-quarters of patients with cancer of the larynx can be cured by irradiation with preservation of a good, useful voice. In the remainder, the larynx must be sacrificed to save the patient's life. The ultimate control of laryngeal cancer lies in eradicating the extensive primary lesion and metastatic nodes, a common problem in the management of squamous cell carcinoma elsewhere in the body.« less

Familial susceptibility to cancer

Abstract: Dr. Anderson: Relatives of patients with cancer of the stomach, breast, large intestine, uterus, lung, childhood brain tumors and sarcomas were found to have two to fourfold increased risks compared with control relatives or the general population. Results of studies on prostatic cancer and leukemia were equivocal. However, a recent consanguinity study in Japan suggests that genetic factors play an important role in the etiology of leukemia occurring in siblings. Retrospective studies on esophageal or cervical carci noma revealed no significant excesses in familial risk. These increased risks only applied to the patient's type of cancer and not to cancer in general.

Editorial: Restoring confidence in mammography

Abstract: cratic Oath states a basic precept of med icine: “¿ The regimen I adopt shall be for the benefit of my patients according to my ability and judgment,and not for theirhurt. . .“ In practice, theartof medicine often lies not only in deciding what is beneficial for the patient and what is harmful, but in evaluating which regimen carries the greatest benefit and the least risk. This is the central issue in the current controversy concerning the advisability of mammography. Un fortunately, recent publicity about mam mography guidelines has served more to confuse than to clarify. The guidelines, which are advisory and not regulatory, are derived from the recommendations of committees ap pointed by the National Cancer Institute and charged with the responsibility of evaluating the po@sible benefit of screen ing to find early breast cancer versus the possible risk of inducing breast cancer by radiation exposure.Threegroupsof women, all of whom had been pre viously exposed to high or very high levels of radiation, are the basis for the initial statistical evaluation and subse quent predictions of risk.* These women included survivors of Hiroshima and Nagasaki atomic bombings, young women irradiated many years ago for. postpartum mastitis, and' another group of young tuberculosis patients who had undergone repeated fluoroscopies. The results of this retrospective statistical study suggest that while there may be a theoretical risk from low-dose radiation exposure (after a latency period of many years), the risk is extremely small for the individual woman. Extrapolating from very large doses to very small doses and indicating that there is no absolutely “¿ safe― dose, it is speculated that if a woman has a mammogram, with ap proximately one rad absorbed by the breast, herchancesofdevelopingbreast cancer theoretically change from an ex pected .07 (7.0 percent) to .0707 (7.07 percent). Stated more simply, (if these estimates are applicable) her probability of eventually developing breast cancer is said to increase from one in 14.3 women to one in 14.1 women. Any risk, no matter how small, should not be com pletely dismissed. At the same time, we must not minimizetheriskof sponta neous breast cancer, which remains the leading cancer killer of American women and the leading cause of death in women 39-44 years of age. The onlyrecognizedapproachtosav ing more lives from breast cancer is de tection at a localized, highly curable stage, hopefully before the cancer be * Report of the Advisory Committee on the Biolog

Rehabilitation of the postmastectomy patient with lymphedema.

Abstract: Most patients experience some degree of lymphedema following radical mastec tomy, at least initially. However, in about 10 percent of women, the collec tion of lymph in interstitial tissues, re sulting from a functional overload of the lymph system, can cause not only annoyance and discomfort, but also dis ability.'-4 Twenty years ago, no effec tive treatment for postmastectomy lym phedema existed. Although the efficacy of individual procedures is still limited, a coordinated treatment program, which pays attention to seemingly trivial de tails, can now significantly reduce lym phedema and increase the functional ca pacity of the extremity. The etiology of postmastectomy lym phedema is somewhat controversial, and probably a combination of factors are involved.5'6 The' most likely are a combination of surgical techniques,7'8 infection7 and irradiation @9.10Venous obstruction, autonomic nervous system reflex spasm and obesity have also been cited,7'9― but are less likely. Regardless of the specific etiology, the mechanism producing lymphedema is the 12Lymph flow from the ex

