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The John Palmer Lecture


John Palmer
John Palmer

John Palmer lived from 1925-1984. He trained in general and plastic surgery at the University of Toronto and then completed fellowships in Edinborough in plastic surgery and colorectal surgery at St. Mark’s in London. He was a self -described "head to tail surgeon". Among his many talents were playing the trombone, refinishing furniture and painting beautiful landscapes, two of which were shown by Paul Greig during his thoughtful introduction of professor Michael A. Choti, this year’s Palmer lecturer.

A graduate of Yale, University of Pennsylvania and Memorial Sloan Kettering, Professor Choti joined the John Hopkins Faculty in 1992. He has served as director of the Hopkins’ Surgical Oncology Fellowship and Chief of the Surgical Oncology Program. His research is focused on ultrasound guided ablation techniques for liver tumours. He is the Jacob Handelsman Professor of Surgery, named for a gifted surgeon with interests and avocations similar to those of John Palmer.

Hepatic surgery is evolving in important ways. The mortality for ablation or resection of hepatic metastasis is now at 1% or lower and the five-year survival for hepatic resections for cancer exceeds 50%. Where resection was previously limited to one or two metastases, it is now common practice to resect even patients with many metastases. These dramatic advances are related to the improvements in preoperative therapy, imaging and surgical technique. The imaging requires a fusion of surgery and imaging techniques analogous to the work that is being done in urologic, cardiovascular, and neurosurgery. Unlike the brain or prostate, the liver moves with respiration and position, and the use of registered preoperative images in the operative theatre is more challenging. Additional metastases are found at exploration in 10% of cases. Another challenge is the disappearance of tumours that were imaged in the pretreatment interval, as they are often unfindable following chemotherapy. It is nevertheless important to resect the sites, as residual tumour cells are generally present despite their apparent disappearance on intra-operative imaging. The Hopkins group - comprised of engineers, surgeons, medical oncologists, and radiologists are actively exploring the use of more advanced techniques for imaging and resection. The group has patented a robotic ultrasound tool licensed to Intuitive Surgical. Such a device can be used to improve minimally invasive robotic procedures using image-guidance, including cancer ablation. Ablation techniques currently in use include chemical ablation (using ethanol or acetic acid), and thermal ablation using radiofrequency or microwave energy. The Choti team has developed a staging system based on the surgeons’ confidence in the completion of the ablation. In this way, this form of therapy may be able to achieve comparable results to that of more invasive resectional therapy. They are working with three dimensional ultrasound, motion tracking using video-gaming systems, and fusion of CT and MRI with operative ultrasound to resolve some of the imaging problems. Some metastases are isoechoic, i.e. they cannot easily be found by reason by their hypo or hyper echoicity, even if they are evident on CT. They are working with GE, Siemens, Phillips and other manufacturers to resolve these challenges. To improve conspicuity, they are adding elastography - a technique to visualize differences in stiffness that results from thermal destruction.

The current novel robotic probe works with high frequency therapeutic ultrasound to shape the ablation field.

Paul Grieg, Michael Choti and Ori Rotstein
Paul Grieg, Michael Choti and Ori Rotstein

John Trachtenberg asked about the use of magnetic resonance thermography, which he is employing successfully in prostate cancer ablation. Professor Choti felt that the system was more difficult in the hepatic application as the apparatus is awkward and expensive. Andy Smith asked about the drift of surgery toward radiology and radiology towards surgery. Choti answered that, indeed, the specialties are blending somewhat, as are the cultures. Radiology residents are getting more adept at patient care as interventional oncologists; they now see and follow patients. Hepatobiliary surgeons are learning radiology, though the specialties are clearly interdependent. Paul Greig asked about the use of ultrasound contrast to strengthen imaging. Choti answered that the Hopkins group is not exploring this at present, but the Europeans are very active in contrast ultrasonography. Ori Rotstein asked about the interaction of surgeons and engineers. Choti answered that it is hard to bring the mindsets together. "Surgeons are trained in mechanistic hypothesis testing, whereas the engineers’ thinking is based on system development and validation. They design robots and create software. The co-principal investigative model is in progress".


John Angus Palmer was born in Meaford Ontario in 1925. He attended school in the Georgian Triangle and went to medical school at the University of Toronto. Dr Palmer went on to complete the Gallie Course in General and Plastic Surgery in Toronto.

After obtaining his FRCSC, John was awarded the prestigious Nuffield Scholarship to do fellowship training in reconstructive surgery at the University of Edinburg. After this, he did additional training in colorectal surgery at St Marks.

In 1952 he returned to Toronto as what we would now call a Surgical Oncologist. He referred to his specialty as "Head and Tail Surgery".
John Palmer developed interest and expertise in a very broad range of general surgery, Head and Neck, Head and Neck reconstruction, Thyroid, Parathyroid, GI malignancy, Skin cancer, melanoma, Perianal malignancy, and Radiation enteritis. More Head to tail, than Head and Tail.

He did not publish prolifically but what he did publish was pivotal, particularly his papers on radiation induced injuries to the GI tract and his work on Primary Hyperparathyroidism.

John Palmer was a master surgeon, an astounding technician, a thoughtful clinician and gifted teacher.

John had numerous and eclectic interests outside of surgery: his family, painting, collecting art, playing the trombone, collecting and refinishing antiques, carving decoys, anatomy, skiing, boating: to name a few, he also mixed a mean pitcher of Martinis. As a centennial project in 1967, he and his family dismantled a pioneer log house and reconstructed it near their family cottage in Dwight Ontario. They then opened it to the public as an antique shop. It was charming.

Dr. Palmer was a very accomplished painter. In February of 1973 he held his first one-man show of fifty landscapes at the Framing Gallery, Toronto. Here are 2 examples of his work.

John Palmer died prematurely in 1984 of ironically, malignant disease. He is survived by his wife Margot, his son John, his daughters Valerie, Marilyn and Jenifer.

Painting by Palmer
John Palmer - Cathedral
Painting by Palmer
John Palmer - Swamp Highway 60 North of Huntsville

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