THE AMERICAN JOURNAL OF CANCER A Continuation of The Journal of Cancer Research

VOLUMEXXXVI JUNE, 1939 NUMBER2 -______

CARCINOMA CUTIS

ERIK POPPE From the General Department of the Norwegian Radium Hospital, Oslo (Chief: Rolf Bull Engelstnd, M.D.) and thc Hospital's Laboratory for Pathology (Chief: Professor Leiv Kreyberg, M.D.)

Histologically three types of skin carcinoma are recognized : the squamous- cell, the basal-cell, and the intermediate. A brief review of these well known forms will suffice. ( 1) The squamous-cell carcinoma is distinguished histologically by dif- ferentiation of the tumor cells, sometimes to a considerable degree, with well marked intercellular bridges and horny pearl formation (Fig. 1). The more malignant forms are less highly differentiated, with nuclei of various sizes, hyperchromasia, and many mitoses. (2) The basal-cell carcinoma is reminiscent of the basal-cell layer in the epidermis or, even more, of the epithelium of young hair sheaths. The nucleus of the tumor cell is spindle-shaped and the cytoplasm is sparse. The appearance of the basal-cell carcinoma varies somewhat. The form most frequently seen consists of solid cords of atypical epithelium outlined by a highly differentiated columnar-cell layer with deeply staining spindle- shaped nuclei (Fig. 2). The tumor cells of the deeper layers are less dif- ferentiated and their nuclei are paler. Some tumors show an adamantinoid type of growth, the cell strands being lined by similar columnar epithelium (Fig. 3). In others there is an alveolar arrangement of the tumor paren- chyma (Fig. 4) suggesting glandular structures. In some of this group a substance resembling mucus is present in the loose connective tissue between the epithelial cords. Such cases are often designated cylindroma (Fig. 5). Less differentiated forms (Fig. 6) also occur, in which the basal-cell layer is indistinguishable, the nuclei are of equal size, ovoid, with few or no mitoses, and the connective tissue is often fibrous. As a general rule this form is not characterized by any great degree of malignancy. Occasionally a basal-cell carcinoma is seen containing pigment cells (Fig. 7), but this is unusual. (3) The intermediate forms comprise the so-called type mixte and type interme'diaire. As these designations indicate, the histologic picture is partly intermediate between the squamous-cell and basal-cell forms mentioned and partly a mixture of the two. 179 180 ERIK POPPE

FIG. 1. SQUAMOUS-CELLCARCINOMA. X 35

The present paper is based upon all cases of cutaneous carcinoma (exclu- sive of carcinomas of the lip, anus, and vulva) which have been treated at the Norwegian Radium Hospital from its opening in May 1932 up to May 1935. The period of observation for the total material is at least three years from the time of treatment. The entire series consists of 198 cases. In 172 of these the tumors have been examined histologically in the hospital’s laboratory and all the sections have been reviewed by the chief of the laboratory, Professor Kreyberg, with a view to obtaining the most uniform classification possible. In 17 cases no histologic study was made; the remainder were examined at other laboratories, from which sections were unobtainable. Of the 172 tumors histologically examined and verified, 49 or 28.5 per cent were squamous-cell carcinomas, 108 or 62.8 per cent were basal-cell carcinomas, and 15 or 8.7 per cent were of intermediate type. Squamous-cell Carcinoma: Of the 49 patients constituting this group, 2 1 were women, of an average age of sixty-nine years; 28 were men, of an aver- age age of sixty-seven years. Thirty-eight of the tumors were located on the head, 34 of these being on the face; 11 were on the trunk and the extremities. The following lesions were mentioned in the case records as preceding the de- velopment of cancer : senile hyperkeratoses, scars from burns, frost-bite, chronic fistulas, and chronic leg ulcers. In several instances of tumor of the scalp the patient had for many years had a ‘( fatty tumor ” (atheroma?) at the same site. Fig. 8 shows the distribution of the individual tumors according to size. From this figure it is clear that a great number of the patients came for FIGS.2 AND 3. BASAL-CELLCARCINOMA

Fig. 2 (above) X 50. Fig. 3 (below) X 220. See text.