Definitive radiation therapy

Abstract: cure, has been a major aspect of radia tion therapy since the earliest days of its use in cancer management. Prior to the development of supervoltage irradia tion, radiation therapy was limited to the treatment of tumors at relatively accessi ble sites. At these locations, adequate tumor doses could be delivered without excessive irradiation of intervening nor mal tissues. Some of the best results were, and still are, obtained in tumors at sites where it was possible to use inter stitial therapy, with radium needles placed directly into and around a tumor, as in cancer of the oral cavity, or intra cavitary therapy with radium sources placed close to the tumor in natural body cavities, as in carcinoma of the cervix or corpus uteri. Excellent results were obtained in this manner in early oral and early gynecologic cancers. However, more advanced lesions, even at these sites, called for volumes and doses that were beyond the capability of orthovolt age therapy, and only extremely radio sensitive deep-seated tumors, such as seminomas, could be cured regularly. A major breakthrough occurred in the early 1950's when cobalt-beam therapy and supervoltage (in excess of two mil lion volts) X-ray therapy became gener ally available. These radiations made it possible to deliver high doses of therapy to any depth of the body without damag ing interposed normal tissues exces sively, to encompass relatively large tar get volumes including the tumor and, because of the decrease in scattered radi ation, to shape the high-dose volume to conform with the tumor and its exten sion, thus avoiding unnecessary irradia tion to normal tissues not involved by the tumor. The development of sophisti cated dosimetry assured precision in de livering high doses of radiation to the predetermined target volume. At the same time, a better understand ing of the biologic nature of cancer, its patterns of spread and the response of normal tissues and tumors to irradiation have led to new concepts in radiation therapy. These concepts have further demonstrated the value of definitive ra diation therapy. As it became apparent that cancer at many sites could be cured consistently, the quality of survival in the cured cancer patient assumed a major impor tance. It was no longer enough to rid the patient of his tumor. It became impor tant to consider his functional and cos metic integrity as well, so that the cured patient could resume his useful place in his family and in †̃¿ society. Where cure rates were comparable, radiation ther Dr. Kramer is Professor and Chairman. Department of Radiation Therapy and Nuclear Medicine. Thomas Jefferson University Hospital, Phila delphia, Pennsylvania.

Radiation oncology: Present status and future potential

Abstract: of “¿ a new kind of rays―in 1895 revolu tionized the world of medicine. Almost immediately, these new-found X-rays were recognized as a potentially valu able form of treatment for cancer. Progress in radiation oncology has been prodigious, from the first radiation produced cure of cancer in 1899 to the curative, palliative and combination use of radiation therapy today, from a Crookes tube to a linear accelerator. In 1976, 50 percent of those patients diag nosed with cancer in the United States will require radiation therapy. The qual ity of care is of critical importance. Modern radiation therapy is a com plex field of standardized units of meas urement, treatment plans and delivery systems, as well as highly technical equipment. It involves the application of cancer biology and techniques for defi nition of tumor extent in treatment. Since there are too few radiation oncolo gists to treat all cancer patients, the re sponsibility is often shared. This special issue of Ca—A Cancer Journal for Clinicians attempts to sur vey present-day radiation therapy for cancer, its achievements, its limitations, its goals for the future. Topics include: •¿ radiologic and radioisotope tech niques for tumor localization and def inition, by site and extent of disease; •¿ radiation as the treatment of choice for cancer; •¿ postoperative radiation therapy for cure; •¿ combination treatment strategies based on seven failure pathways; •¿ most effective chemotherapy/radio therapy regimens, by site; •¿ supportive care; •¿ palliative radiation to reduce pain, bleeding, pressure on vital structures and to restrain growth; •¿ advances in instrumentation for better dose localization; •¿ new forms of high LET radiation. In all of the articles in this issue, one concept predominates: to improve radia tion therapy and, thus, to improve the control of primary and metastatic cancer, without causing a concomitant increase in morbidity. Improvements in the early detection and definition of primary cancer and of tumor recurrence are especially impor tant. The development of computerized axial tomography and the application of heavy ion radiography may help to real ize this goal. Nuclear medicine, which plays a major role in tumor localization, might be made more effective by im proved intra-arterial injection tech niques, radioactive labelling of tumor specific antibodies, better imaging pro Dr. Brady is American Cancer Society Professor of Clinical Oncology and Professor and Chairman, Department of Radiation Therapy and Nuclear Medicine. The Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania.

