An extrapulmonary oat cell carcinoma arising in the larynx is described. Ultrastructurally the tumor is identical to the oat cell carcinoma of pulmonary origin. T h e pressure of neurosecretory granules in our case strongly suggests that the tumor is derived from Kulchitsky-like cells, a histogenesis previously proposed for oat cell carcinoma of the lung. CASE REPORTA 64-year-old black man presented with a 3-month history of increasing shortness of breath, hoarseness, and an enlarging right neck mass.Physical examination revealed a 5-cm fixed mass in the right neck. Laryngeal exmination revealed a mass involving the right true and false cords and the right aryepiglottic fold and pyriform sinus. Biopsy revealed a small cell carcinoma of oat cell type. Bronchoscopy, full lung tomograms, and pulmonary scan were negative, as were scans of the brain, liver, and bone. Laboratory studies were all within normal limits.Preoperative radiotherapy of 5500 rads was given to the larynx and both sides of the neck. Pathologic examination of the tissues obtained by laryngectomy and right radical neck dissection that followed revealed no residual tumor in the larynx, and foci of metastatic small cell carcinoma of oat cell type in nodes at all levels.Three months following discharge the patient was readmitted with right shoulder pain and a 10-lb Light Microscopic FindingsHistologically, the tumor involved the laryngeal mucosa and submucosa. It was composed of sheets of closely packed cells with little cytoplasm a n d hyperchromatic nuclei. The cells showed considerable plemorphism with round, oval, and spindleshaped nuclei. Mitotic figures were not frequent (Fig. I ) . Identification of a surface epithelial or minor salivary gland origin for this tumor was not possible, due to the diffuse nature of the laryngeal involvement. Electron Microscopic FindingsSmall blocks of tumor tissue were fixed in 2% gluteraldehyde in phosphate buffer, postfixed in osmium tetroxide, and embedded in Spurr low viscosity embedding medium.' Thin sections were stained with uranyl acetate and lead citrate and examined in a n KCA-Eh4U-4 microscope.Ultrastructurally, the tumor cells varied in size and shape and were characterized by prominent nuclei and scanty cytoplasm. The nuclei frequently contained prominent nucleoli and showed marginal condensation of chromatin (Fig. 2). The cytoplasm showed numerous mitochondria and prominent endoplasmic reticulum (Figs. 3 and 4). Golgi complexes were not uncommon (Fig. 3). Spherical granules composed of a n electron-dense core separated from a single limiting membrane by a thin clear space were identified within approximately onefourth of the cells studied (Figs. 2, 3, and 4). Slight variability in the density of the core was observed. The granules measured from 50-200pm in diameter. The granules in our case are similar to the neuro- 145

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ABSTRACT.Fifty-seven cases of recurrent head and neck malignancies unsuitable for further X-ray or surgery were treated with cryosurgery. The cases were divided into two groups: a symptomatic group of 21 cases treated only when symptoms became severe and an asymptomatic group of 36 cases treated early in an effort to produce significant prolongation of life. In the symptomatic group, pain relief was obtained in 7 of 8 patients (86.5 percent) and symptoms related to tumor bulk were relieved in 11 of 13 patients (84.6 percent). Thirty-six asymptomatic cases treated at the time recurrence was first diagnosed, showed a definite trend of increased survival when compared with matched cases treated prior to the advent of cryosurgery.

In the mid 1970s medical malpractice insurance carriers, faced with huge increases in both the number of claims and the size of awards, elected either to discontinue writing medical malpractice insurance policies or to raise premiums for this type of insurance by a factor of two or three. Faced with the prospect of unavailability of affordable medical malpractice insurance many physicians elected to go without any malpractice coverage, went into early retirement terminating their practices altogether, or narrowed the scope of their practices to eliminate those procedures which carried an inordinately high risk of medical malpractice litigation. In response to the potential unavailability of adequate health care because of the impending medical malpractice insurance crisis many states enacted remedial emergency legislation in an attempt to deal with the crisis by providing an incentive for insurance carriers to either reenter the medical malpractice field or for those remaining to limit their proposed premium increases substantially. California was one of those states which enacted broad remedial legislation. In addition other states enacted legislation quite similar to California's. An attempt will be made to review those statutes passed by California in specific response to the medical malpractice crisis and their history as they underwent constitutional attack in the California appellate court system. The legislation reviewed here is of course applicable only in California. However, many other states have enacted comparable legislation and many jurisdictions currently are considering statutory changes which would parallel California's laws. California's current statutes dealing with medical malpractice litigation could be considered a model for those jurisdictions currently facing a crisis in affordability or availability of malpractice insurance coverage.