181 182 ERIK POPPE

FIG.4. BASAL-CELLCARCINOMA WITH ALVEOLARARRANGEMENT OF PAREE~CHYMA.X 80

treatment at a late stage. Tn 16 cases the tumor area exceeded 10 sq. cm. Most of these tumors were very large; in 12 there was infiltration of the deeper tissues and in 8 the regional lymph nodes were enlarged. The results of treatment, arranged according to the size of the tumor, are also shown in Fig. 8. These indicate the great bearing of tumor extension on the outcome. All of the 10 tumors measuring less than 1 sq. cm. disappeared, whereas of the 16 which exceeded 10 sq. cm. only 6 disappeared. Of the 49 patients with squamous-cell tumors, 11 had metastases. Of this group, 7 died after a period of one to fourteen months while 4 are still alive and free from recurrence. These 4 cases may be briefly described. CASEIX: A man, seventy years old, had a tumor 3 X 3 cm. in front of the right ear and a hard node about 3.5 X 2.5 cm. in the right supraclavicular fossa. Biopsy of the primary lesion showed slightly differentiated squamous-cell carcinoma with numerous mitoses. Following teleradium therapy the patient has been free of recurrence four years. CASEX: A man, sixty-three years old, had had a primary carcinoma of the right cheek radically removed a year prior to admission. Back of the angle of the jaw, on the right side, was a hard node some 4 to 5 cm. in diameter. Biopsy showed this to be a squamous- cell carcinoma. Roentgen irradiation and teleradium therapy were given and there was no recurrence three and a quarter years later. CASEVII: A man of forty-eight had a tumor in the right infraclavicular fossa, measur- ing 2 x 2 cm., and a hard node about a centimeter in diameter in the right axilla. A biopsy of the primary tumor showed a rapidly growing squamous-cell carcinoma ; the metastatic growth was of the same type. A radical axillary node operation was done and the patient was well four and one half years later. CASEXXXVI: A woman of fifty-six had had a tumor in the skin of the scalp radically removed a month before admission, This proved to be a slightly differentiated squamous- cell carcinoma. A node about 2.5 X 1.0 cm., beneath the left mastoid process, showed the same histologic picture. This was extirpated and given teleradium therapy. Five years later there was no recurrence. FIGS.5 AKD 6. BASAL-CELLCARCIKOMA Fig. 5 (above) is of the type known as cylindroma. X 200. Fig. 6 (below) is a less differ- entiated form in which the basal-cell layer is indistinguishable.

183 184 ERIK POPPE

FIG.7. BASAL-CELL CARCINOMA CONTAINING PIGMENT CELLS

The results of treatment in the 49 cases are as follows:

Squamous-cell Carcinoma: Results of Treatment of 49 Patients Free from recurrence for more than three years ...... 27 Symptom-free: death from intercurrent disease within three years ...... 7 Symptom-free; relapse; further treatment; again symptom-free for Less than one year ...... 1 One year ...... 0 Two years ...... 1 Improved: death from intercurrent disease ...... 3 Death from cancer of the skin ...... I0 The patients who died of skin carcinoma will be referred to in greater detail later, as it is of interest to consider the reasons for failure of the treat- ment in these cases. Basal-cell Carcinoma: Of the 108 patients with basal-cell carcinoma, 50 were females and 58 males. The average age of the women was sixty-two years, that of the men 65.5. One hundred of these tumors were on the face; there were 4 on the scalp and 4 on the trunk or extremities. Twenty-one patients gave a history of a wart or a birthmark at the tumor site ‘(for a very long time ” or “ always.” In 7 cases the patient mentioned chronic irritation caused by spectacles or a pince-nez. A great number showed senile skin changes. Both in the present material and in that seen more recently we have ob- served that tumors which are situated in the trunk may show a clinical picture differing from that of the ordinary basal-cell carcinoma. The tumors form large or small, pink or brownish-red spots with a scaly surface and with only very superficial infiltration, or even none at all. In our more recent material CARCINOMA CUTIS 185 we have also seen multiple tumors on the trunk, resembling a restricted chronic eczema or psoriasis (Jadassohn) . Fig. 9 shows the distribution of the individual basal-cell tumors according to size, with the results of treatment in the different groups. From the dia- gram it is seen that the small tumors, less than l sq. cm., rarely infiltrate the deeper tissues and that all these tumors have been cured. Of the tumors

Size of tumor Size of tumor Size of tumor :1 sq. cm. or less 1-10 sq. cm. larger than 10 sq. cm.

