Frank Hinman 243 



tomy and X-ray therapy. Definite diagnosis, of course, can be made only by 

 the microscope and there is a distinct advantage therefore in early orchidec- 

 tomy. I can see no benefit to be gained by preoperative irradiation which 

 carries a risk of sterilization even with the best of lead protection for the good 

 testis. W^ith high exposure of the cord at the external ring and its double liga- 

 tion and division before manipulation of the tumor, orchidectomy w'ould 

 seem to be perfectly free from any danger of spreading metastases. Ordinarily 

 it is advisable to have collected urine for 24 hours or more for determination 

 of the gonadotrophic hormone. There is no advantage in waiting for the 

 result of this test, however, before performing orchidectomy inasmuch as 

 neither the presence nor the absence of the hormone would modify the plan 

 of treatment. The specimen removed is sent to the pathologist for careful 

 serial examination and this study together with the report from the biochemi- 

 cal laboratory gives reliable information as to prognosis. To those patients 

 in whom metastases were not demonstrated clinically before operation, a 

 prophylactic course of X-ray therapy to the preaortic lymph zone is given. 

 In those patients in whom metastases were demonstrated before orchidectomy 

 the areas of metastasis, as well as the preaortic lymph zone even if uninvolved 

 clinically, are irradiated. Experience is not yet sufficient to permit any re- 

 liable prediction of the effect of irradiation. As a rule the more primitive 

 types of tumor are the most radiosensitive, that is, such masses disappear most 

 readily under irradiation so far as clinical evidence goes, yet few of these 

 patients are cured. On the other hand, the embryonal carcinomata, which are 

 not nearly so primitive or radiosensitive, show the most favorable results 

 after irradiation. During the first year it has been our custom to submit for 

 biochemical assay 24- or 48-hour collections of urine from patients upon 

 whom orchidectomy has been performed and followed by radiation therapy; 

 thereafter such specimens are submitted at intervals of six months for the next 

 two years. This has been done as a routine even on those patients who showed 

 no increase of the hormone above normal before orchidectomy. Only on very 

 rare occasions have abnormal amounts of the hormone appeared in these 

 subsequent tests. 



Under the foregoing plan of treatment the prognosis depends on early recog- 

 nition of the tumor, the pathologic type of growth found after orchidectomy, 

 the finding of a functioning or nonfunctioning growth, and the presence or 

 absence of metastases as determined by clinical examination. A good prognosis 

 may be offered for patients with an early growth and no metastases clinically, 

 with no gonadotrophic hormone in the urine, and with a type of tumor having 

 fairly well differentiated cells. On the other hand, in spite of early diagnosis, 

 a poor prognosis is all that can be advanced for the patient who shows a high 

 content of hormone in the urine and a type of tumor having primitive cells 

 even though no clinical evidence of metastases is present. The chorionepi- 

 theliomata are the most malignant of all these tumors and, in our experience, 

 always are fatal. Glancing back at table 1, it is seen in fact that no patient who 



