Cancer Stages

[cancer among veterans, early diagnosis] [presented by the administrator of veterans'affairs.] [produced by division of motion pictures,department of the interior.] [under the direction of veterans administrationexhibits committee. photomicrography by l. h. prince, m. d., hines, illinois. photographyby walter k. scott.] [narrative by... max cutler, m. d., consultant,tumor clinic, veterans administration facility, hines, illinois.] [narrator:] under the direction of the administratorof veterans' affairs, the veterans administration is making every effort towards furnishingex-servicemen with the benefits of early diagnosis

and the prompt and skillful treatment of cancer. this parent hospital at hines, illinois providesmore than 400 beds for tumor cases and serves as a training ground for physicians selectedto specialize in the diagnosis and treatment of this disease. leaving the beautiful and spacious grounds,we enter the hospital where the tumor board is in session and hear the voice of dr. maxcutler, consultant in tumors at the hines facility, who will present his subject, theearly diagnosis of cancer. dr. cutler. [dr. max cutler:] early diagnosis is the keystoneto cancer control. an accurate diagnosis is the basis of correct and effective treatment.

all the progress that has been realized inthe surgical and radiation treatment of cancer is of no avail unless the lesion is recognizedearly and treated correctly before it has become disseminated. [dr. max cutler:] thus early diagnosis resultingin the elimination of precancerous conditions and in the cure of early cancer is by farthe most important single factor in the curability the external cancers can be detected in theirvery early stages and are both presentable and curable. the internal cancers unfortunatelypresent a much more complex problem. and although much can be accomplished by carefulattention to early diagnosis, real progress in this group awaits the discovery of a diagnostictest much more delicate then is now available.

we will now consider three forms of cancerwhich pass through definite precancerous stages and are, therefore, not only curable but preventable. cancer of the mouth, preceded by leukoplakia;cancer of the skin preceded by hyperkeratosis; and melanoma preceded by apparently innocentmoles. we begin with leukoplakia, one of our mostimportant precancerous conditions. this lesion is ten times as common in men as in women.hence, 90 percent of cancers of the mouth occur in men. the well known relation between tobacco andleukoplakia has given rise to the term, "smoker's patch."

here you see a leukoplakia of the mucous membraneof the cheek in which smoking is the etiological factor. an underlying susceptibility of thetissues to nicotine must be present for leukoplakia to develop. in susceptible individuals, it is probablethat infinitesimal amounts of the stimulating chemical agent can result in this condition. the relationship between leukoplakia and canceris well-illustrated in this case, where you see an intense radiation reaction after treatmentof a cancer of the right cheek, which developed in a patch of leukoplakia. leukoplakia often occurs at the site of artificialdentures as in this case. here we see a diffuse

leukoplakia of the roof of the mouth in apatient whose mucous membrane is evidently susceptible to chronic irritation and to nicotine. a combination of factors is usually responsiblefor this type of lesion. when a patch of leukoplakia begins to undergo malignant degeneration,it exhibits certain clinical signs. it becomes thickened and somewhat induratedand its surface becomes fissured and eroded. in this stage the lesion is either precancerousor already fully malignant. true ulceration almost invariably means thatcarcinoma has become established. when these clinical signs appear, a biopsy is usuallynecessary to establish the diagnosis of cancer. in this connection it should be emphasizedthat a negative biopsy by no means excludes

the presence of cancer and one must be guidedlargely by the clinical picture. dental caries is etiologically related tocancer of the oral mucous membrane. a sharp or broken tooth can produce repeated traumato the adjacent mucous membrane and results in a traumatic ulcer and finally in carcinoma. this is a remarkable example of this type.note the precise relationship between this jagged tooth and the lesion in the mucousmembrane of the cheek. removal of the source of irritation results in prompt disappearanceof the ulcer when it is only inflammatory. leukoplakia of the oral mucous membrane frequentlyarises at the site of dissimilar metal fillings in patients who are non-smokers and in theabsence of both non-specific inflammation

and syphilis. the development of the leukoplakia at theexact site of the dissimilar filling as in this case and the absence of other etiologicfactors constitute significant evidence of this probable relationship. the lateral border of the tongue being inclose proximity to carious and infected teeth is a common site of leukoplakia. the dorsumis affected more commonly when the lesion is diffuse. often it is on a syphilitic basis. extensive diffuse leukoplakia is usually associatedwith syphilis. the cancers of the lip and tongue are quite independent. each arose ina separate patch of leukoplakia. such lesions

may arise simultaneously or they may be separatedby months or years. the prognosis of cancer of the mouth associatedwith syphilitic leukoplakia is extremely grave. the modification in the connective tissueand blood vessels resulting from the syphilitic infection has a most unfavorable influenceupon the surgical and radiation result and a cure is almost never accomplished in spiteof the efficiency and thoroughness of the treatment. in spite of the early signs they produce,cancers of the oral cavity still reach an advanced stage in many patients. the lasttwo cases are examples of this fact. cancer of the lower lip is overwhelminglya disease of men. the lesion begins as a small