FIG. 8. SQUAMOUS-CELLCARCINOMAS GROUPED ACCORDING TO SIZE,WITH AN INDICATIONOF THE TREATMENTRESULTS IN THE INDIVIDUALGROUPS Column I: Total number in the group. Column 11: Number of tumors in the group which infiltrated the under layer. Column 111: Number of tumors in the group with metastases. Column IV: Number cured.

exceeding 10 sq. cm., more than half infiltrate the deeper tissue and the results of treatment are correspondingly poorer.

Basal-cell Carcinoma: Results of Treatment in 108 Patients Free from recurrence for more than three years ...... 79 (73.2%) Symptom-free: death from intercurrent disease within three years ...... 10 Symptom-free: relapse; further treatment; again symptom-free for Less than one year ...... 1 One year ...... 2 Two years ...... 2 Improved; alive with cancer ...... 1 Improved; died of intercurrent disease ...... 3 Died of carcinoma of the skin ...... 10 Calculated three-year cures ...... Sl.S%

The percentage of " calculated three-year cures " is arrived at by adding together (1) the number of patients alive and free from recurrence after the lapse of three years, and (2) the number of patients free of symptoms but dying of intercurrent diseases before the end of three years, minus the number of relapses which would probably have occurred a,mong these patients had they lived (calculated on the basis of the total number of relapses). Intermediate Type. Since there were only 15 tumors in this group it is not possible to draw any definite conclusions concerning them. Twelve of the tumors were located on the face, the other 5 on the trunk. In only 2 186 ERIK POPPE

cases did the tumor infiltrate the underlying tissue. No metastases were established. Intermediate Type: Results of Treatment iu 15 Patients Free from recurrence for more than three years ...... 13 Symptom-free; death from intercurrent disease within three years ...... 1 Improved; death from intercurernt disease ...... 1 Death from carcinoma of the skin ...... 0

Size of tumor Size of tumor Size of tumor 1 sq. cm. 1-10 sq. crn. larger than or less 10 sq. cm.

FIG.9. BASAL-CET.T,CARCINOMAS GROUPEDACCORDING TO SIZE, WITH AN INDICATION OF THE TREATMENTRESULTS IN THE INDIVIDUAL GROUPS Column I: Total number in the group. Column 11: Number of tumors in the group which infiltrated the under layer. Column 111: Number cured.

The Total Material: Of the entire group of 198 tumors including those in which no biopsy was done, as well as those which, for one reason or another, received incomplete treatment or none at all, the results were as follows: Results of Treatmertt: 198 Cases Free from recurrence for more than three years from time of treatment . . ,139 (70.2%) Symptom-free: death from intercurrent disease within three years ...... 23 Symptom-free ; relapse; further treatment; again symptom-free for Less than one year ...... 2 One year ...... 3 Two years ...... 4 Improved; alive with cancer ...... 1 Improved; died of intercurrent disease ...... 6 Died of carcinoma of the skin ...... 20 (10.10%) Calculated three-year cures ...... 80.8% One hundred and four of these patients were men and 94 were women; the average age of the men was 65.6 years, of the women 65.7, that is to say, practically the same for both sexes. The mortality of 10.10 per cent may seem to be unduly high. The figure, however, is explained by the numerous advanced cases which were admitted to the hospital during the years immediately succeeding its opening, more than one-half of which had been treated for years unsuccessfully. The fatal cases were briefly as follows: CARCINOMA CUTIS 187

