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ADENOCARCINOMA of pancreatic ductal cells is almost always fatal. Despite many thousands of pancreatoduodenectomies during the last 40 years, fewer than 100 cured patients are known. The past 20 years have produced only about 50 five-year survivors among 1,250 patients treated for cure (4% rate), and many of those have later died of recurrent cancer. To the contrary, some patients counted as cures have only been explored, not resected. Thus, the traditional logic of oncological surgery—resecting local disease and the pathways of its local spread and nodal metastases—dictates ineffective treatment of pancreatic cancer because the disease is usually systemic by the time of diagnosis. Progress requires (1) identifying the causes of pancreatic cancer so as to minimize them, (2) detecting the cancer while it is localized, (3) devising effective nonsurgical therapy for residual local disease and suppression of metastases, and (4) ensuring valid assessments of surgical and nonsurgical treatments by

We surgeons perform some cures; more often we palliate, leaving unfinished business that then becomes the responsibility of some member of our profession. I propose that the act of fulfilling this responsibility should be undertaken, at least occasionally, in the patient's home and by his surgeon. Take, for example, the lonely frightened woman with a long-standing ileostomy for ulcerative colitis suffering severe abdominal cramps and having no neighbors, friends, or ready means of transportation; the older patient with recurrent cancer of the pharynx, obviously preterminal, but with an intermittent airway problem; the patient with a large venous stasis ulcer being treated at home on wet dressings and elevation; the hemiplegic with a failed femoropopliteal bypass graft for toe gangrene in his paralytic leg, awaiting decision for or against amputation. The surgeon is rarely called to the home to see new patients suffering from "primary care" problems. But those whom he

During the Western Sectional Meeting of the Triological Society in January 1988, in Coronado, Calif, Jonathan Ferguson and Larry DeSanto from the Mayo Clinic, Rochester, Minn, described their experience in pharyngoesophageal reconstruction after circumferential resection of the pharynx and esophagus during cancer surgery. They used a free jejunal graft (autotransplant) for reconstruction of the upper digestive tract. A total of 18 patients were described. Six major complications occurred, including abdominal and cervical bleeding and graft failure. One patient died due to the operation. Six minor complications were reported, such as fistulas. Twelve (66%) of 18 patients had significant complications. The mean length of survival was 349 days after resection and reconstruction. Ten of 18 patients died of their disease. Five had recurrent cancer in the neck and the other five had distant metastasis. The authors express concern regarding the morbidity and mortality in their series, and take a critical look

In this new and updated volume on chemosurgery, Mohs includes considerable material bearing on the freshtissue techniques and melanoma treated by chemosurgery. In a clear manner, he presents his special method of treating primary and recurrent cancer not only on the skin surface but also from areas subjacent to the surface of the skin or approachable through orifices adjacent to the lesions. Sections concerning benign tumors, infections, and gangrene treated by the technique or modifications of the technique are also included. Many years of painstakingly gathered statistics bearing on cure and recurrence rates as well as good blackand-white photographs document the essential conservatism and effectiveness of microscopically controlled surgical excision of cancer and other tumors. This volume is sufficiently complete and detailed, down to the specifics of equipment, personnel, and layout, for a chemosurgery office or clinic. Of special interest are Mohs's observations on how and where skin cancers spread

At the age of 32 years, she had borne five children and had undergone a hysterectomy. Two years later, because of nephrolithiasis and irreversible chronic inflammation, one kidney was removed. She felt chronically tired and had intermittent edema of her face and extremities of undetermined cause. At the age of 37 years, she was referred for us to treat a cancer of the mouth with metastases to lymph nodes in the neck. The then-customary treatment was given, consisting of six weeks of radiation therapy to the mouth and neck, followed by a resection of the floor of the mouth, a radical neck dissection, and a temporary tracheostomy. During the next five years, she traveled the long distance to this hospital for five operations. On two occasions, portions of osteoradionecrotic mandible were removed, and three further ablations for recurrent cancer were undertaken. By this time she had lost all of her

Twenty-four consecutive patients with recurrent cancer of the breast were treated by bilateral oophorectomy and adrenalectomy. Fourteen or 58% secured marked subjective improvement and survived for an average of 44 months. Seven patients are still living, an average of 60 months since adrenalectomy. It is suggested that this procedure be employed as soon as metastatic lesions from breast carcinoma are diagnosed.

THE PROBLEM of recurrent cancer in the upper gastrointestinal and biliary tracts has not created the surgical unrest that equally malignant lesions on the surface of the body or in the musculoskeletal system have evoked. The defeatist attitude regarding the prognosis following the reresection of gastric cancer has been manifest in cancer producing biliary obstruction, and most surgeons do not feel justified in performing an operation in either area for recurrence offering a major risk of morbidity or mortality. It is an incontrovertible fact that the radical operation for neoplastic biliary obstruction is attended by a high mortality rate and a discouraging salvage. As previously stated in regard to the problem of resection in the face of recurrence of gastric cancer, 1 secondary resections of locally recurring lesions afford patients greater comfort with a more extended span of life than other surgical and nonsurgical methods of palliation and in an

Three of 15 cancer patients with suspected intrathoracic tumor recurrence were found on biopsy to have only benign mass lesions. These cases emphasize that medical work-up, short of biopsy, is often inadequate in the evaluation of intrathoracic masses, and that a history of neoplasm is not sufficient cause to abandon tissue diagnosis before proceeding to therapy.

To the Editor.— In the discussion of the therapy of the menopausal woman, following mastectomy, it seemed to me to be quite obvious which of the three consultants actually treats women with this problem (219:1642, 1972). Dr. Kistner's remarks were "right on," to use the modern expression. His approach is as knowledgeable as possible in an area in which so little is known factually, yet also quite practical. Dr. Goldenberg's remarks imply that "carefully planned tranquilizing therapy and strong psychological support" are "simple measures." Most gynecologists dealing with these patients find that this aspect of therapy is quite demanding, even with the use of estrogens, and generally occupies a good deal of time both in the office and on the telephone. Dr. Kennedy's rather hopeful implication that large doses of estrogens produce regression of recurrent cancer in postmenopausal women, without qualification, is quite an ideal. I find it most interesting