Metastasis

“ The following facts should be constantly kept in mind by the surgeon to enable him to differentiate between the two forms of pyæmia: In pure cases of purulent infection, without metastasis, the disease is called pyæmia simplex, and in cases with metastasis, pyæmia multiplex. The various conditions on which the metastasis may depend are shown by Hueter, who says: "The metastatic abscesses of pyæmia multiplex met with in the lungs, liver, spleen, and other internal organs are regarded, with the greatest probability, as a result of the embolic process. ”

“ In the vertebræ, it is attended with a painful form of paraplegia, which may involve the lower or all four extremities. On the other hand, the disease may show itself clinically as a tumour of bone, which may attain a considerable size, and may be mistaken for a sarcoma, unless the existence of the primary cancer is discovered.
The cancers most liable to give rise to metastasis in bone are those of the breast, liver, uterus, prostate, colon, and rectum; hyper-nephroma of the kidney may also give rise to metastases in bone. ”

“ Not only are the subjective symptoms alleviated, but also the tumors appear to become cleaner and softer; the rate of growth is retarded; necrosis and metastasis are prevented, and inoperable tumors become operable. How are we to interpret these observations? How are we to explain the fact that they are the almost invariable accompaniment of the most diverse methods of treatment? I have already quoted the statement of Ledoux-Lebard that every therapeutic novelty appears to exercise a favorable effect on cancer cases. ”

“ H. stated that four years after operation 43 per cent remained free of the disease, eight years after only 16 per cent, and 20 years after only 2.5 remained free from the disease. There were a great many cases of carcinoma of the breast reported in which the patient died from metastasis in different organs without local recurrence 10, 15, and 20 years after the operation. The late metastases most frequently took place in the skeleton, which was due to the fact that skeletal lesions might continue a long time without causing clinical symptoms. ”

“ From our study of inoperable and recurrent cancer, and of metastasis and the blood conditions in the disease, we see what a formidable task is before one who would attempt to lessen its morbidity and mortality. We see also how blind all have been who have so long looked to surgery to stay its progress. In my former lectures I collected and quoted statements from many surgeons of prominence in times past, and even some in quite recent times, all expressive of a belief in a constitutional origin of cancer, and many of them looking to a dietary cause. ”

“ As a rule, they depend upon malignant disease of the liver or abdominal glands through metastasis or by extension of growth. They sometimes grow with almost incredible rapidity. The symptoms are very obscure, and the presence of the malignant infiltration cannot be detected unless hard nodulated masses are formed, which become perceptible through the abdominal wall, as in hepatic cancer. ”

“ All know that while primary carcinoma of the liver is very rare, its secondary or metastatic involvement is very common. The bones, lungs, spleen, kidney, and viscera generally are 130all often found to be the seat of metastases, and in general carcinosis, which has lasted some time, metastases will be found abundantly both in the lymphatics of many parts of the body and in many organs and tissues. Metastases in the lungs are not uncommon in breast cancer, as also metastasis in the bones of the thorax. ”

“ Besides the ordinary symptoms, mumps in certain instances shows a peculiar tendency to metastasis, or secondary involvement, of the testicle and scrotum in males, and the mammæ, vulva, and ovaries in females. This metastasis occurs much more frequently in males than in females, and is usually met with in pubescents and adults, being very rare either in childhood or old age. It generally begins six or eight days after the appearance of the parotid tumor. ”

“ New growths which originate in the skeleton are spoken of as _primary tumours_; those which invade the bones, either by metastasis from other parts of the body or by spread from adjacent tissues, as _secondary_. A tumour of bone may grow from the cellular elements of the periosteum, the marrow, or the epiphysial cartilage. ”

“ On the other hand, a malignant tumor in its primary growth may so implicate a vital organ as to destroy life before metastasis can occur or even before cachexia can develop. Thus, to the untrained observer, environment may so operate as to cause these two classes of new growths to simulate each other. ”

“ The frequency and rapidity of metastasis- formation varies greatly. As a general rule cancer of the breast is more liable than other forms of growth to be followed by widespread secondary deposits. On the other hand, in cases of cancer of the skin secondary infection is usually confined to the neighbouring lymphatic glands, and seldom occurs in any of the internal organs. 3. Termination of Malignant T umours.-In one or two well authenticated cases a malignant tumour has disappeared of its own accord without any treatment, and a natural cure may be said to have occurred. ”

“ I then turned to my text book on this subject and read as follows: "Seventy-five per cent of all cases terminate fatally within six months." Then in italicized words it said "Cyncisiomia Malignant is the most fatal of all known tumors, that by an early and complete removal of the uterus before metastasis has taken place, some cases, it has been reported, have been cured." ”

“ About middle life more active growth begins, the swelling becomes more fixed and is painful, and once it begins to grow, it increases rapidly and within a month or two may reach the size of a child's head. In spite of its size, however, it seldom causes interference with breathing or swallowing, and it has comparatively little effect on the general health. Clinically, the induration and fixation of the tumour suggest its epitheliomatous character, but the absence of a primary growth in the mouth or pharynx excludes its being a metastasis in the lymph glands. ”

“ His staging CT imaging demonstrated a right upper lobe lung spiculated lesion of size 5.6 mm × 3.8 mm × 5.1 mm that was suspicious for further metastases or a new primary lung pathology. There were suspicious lesions in liver on CT scan and were hyperechoic on ultrasound scan consistent with the hemangiomas of the liver, not appearing to have any typical features suggestive of metastatic deposits. ”