CASE I: A man, fifty-five years old, had a cauliflower-shaped tumor close to the root of the penis, measuring 10 X 10 cm. It had been present without treatment for two years. There were metastatic nodes in the groin some 3 cm. in diameter. Biopsy showed squa- mous-cell carcinoma. Roentgen therapy was followed by application of a radium moulage to the primary lesion, after which a radical operation was done. The patient died of cancer nine months later. CASE 11: A man of fifty-five was admitted to the hospital with a tumor of the scalp measuring 12 X 6 cm., with some bone destruction and enlargement of the regional lymph nodes. An operation had been done elsewhere a month previously. Biopsy showed squamous-cell carcinoma and roentgen and teleradium therapy were given. The patient died six months later with metastases in the lungs (diagnosed roentgenographically). CASE 111: A sixty-three-year-old man gave a history of ulcers of the leg for many years. The Wassermann reaction was positive and he had received antisyphilitic therapy. On the lower leg was a cauliflower-shaped tumor measuring 7 X 8 cm. which proved on biopsy to be a squamous-cell carcinoma. There was no evidence of metastasis. Teleradium therapy was given and amputation was advised but refused. Death occurred after six months. CASE V: A man of seventy-two, admitted in a stuporous condition, had an ulcerated tumor some 9 X 5 cm. in the right axillary region, with an abundant foul-smelling secretion. It had been incised previously. Biopsy showed squamous-cell carcinoma. There were no metastases. The patient died three days after admission without treatment. CASEXXIX: A woman of seventy-four had a tumor involving the nose and adjacent cheek, adherent to the underlying tissues. It had been present a year but had not been treated. Biopsy showed squamous-cell carcinoma. There were no metastases. Tele- radium therapy was given without evident effect. The course was steadily down hill and death occurred seven months after admission. CASE XXX: A woman of fifty-two was admitted with a recurrence in the scalp fol- lowing radical removal of a tumor two years before. The recurrent tumor occurred in the operative scar and invaded the underlying bone. There were no metastases. Biopsy showed squamous-cell carcinoma. Teleradium therapy, electrocoagulation, and application of a radium moulage were followed by further recurrence and death in six months. CASE XXXlI: A woman fifty-five years old had a tumor 20 X 35 cm. on the right thigh and hip in an old burn scar. The burn dated back to the age of two years; the tumor had been present a year and had received no treatment. The regional nodes were enlarged. Biopsy showed squamous-cell carcinoma, and following roentgen irradiation a radical opera- tion was attempted. Postoperative embolism developed with gangrene of the extremity, and death ensued a month later. CASEXXXIII: A woman of seventy-five had a polypoid tumor in front of the ear, recurrent after radical operative removal two years earlier. It infiltrated the parotid gland and the cartilage of the ear and the regional lymph nodes were enlarged. Biopsy showed squamous-cell carcinoma. Teleradium therapy produced little or no improvement and the patient died after seven months. CASE CXXIII: A woman of seventy-eight had a tumor 5 X 6 cm. at the supraorbital margin with infiltration of the bone. It had been present twelve years and had been treated elsewhere by radium and surgery. It proved on biopsy to be a basal-cell carcinoma and was without metastases. A radium moulage was applied, followed by electrocoagula- tion, but the wound did not heal. The patient died after three years, with severe hemorrhages. CASE CXXV: A woman of forty-six years had several ulcers around the root 6f the nose and the inner canthus of either eye, with infiltration of the periosteum. The lesions dated back sixteen years and had been treated by roentgen rays. There was no evidence of metastasis. A radium moulage was applied, but the patient, who was of a low grade of intelligence, refused to continue with the treatment. The dura was eventually invaded and death occurred after six years. CASE CXXVI: A seventy-year-old woman had a tumor measuring 2 X 2 cm. in the inner canthus of one eye, infiltrating both lids. It had been present nine years and had been treated by radium on several occasions. There were no metastases. Biopsy showed 188 ERIK POPPE basal-cell carcinoma. In spite of teleradium therapy the tumor continued to grow, eventually destroying the eye. Death occurred after four years. CASELXV: A man of sixty had a large tumor which infiltrated the entire right cheek and upper lip and had destroyed the cartilages of the nose. It had been present twenty years and had been treated by surgery and roentgen irradiation. Biopsy showed basal-cell carcinoma, There were no metastases. Radium was applied by moulage on 3 different occasions, with improvement each time. The patient was free from symptoms for two periods of six months each but after two years died of cancer of the face. CASE LXVI: A sixty-five-year-old man had a tumor involving the entire left side of the face, with great destruction of bone in the maxillary sinus. The growth had been present sixteen years; the patient had several times been operated upon and radium and roentgen therapy had been given. The tumor proved to be a basal-cell carcinoma without metastases. Teleradium therapy was followed by operation with exenteration of the eye but death occurred in two years. CASELXVII: A man of eighty-one years had a tumor of the inner canthus with in- volvement of both lids. It had been present, without treatment, for ten years. Biopsy showed it to be a basal-cell carcinoma. Teleradium therapy was instituted but the patient did not return for observation and further treatment. He died after one year. CASELXVIII: A seventy-five-year-old man had a tumor on the cheek which measured 5 x 5 cm. and had destroyed the tragus. It had been present ten years but had received no treatment. Biopsy showed basal-cell carcinoma. There were no metastases. Tele- radium therapy was instituted but after two days the patient refused further treatment. He died ten days later. CASELXIX: An eighty-nine-year-old man had a tumor, 3 x 3 cm., on the auricle of the ear. It had been present six months without treatment. It was a basal-cell carcinoma with no metastases. A radium moulage was applied and the lesion disappeared. It re- curred after nine months and teleradium therapy was without effect. Death occurred after one year. CASELXX: A man of eighty-eight had a basal-cell carcinoma, proved by biopsy. It measured 6 X 6 cm. and had destroyed the auricle of the left ear. It had previously been treated by electrocoagulation. Teleradium therapy was given but the tumor eventually destroyed the mastoid process. Death occurred after eighteen months. Two other patients are listed as dying of carcinoma of the skin, though it is possible that in these cases death was due to a new independent tumor. CASEIV: A man of sixty years was admitted ten days after operation elsewhere for a tumor of the face which had been present three months. The tumor had not been radically removed. It involved the cheek and infiltrated the parotid gland. The regional lymph nodes were enlarged. Biopsy showed squamous-cell carcinoma. Following roentgen irradiation both the primary tumor and the metastatic nodes disappeared. The patient died fourteen months later, ostensibly of esophageal cancer. There had been no local recurrence. CASEXXXI: A woman eighty years old was seen after extirpation of a tumor of the right cheek. The tumor had not recurred but the regional nodes were enlarged and biopsy showed squamous-cell carcinoma. Following teleradium therapy the nodes were removed. The patient died a year later without local recurrence but with a palpable tumor in the epigastrium, ascites, and pulmonary metastases. The methods of treatment employed in this series are as follows:

Radium therapy (radium needles, radium moulage, teleradium ...... I5 cases Roentgen therapy ...... 1 case Radium + roentgen therapy ...... 4 cases Elect rocoagulation ...... 6 cases Operation ...... 1 case Irradiation + electrocoagulation or operation ...... 30 cases No treatment ...... 1 case CARCINOMA CUTIS 189 An effort has been made to give a sufficient dose to obtain a complete cure, as far as possible, at a single sCance, or, if teleradium therapy is used, in a single series of daily treatments. Protracted radiation is regarded with favor. By this technic we believe that the best therapeutic effects are obtained with the least amount of injury. A skin cancer generally requires a period of treatment of five to six days. In the present material surface application of radium has most commonly taken the form of a radium moulage with a radium-skin distance of 0.7 cm. In a number of cases implantation of radium needles was employed. In some regions, e.g. tumors near the eye, this method is regularly used, with a filter of 0.7 to 1 mm. Pt. In the case of large, deep-seated tumors, which do not easily lend themselves to treatment by radium moulage or needling, teleradium therapy has been employed. By this means it is possible so to reduce the tumor in size that the remainder can be treated with advantage by implantation of radium needles or a moulage. Radiation injuries: Desjardins has published a critical review of the literature on the biological effects of radium and roentgen rays on the eye. He concludes that the eyelids and conjunctiva are the most radiosensitive parts of the eye, being somewhat more sensitive than the surrounding skin; the cornea and iris are more resistant. In none of these parts is there any significant difference in radiosensitivity between young and full-grown ani- mals. The sensitivity of the lens, however, is largely dependent upon age. In young animals the resistance to radiation is slight and small doses of rays produce cataract. In full-grown animals the lens is considerably more re- sistant. Desjardins believes that the lens of full-grown animals is somewhat less radiosensitive than the conjunctiva and eyelids and that the doses tol- erated by the latter parts have no injurious effect on the lens. There is by no means any general agreement as to this, however, and some students hold that the lens of the adult animal is far more sensitive than is assumed by Desjardins (Aulamo, Rohrschneider) . In a clinical material it is difficult, or even impossible, to determine whether a cataract appearing some years after radiation is due to the treat- ment or is of spontaneous origin, particularly as the age of the patients is frequently high. Establishment of the cause of injury to the eye is rendered difficult, also, in some cases, by infiltration of the lids by the carcinoma. In order to determine with greater certainty the effects of radiation on the eye and any injuries which may result from such treatment, every patient should be examined by an oculist both before and after exposure to the rays (Mag- nusson). This was not done in our material, and it is possible, therefore, that pathological conditions which may have existed when the treatment was begun were overlooked. Any complaints as to vision after treatment have been noted and the patient, as a rule, has been referred to an oculist. In 45 of the present series of cases the tumor was situated in the eyelids, the canthus internus or externus, or the immediate vicinity of the eye, up to 1 cm. from the lids. In a number of these cases, where the tumors were ex- tensive, the eye was unavoidably exposed to fairly large doses of rays. In 13 of the 45 cases permanent injuries followed in which a possible effect of irradiation could not be ruled out. These included protracted conjunctivitis, 190 ERIK POPPE keratitis, cataract (3 cases, one of which developed four and one-half years after treatment), increased tension (3 cases), and panophthalmitis. In 13 of the 45 cases of carcinoma of the eyelids or the immediate vicinity of the eye implantation of radium needles was the only form of treatment employed. In only one of these cases was there any change in the eye-a protracted conjunctivitis. A radium moulage was used alone in 16 cases, and in 3 of these symptoms referable to the eye appeared; conjunctivitis in 2 cases, and cataract in 1 case, four years after treatment. Two cases were treated by electrocoagulation and no unfavorable effects on the eye were observed.

