Biomedical subjects
Publications and source records attributed to B Castleman.
The author reports on an informative and confrontational discussion at the Indian Association of Occupational Health conference in New Delhi in February 2001. The president of the association, Dr. T. K. Joshi, took a strong and principled stand against the asbestos industry and many of his colleagues in maintaining his position that the use of asbestos should be banned in India.
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A series of 104 consecutive patients treated at the Massachusetts General Hospital between 1933 and 1978 for primary hyperplasia was reviewed. Early in this period (1933-1958) nine patients were treated by what was the considered subtotal resection (five with clear cell and four with chief cell hyperplasia). Hypercalcemia persisted in four cases; three from inadequate resection and one (case 170) associated with a fifth gland in the mediastinum that was removed at a second stage operation. Later (1959-1978), adequate subtotal resection, leaving 30 to 50 mg of viable hyperplastic tissue, was performed in 28 patients (7 with clear cell and 21 with chief cell hyperplasia). The operation was successful in 27 patients (96%). In one patient (case 442) subtotal resection failed, and hypercalcemia recurred, requiring a second operation. Sixty-seven patients in this series had excision of one, two, or three (but not more than three) glands. Of these 21 (31%) had persistent hypercalcemia after operation and required further surgery. Transient hypocalcemia occurred in 40 patients, permanent hypocalcemia in two. This study shows that subtotal resection, leaving 30 to 50 mg of viable tissue, is the surgical treatment of choice for primary parathyroid hyperplasia. It is effective in the great majority of patients. We have not found total parathyroidectomy with autotransplantation necessary and believe that it should be reserved only for selected cases.
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An analysis is presented of the treatment of 103 patients with thymoma, 56 with myasthenia gravis and 47 without. In a 1966 report on the first 63 patients, it was stated that the presence of myasthenia and the finding of local tumor invasion at operation were ominous prognostic indicators. The augmented series suggests that myasthenia no longer carries this stigma, possibly because of improved methods in its management in patients who have undergone operation.
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Parathyroid hyperplasia of all four glands was found to be the cause of primary hyperparathyroidism in 85 of 557 cases seen at the Massachusetts General Hospital between 1930 and 1973. There were 66 cases of chief cell hyperplasia and 19 cases of clear cell hyperplasia that were grossly, microscopically, and ultrastructurally distinct. Although the clinical findings overlap, there are several differences in the signs and symptoms between these two forms of hyperplasia. Both types are treated by subtotal removal of all the parathyroid tissue. Removal of insufficient tissue has left residual hyperparathyroidism in 45% of those with chief cell hyperplasia and 11% of those with clear cell hyperplasia after what was thought to be definitive surgery. Postoperative hypoparathyroidism was found in 15% of the patients with chief cell hyperplasia and in none with clear cell hyperplasia. These findings further suggest that removal of three and one-half glands in the more than 86% of patients with one gland involvement (adenoma or carcinoma) as the cause of primary hyperparathyroidism is unwarranted.
An unusual case of primary hyperparathyroidism involving six parathyroid glands is reported. Despite markedly elevated parathormone levels, neoplastic features were not found. This patient also had ovarian dysgenesis and hypertrophy and clear cell appearance of the salivary glands.
A comprehensive program of therapy has evolved with collaborating roles for surgery, pathology, radiotherapy, and chemotherapy. Our experience includes 131 patients with breast cancer treated at the Massachusetts General Hospital since 1956 by limited excision of the cancer. The tumors of 10 patients were noninvasive or sluggishly so; the patients received no further therapy. Because of the invasive character of their tumor, 121 patients received heavy postoperative irradiation. In 12 of these 121, the irradiation has been followed by immediate and prolonged chemotherapy. It is too soon to judge the effect of the chemotherapy, but survival rates of those treated by limited excision and primary irradiation compare favorably with those of patients treated by radical mastectomy.
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This study was undertaken to determine the amount and histologic appearance of the persistent thymic tissue removed post mortem from 20 patients over 60 years of age with myasthenia gravis. One patient died several days after thymectomy. No recognizable thymic tissue on gross examination was seen in any patient. On microscopic examination, 11 patients had no thymic tissue. The other nine patients, including the one with thymectomy, all showed marked involution of the thymus. No germinal centers were seen. The thymus glands of two additional patients, still alive after thymectomy at ages 62 and 70, showed similar findings. Marked involution of the thymus also was found in each of six elderly controls. Thymectomy is not likely to be effective treatment of the elderly myasthenic patient.
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