“ If the cells undergo degeneration and absorption and the stroma contracts, the tumour becomes still harder, and tends to shrink and to draw in the surrounding parts, leading, in the breast, to retraction of the nipple and overlying skin, and in the stomach and colon to narrowing of the lumen. When the cells of the tumour undergo colloid degeneration, a _colloid cancer_ results; if the degeneration is complete, as may occur in the breast, the malignancy is thereby greatly diminished; if only partial, as is more common in rectal cancer, the malignancy is not appreciably affected. ”

“ I explained at the time that any attempt to excise portions of tissue for such study would at once endanger the patient and imperil the success of treatment, by giving occasion to metastases, from the opening of blood vessels and lymphatics. This matter is treated of more fully in the present lectures. It is to be remembered that the vast majority of operations for cancer are undertaken upon a purely clinical diagnosis, and it may be undeniably stated that not one half of them are confirmed subsequently by competent microscopic evidence, except, of course, in properly equipped hospitals. ”

“ The situation of a malignant tumour exercises considerable influence on the rapidity, as well as on the mode, in which it causes death. Some cancers, such as that known as "rodent," show malignant features which are entirely local, while others, such as melanotic cancer, exhibit a malignancy characterised by rapid generalisation of growths throughout the body. Tumours that are structurally alike may show variations in malignancy, according to their situation and to the age of the patient, as well as to other factors which are as yet unknown. ”

“ The sarcoma ta and carcinoma ta differ somewhat as regards the path of dissemination. The former are vascular tumours, well supplied with blood-vessels; consequently dissemination usually occurs by way of the blood-stream rather than by the lymphatic circulation, and the commonest site for the secondary deposits of sarcoma is the lung. The carcinoma ta are less vascular, and the tendency of the growth is to invade the small lymph channels, so that the first signs of metastases are to be looked for in the lymphatic glands ”

“ If a far advanced primary growth of cancer could be stained in its entirety with a black dye, and if the patient were transparent, we should probably see that the tissues round about the growth were dusky, and that a thin, smoky coloring extended through the lymphatic vessels to the veins into which they empty. As a malignant tumor increases in size at its original situation the nerve filaments are pinched, and pain is caused as a rule; but sometimes the growth will progress with little or no accompanying pain. ”

“ The diagnosis is always difficult, and is seldom made until a portion of the growth has been removed and examined microscopically. The more slowly growing forms, if removed before ulceration has taken place, show little tendency to recur, but those which grow rapidly and break down, not only recur locally, but are liable to give rise to metastases. The treatment is the same as for cancer; the use of radium is more likely to be beneficial than in epithelioma.
Innocent Tumour and Cysts.—Lipoma, fibroma, and various forms of angioma (Fig. 258) are occasionally met with. ”

“ The only chance of a radical cure consists, he says, in making a complete excision of the part; but in doing this he forbids us to secure the arteries with ligatures, as they will occasion a recurrence of the disease. The part, he says, is loaded with a thick, black, or recrementitious blood. When the cancer is ulcerated, he disapproves of cutting and burning.
Celsus describes carcinoma as an immovable and unequal tumour, attended with swelling of the veins, which are pale or livid. ”

“ Tumors originate from many causes. Some are congenital and others grow in later life from an inherited tendency.
Any continued irritation which acts mechanically or chemically so as to maintain a constant, though slight, degree of undue vascularity of a part, such as the hot, rough stem of a clay pipe or a jagged tooth, favors the development of a malignant growth. Certain benign growths, such as warts or moles, are especially prone to malignant change. Age and sex also predispose to tumor formation.
Thus carcinoma is a rarity under thirty years of age ”

“ It so happens, however, that in a histological as well as in a clinical sense the term is appropriately applied to all but a very few of the malignant new growths that develop in the parts under consideration, if we adopt, as seems proper, the opinion of most modern pathologists, that cancer or carcinoma should only include those tumors "consisting of cells of an epithelial type, without any intercellular substance, grouped together irregularly without the alveoli of a more or less dense fibroid stroma." ”

“ The tumour consists of a dense framework of fibrous tissue, with groups of cancer-cells in the spaces. The malignancy of the disease depends upon the cells, not upon the fibrous tissue. In young subjects the cells predominate, but in old ones the contraction of the fibrous tissue throughout the breast compresses and destroys the cells, and this sometimes to such an extent that there is at last nothing left at the site but contracted fibrous tissue, all trace of malignancy having disappeared. This variety of the disease is found in old people, and is called atrophic cancer. ”

“ In attempting to arrive at a conclusion as to the innocence or malignancy of any tumour, too much reliance must not be placed on its histological features; its situation, rate of growth, and other clinical features must also be taken into consideration. It cannot be too emphatically stated that there is no hard-and-fast line between innocent and malignant growths; there is an indefinite transition from one to the other. The possibility of the transformation of a benign into a malignant tumour must be admitted. ”

“ The formation of the corpuscular elements of the blood must be greatly interfered with when metastases occur in the blood making organs, the lymphatic tissue, bone, marrow, and spleen, which probably occur 78more frequently than is generally recognized. It seems that the toxic secretion from a cancerous mass has a distinct action upon the blood, for after complete removal there is often observed an increase of hæmoglobin, as I have witnessed, and a high leucocytosis has disappeared after the removal of schirrus of the breast, only to return again with the recurrence of the tumor. ”

“ Secondary cancer is a comparatively common disease, and, as in metastases in other tissues, the secondary growths resemble the parent tumour. The soft forms grow rapidly, and eat away the bone, without altering its shape or form. In slowly growing forms there may be considerable formation of imperfectly formed bone, often deficient in lime salts; this condition may be widely diffused throughout the skeleton, and, as it is associated with softening and bending of the bones, it is known as _cancerous osteomalacia_. ”