FIG. 10. LARGEMUSHROOM-SHAPED SQUAMOUS-CETL CARCINOMA OF RIGHTCHEEK OBSCLJRI~G VISION,PREVIOCSLY UNTREATED Teleradium treatment alone or in combination with one of the other meth- ods was used in 14 cases, mainly during the first two years of the hospital’s work. The majority of these cases had previously been treated in vain either with radium or by operative means. In 8 of the 14 cases injuries to the eye occurred; conjunctivitis, keratitis, cataract (twice) and glaucoma. Finally, roentgen treatment was given in combination with radium implan- tation on one occasion. A sharp attack of conjunctivitis resulted and the eye became blind. In judging these 13 instances of injury to the eye it must be borne in mind that it was necessary, in a number of cases of large tumors, to sacrifice the eye in order to have any chance at all of treating the tumor radically. Fur- thermore, it is probable that destruction of the eyelids by the tumor, with lagophthalmos, may have led to injury to the eye in some instances. Carcinoma of the lids is now treated by implantation of radium needles in all cases where this is possible. By this means the distance between the CARCINOMA CUTIS 191 radium and the tumor is minimized, so that the tumor tissue is exposed to the maximum dose of radiation. With this technic we maintain that injuries to the eye can practically always be avoided. Teleradium treatment is adopted for tumors in the neighborhood of the eye only when it is known that other methods will not avail, and in such cases it is taken for granted that the eye must be sacrificed. A case of this kind is illustrated in Fig. 10. The tumor, measuring 7 >( 7 cm., springs from a wide base in the right cheek and spreads outwards in mushroom form. The eye is not affected but vision is completely cut off by the large neoplasm, the margin of which covers the eye. No other injuries of any consequence resulting from radiation treatment have been observed. In one case there was a necrosis at the site treated. This occurred four years after treatment as a result of frost-bite and was regarded as a deferred radium injury provoked by frost. Our point of view in regard to the treatment of carcinomas of the skin is briefly as follows: Irradiation, particularly by radium, probably produces better permanent results than surgical treatment, and the cosmetic result is, as a rule, more satisfactory. In some cases in which, owing to the size of the tumor, radical surgical treatment is out of question radium treatment has an excellent palliative effect and may even result in a complete recovery. The ideal is that every case of skin carcinoma should be treated radio- logically. In a country such as Norway, however, where distances are great, there can be no objection to surgical treatment of small superficial growths at sites which permit of wide excision without interference with important structures. A professedly radical operation before the patient is submitted to radiological treatment cannot be regarded as offering any advantage. With the irradiation technic employed the risk of injury is negligible; except for tumors in and about the eye, it is practically nil. The large tumors in the immediate vicinity of the eye form an exception. As far as these are concerned, however, any treatment, whether radiological or surgical, will necessitate injury to the eye or its complete loss in a number of cases. In those carcinomas of the skin which are not unreasonably far advanced the prospect of permanent cure by radiological treatment closely approximates 100 per cent. SUMMARY Of 198 cases of cutaneous carcinoma exclusive of lesions of the lip, anus, and vulva, 172 were proved histologically. Of these 28.5 were of the squam- ous-cell variety, 62.8 per cent basal-cell, and 8.7 per cent mixed types. The average age for both men and women was just above sixty-five years. Treatment was chiefly by irradiation, supplemented in some cases by electrocoagulation or operation. Of the entire series of patients, including those in whom treatment could not be completed, 70.2 per cent were well for more than three years. The calculated three-year-cure rate, arrived at by adding to the number of patients known to be without symptoms, those who died of intercurrent disease, with a reduction for possible recurrences, is 80.8 per cent. 192 ERIK POPPE