Epidermoid cancer of the vulva

Abstract: Epidermoid cancer of the vulva is essen tially a cutaneous disease, modified by its site in a specialized epithelium that is subjected to rather special environ mental, hormonal, infectious and func tional factors. Vulvar cancer has a well defined natural history and an “¿ at risk― population that is beginning to be identi fied.1@2It accounts for 3.5 percent of all gynecologic cancer. In its natural course, this lesion pro gresses from dysplasia through in traepithelial neoplasia to invasive cancer as an inter-related function of time and the status of the patient's defense mech anisms. Therefore, a more advanced le sion is expected in a patient with the longest history of disease and the poorest immunologic response .@Based on historical data, dysplasia and in traepithelial cancer may be present for 10 years or longer.4 An invasive lesion

Laetrile: Focus on the facts

Abstract: Dr. Eyerly: I welcomethe opportunityto discussthis most importantand controversial issue. As you know, Laetrile, identified as the chemical amygdalin and produced from ground, defatted apricot kernels and concentrates of apricot and peach pits, is not a new discovery. For more than 20 years, the proponents of this drug have claimed that Laetrile can “¿ cure― cancer. For more than 20 years, these claims have been refuted by, to name only a few: the Cancer Commission of the California Medical Associa tion, the California Cancer Advisory Council, the American Medical Association, the National Cancer Institute, and the American Cancer Society. The Food and Drug Administration

Supportive and palliative radiation therapy

Abstract: The total care of the cancer patient un dergoing radiation therapy must include emotional support, prevention and cor rection of tissue dysfunction, augmenta tion of nutrition, metabolic and electro lyte regulation, rehabilitation and voca tional support. In addition, the physician should be concerned not only with sur vival, but also with the quality of life. Proper palliation can help the patient live comfortably and productively dur ing the last phase of his life.

New instrumentation in radiation oncology

Abstract: cancer therapy is the local and regional control of malignant neoplasms, with complete regression as the usual result of definitive radiation therapy. Despite an overall local response rate of approxi mately 95 percent, permanent control in the treated regions does not always re sult. Of 12 sites of disease in which radi ation therapy plays an important or adju vant role, failure of local control re sulted in an estimated 65,000 deaths in

Part II Cancer of the larynx: Surgery

Abstract: In the past, the selection of treatment for laryngeal cancer was not complicated. Patients with true vocal cord cancer un derwent radiation therapy or the laryn gofissure and cordectomy procedure. Patients with other “¿ intrinsic― lesions were treated by total laryngectomy; those with “¿ extrinsic― tumors were managed by total laryngectomy and rad ical neck dissection. Today, however, the introduction of more sophisticated diagnostic and therapeutic techniques has made the choice of treatment more complex. Treatment should result in maximum cure rates and preservation of maximum uninvolved laryngeal tissue, while producing minimal disability. Thus, conservative procedures are used when ever possible to avoid the severe depres sion, withdrawal and inability to com municate that may accompany more rad ical surgery. The choice of conservative therapy is further supported by the find ing that only 50 percent of totally laryn gectomized patients over 60 years of age develop a serviceable voice.1 Further more, in selected patients, cure rates were not improved when conservative

Radiology in tumor localization and definition

Abstract: Radiologic techniques for the diagnosis of cancer are thoroughly understood and well applied. Less so are imaging proce dures for the pretreatment localization and definition of disease. In recognition of this situation, the following article re views the responsibilities of the physi cian in radiologically defining the pri mary tumor, as well as nodal and extra nodal metastases. (Table 1.) Inmost instances, tumor visualization is size-limited and location-dependent. Computerized axial tomography, ultra sound, nuclear imaging and newly evolving imaging and recording systems will improve our diagnostic yield. How ever, more appropriate application of existing techniques, combined with a knowledge of the behavioral charac teristics of various tumors and their stag ing-classification schemes should greatly improve the accuracy of pretreat ment tumor definition. Too often, un necessary examinations, such as radio graphic bone surveys for early cervical cancer, are utilized while more appro priate studies, such as lymphography for advanced cervical cancer, are not con sidered. Nuclear medicine procedures will only be referred to in general terms, as they complement radiographic studies. Nuclear imaging techniques are de scribed as either indirect or direct. Indi rect tumor images, such as routine brain, bone and liver scans are more common. These tumor images result from non specific changes secondary to the neo plasm. In the liver, the negative image of the tumor is caused only by the mass itself, while in the brain and bone, images are produced by more complex alterations in the host, such as presumed alterations in the “¿ blood-brainbarrier― in brain scans. Direct nuclear imaging techniques label some aspect of the tumor, thus allowing it to be visualized. An example is the use of a metabolic agent such as 131!to define a functioning metastatic thyroid cancer. Unfortu nately, radiolabeling is non-specific for cancer and is also found in other condi tions, such as infection. Both false-posi tive and false-negative results have lim ited the application of these procedures.' Future improvements in nuclear imag ing techniques and the development of tumor-specific radiopharmaceuticals will greatly enhance the role of nuclear imaging in cancer.