localized nodularity which has to be differentiatedfrom a benign hyperkeratosis. lesions of this extent are readily curableby surgery or by irradiation. in later stages the disease spreads to the adjacent skin andoral mucosa. and the lesion becomes indurated, ulcerated and painful as in this example. lesions of this extent are usually accompaniedby cervical adenopathy and when the growth approaches or crosses the midline, one mustassume that the adenopathy is bilateral, even though this is not demonstrable clinically. a projecting tooth, especially when it issharp, sometimes traumatizes the lip causing first an ulcer than a carcinoma. this is aclinical example. note the precise anatomical

relation between the tooth and the carcinoma. [ showing lesion on lip ] cancer can begin in the mucous membrane ofthe upper or lower lip or cheek as a small, firm, circumscribed and movable tumor, whichgrows slowly and remains non-ulcerated for a long time. these lesions originate in the epitheliumof ducts of mucous glands. because they are non-ulcerated and freely movable they resemblesimple benign mucous cysts and are invariably so diagnosed. they are usually removed inadequately andrecur promptly. they are often highly malignant

and unless this peculiar type of carcinomais diagnosed properly and treated correctly the first time, the results are disastrous. the differential diagnosis of cancer of the mouthmust consider benign papillomatous lesions, primary and tertiary syphilis, papilloma durumof the tongue, tuberculosis and mixed tumors of salivary glands. here we have two cases of tuberculosis ofthe mouth. tuberculosis of the tongue is rare. when it occurs, it is usually associated withan active pulmonary lesion. tuberculous ulcerations appears as a flat non-indurated lesion whichis painful and tender. the ulcer lacks the surrounding infiltrationand induration which is so characteristic

of carcinoma. when the nature of the lesionis in doubt clinically a biopsy should be performed to establish the diagnosis withcertainty. the aberrant salivary glands give rise toan interesting and peculiar group of tumors. in the mouth these tumors arise within thecheek, the lip, the base of the tongue and the soft palate. salivary glands and tumorsof the soft palate may reach a large size as seen in this case. the small tumors are generally cured by widesurgical removal. inadequate excision is followed by prompt recurrence. when these tumors reacha large size and recur in older individuals, the patient's comfort and life expectancyare often benefited by a conservative course.

the chief points in the differential diagnosisare their location, their slow growth, and the fact that they remain circumscribed forlong periods. unlike the carcinomas, they remain non-ulcerated for many years in spiteof their large size. there are three main types of skin cancer.this is the basal cell form and it's commonly referred to as "rodent ulcer." the next isthe squamous cell type with [inaudible] and pearl formation. and the third is the adenoid cystic type,which is usually classified as a sub-variety of basal cell cancer. the majority of cancersof the skin appear on the face. adenoid cystic carcinoma of the skin is aform of basal cell cancer. this type is often

multiple and commonly affects the eyelids,forehead and nose. the lesions are first elevated, then ulcerated.as a rule they are more radio-resistant than the typical basal cell carcinomas. the nose is a common site of cancer of theskin. the majority of the basal cell type, regional metastasis generally does not occuruntil the lesion has involved the mucous membrane. a great effort should be made to cure theseskin lesions at the first attempt, for each recurrence presents greater difficulty. thefirst therapeutic procedure, be it surgery or irradiation, generally seals the patient'sfate. the crucial importance of eradicating thedisease the first time can hardly be exaggerated.

advanced lesions such as these can be avoidedonly by early diagnosis and thorough treatment when the patient first comes under observation. here is a basal cell carcinoma of the lowereyelid. the lesion is early and easily curable. a surface application of radium administeredunder correct conditions results in almost certain cure. but those must be the maximumwhich the normal tissues will tolerate. here is a basal cell carcinoma of the nose,which has been treated and is beginning to undergo repair. note that the edges of thelesion have disappeared. seventy-five percent of cancers of the eyelidare of the basal cell type. regional lymph node metastasis occurs in 20 percent. theinner [inaudible] of the lower eyelid is the

most common site. in this case a carcinoma of the left lowereyelid has disappeared after irradiation. but the sterilization was incomplete and severalyears later an extension of the disease developed. adequate irradiation as a rule avoids thiscomplication. here we see one of the great tragedies ofthis disease. how long did this patient wait before consulting his physician? did the physician choose the best method oftreatment? how accurately and skillfully was the treatment executed? these are the searching questions we as physiciansmust constantly keep before us. carcinomas

of the scalp grow very slowly and almost neverinvade the regional lymph nodes. they tend to adhere to the underlying boneand are usually first seen in their late stages. curable in the beginning, these lesions ultimatelydestroy the bone and involve the meninges and the brain. note the pulsation of the brain in this tragiccase. and now we come to the story of what can happento an apparently innocent mole. there are few tragedies in the whole realm of medicinethat equal the complications which sometimes develop in connection with these apparentlyinnocent lesions. since the average individual harbors about20 moles, the malignant transformation of

a mole is comparatively rare. traumatism playsan important role in transforming the course of a benign nevus. moles, which are so located as to be subjectedto repeated trauma and moles showing clinical signs of activity should be treated by carefuland complete surgical removal. you have just seen a fleshy, pedunculatedmole, a type which is removed without danger. the hairy non-segmented mole belongs to thesame category. pigmented macules are common and my be singleor multiple. they may be present at birth or develop later in life. the danger of melanomais slight. they should be removed only on the indications mentioned.