Injuries to the eye followed irradiation in 13 of 45 cases in which the tumor involved the lid or conjunctiva or was closely adjacent to the eye. . Radiological treatment, particularly radium treatment, probably produces better permanent results than surgical treatment, and the cosmetic result is, as a rule, more satisfactory. With the method described the risk of injury is negligible. In those cases of carcinoma of the skin which are not unreasonably far advanced the prospects of a permanent cure by radiological treatment closely approximate 100 per cent. BIBLIOGRAPHY AULAMO,R.: Klin. Monatsbl. f. Augenheilk. 86: 473, 1931; 87: 106, 1931. BLEGVAD,0.: Acta Ophth. 9: 32, 1931. DESJARDINS,A. U.: Am. J. Roentgenol. 26: 919, 1031. DESJARDINS,A. U.: J. de radiol. et d’dectrol. 22: 305, 1938. ENGELSTAD,R. B.: Acta. radiol. 17: 421, 1936. GANS,0. : Histologie der Hautkrankheiten, Berlin, J. Springer, 192 7. HAYTHORN,S. R.: Am. J. Cancer 15: 1969, 1931. JORSTAD, L. H.: Am. J. Cancer 16: 177, 1932. KREYBERG,L. : Maligne svulster, Oslo, Johan Grundt Tanum, 1937. MACKEE,G. M. AND CIPOLLARO,A. C.: Cutaneous Cancer and Precancer, New York, pub- lished by Am. J, Cancer, 1937. MAGNUSSON,A. H. W.: Acta radiol. supp. 22, pp. 1-287, 1935. NIELSEN,J.: Ugesk. f. Laeger 95: 464, 723, 1933. KOHRSCHNEIDER,W. : Strahlentherap. 38: 665, 1930. ROHRSCHNEIDER,W.: Zentralbl. f. d. ges. ‘Ophth. 23: 289, 1930. ROHRSCHNEIDER,W. : Deutsche med. Wchnschr. 58 : 1126, 1932. THRANE,M.: Nord. med. tidskr. 16: 1248, 1938. DE VRIES, S.: Klin. Monatsbl. f. Augenh. 82: 145, 1929.