it is the flat bluish black or brownish blackmole that is the most dangerous of all. and here we see a remarkable example of malignanttransformation of a bluish black mole. metastases to the regional lymph nodes arealready present. microscopic examination of a melanoma may disclose all of the cellularfeatures without showing the presence of pigments or the characteristic brown intracellularpigment may form a striking feature of the microscopic picture as you see in this photomicrogram. extensive metastasis to the axillary lymphnodes has occurred in this case following excision of a pigmented mole on the left forearm. sometimes invasion remains limited to oneor two regional lymph nodes for a long time.

and it is in this group that radical dissectionhas resulted in apparent cure in isolated cases. the scar on the left forearm indicates thesite of excision of the primary melanoma. melanoma may affect the scalp and metastasizeto regional lymph nodes as in this case. metastasis to axillary and supraclavicularglands also occurred in this case following traumatic treatment of a mole on the leftarm. electrodessication is uncertain and probably dangerous. careful and complete surgical excision offersthe safest course. the presence of small secondary nodules around a melanotic tumor is an importantsign of its malignant nature.

the heel is a favorite site for melanomas.this lesion was already accompanied by pulmonary metastasis when first examined. in discussing early diagnosis it is necessaryto review the steps to which a lesion passes before it becomes malignant. in other words,we must attempt to form a mental picture of the nature of the cancer process. we are now fairly certain that cancer is nota sudden event or an accident in a previously normal tissue, but on the contrary it is theresult of a series of changes, which may have begun many years before. a combination of factors seems necessary forthe initiation of abnormal growth. hereditary

susceptibility unquestionably plays a part,an excess or deficiency of certain hormones and probably the presence of certain chemicalswe call carcinogenic agents combined to initiate excessive growth of cells. we have learned the remarkable fact that abnormalcell growth need not necessarily result in clinical cancer. at one extreme the growthmay be so rapid as to overwhelm the individual in a short period of a few months. and at the other extreme the growth may beso slow that the patient does not live long enough to develop clinical cancer and he diesof other causes, harboring one or more precancerous lesions.

thus certain precancerous lesions require10 years, others 20 years, still others 30 years to reach the stage of clinical cancer.and it is well known that the older we get the more chances we have of developing thisdisease. there is also considerable evidence to indicatethat precancerous lesions can regress and perish in the body as a result of some defensivemechanism, the nature of which we do not yet understand. and it is probable that even fully establishedcancers can under certain conditions cease to grow, regress, and even disappear. when we use the term precancerous we generallythink of it in microscopic terms. we mean

a lesion which exhibits all the morphologicalfeatures of cancer, but which has not yet escaped outside normal boundaries. we must remember, however, that the morphologicalappearance of a cell is a very crude index of its biological state and even a less accurateguide as to its future intentions. thus the group of neoplastic epithelial cellsconfined within the normal boundaries of the duct of the breast may be ready to invadethe lymphatics and blood vessels immediately, or they may remain stationary for many yearsor they may regress and disappear. and yet, the microscope, as a rule, can neitherdistinguish these cells nor predict their future. thus it is evident that cancer isa highly complex clinical, pathological and

biological problem. through the medical and hospital service theveteran's administration has developed over the past 10 years an organization for thestudy and treatment of cancer that is unique in the world. in addition to the hines tumor clinic, thereare five subsidiary units in the five geographical areas into which the country is divided, eachrepresenting a unit organized, equipped, and manned to offer to the veterans sufferingwith cancer the latest knowledge in diagnosis and treatment of this disease. an elaborate system of records is maintainedand a register of tumor cases has been established,

which permits a study of resultant treatment. in addition to highly trained full-time personnel,all six units have consulting staff composed of some of the leading experts in their fieldwhose help and advice are available when special problems arise. the hines facility is not only a hospitalbut is a practical governmentally controlled training school as well. for doctors, it presentsa broad opportunity to study diseases, inviting new methods of eliminating suffering. for patients, the library facilities and themany phases of properly supervised occupational therapy such as wood carving, weaving, metalwork, recreation, etc. offer a greater incentive

to develop new channels of thinking. today this great facility at hines is consideredthe largest government hospital of the veteran's administration, a monument which should continuallyinspire us to strive to conquer this dread disease. it is with such institutions as this thatthe helping hand of the united states government, extended through the veteran's administration,practically demonstrates its appreciation of the spirit and loyalty of its veterans.