Operative strategy for thyroid cancer. Is total thyroidectomy worth the price?

Thyroid cancer in Plummer's disease

Thyroid cancer with concomitant hyperthyroidism is rare. Most foci of malignancy are small and seen postoperatively as incidental findings after surgery for hyperthyroidism. Thyroid masses with clinical features of malignancy and concomitant hyperthyroidism are less-commonly reported. We report two cases of multinodular toxic goitre or Plummer's disease with clinical features of malignancy. Both patients had large multinodular goitres with evidence of metastasis to the manubrium for the first patient and to the lymph node and lungs for the second patient. Both were clinically euthyroid but with free hormone excess and suppressed thyroid stimulating hormone (TSH) on laboratory testing. Both patients received methimazole prior to thyroidectomy. Histopathology revealed follicular variant of papillary cancer with metastasis to the manubrium for the first patient and follicular thyroid cancer with lymph node metastasis for the second. While rare, thyrotoxicosis can occur with malignancy, Plummer's disease may harbour cancer and behave aggressively.

Meta-analysis of thyroidectomy with ultrasonic dissector versus conventional clamp and tie

Background

We conducted a systematic review to evaluate the role of Ultrasonic dissector (UAS) versus conventional clamp and tie in thyroidectomy.

Materials and methods

We searched for all published RCT in into electronic databases. To be included in the analysis, the studies had to compare thyroidectomy with UAS versus conventional vessel ligation and tight (conventional technique = CT). The following outcomes were used to compare the total thyroidectomy group with UAS versus CT group: operative duration, operative blood loss, overall drainage volume during the first 24 hours, transiet laryngeal nerve palsy, permanent laryngeal nerve palsy, transiet hypocalcaemia and permanent hypocalcaemia.

Results

There are currently 7 RCT on this issue to compare thyroidectomy with UAS versus CT. From the analysis of these studies it was possible to confront 608 cases: 303 undergoing to thyroidectomy with UAS versus 305 that were treated with CT. Actually, it was shown a relevant advantage of cost-effectiveness in patients treated with UAS; there is a statistically significant reduction of the operative duration (weighted mean difference [WMD], -18.74 minutes; 95% confidence interval [CI], (-26.97 to -10.52 minutes) (P = 0.00001), intraoperative blood loss (WMD, -60.10 mL; 95% CI, -117.04 to 3.16 mL) (P = 0.04) and overall drainage volume (WMD, -35.30 mL; 95% CI, -49.24 to 21.36 mL) (P = 0.00001) in the patients underwent thyroidectomy with UAS. Although the analysis showed that the patients who were treated with USA presented more favourable results in incidence of post-operative complications (transient laryngeal nerve palsy: P = 0.11; permanent laryngeal nerve palsy: not estimable; transient hypocalcaemia: P = 0.24; permanent hypocalcaemia: P = 0.45), these data didn't present statistical relevance.

Conclusion

This meta-analysis shown a relevant advantage only in terms of cost-effectiveness in patients treated with UAS; it is subsequent to statistically significant reduction of operation duration, intraoperative blood loss and of overall drainage volume during the first 24 hours. Although the analysis showed that the patients who were treated with UAS presented more favourable results in incidence of post-operative complications (transiet laryngeal nerve palsy; transiet hypocalcaemia and permanent hypocalcaemia), these data didn't present statistical relevance.

Surgical approaches to thyroid tumors

This article includes discussions of the surgical approach to benign and malignant disease and the role of prophylactic thyroidectomy and nodal dissection for medullary thyroid cancer. The controversy regarding the extent of dissection for differentiated thyroid cancer and the role of lymph node dissection are reviewed also. A description of the authors' surgical technique for thyroidectomy is detailed. Finally, several emerging technologies are introduced.

Vocal fold paresis and paralysis: what the thyroid surgeon should know

The thyroid surgeon must have a thorough understanding of laryngeal neuroanatomy and be able to recognize symptoms of vocal fold paresis and paralysis. Neuropraxia may occur even with excellent surgical technique. Patients should be counseled appropriately, particularly if they are professional voice users. Preoperative or early postoperative changes in voice, swallowing, and airway function should prompt immediate referral to an otolaryngologist. Early recognition and treatment may avoid the development of complications and improve patient quality of life.

A prospective clinical trial to assess the efficacy of radioiodine ablation as an alternative to completion thyroidectomy in patients with differentiated thyroid cancer undergoing sub-total thyroidectomy

We conducted a prospective clinical trial to evaluate whether radioiodine ablation can be an effective alternative to completion thyroidectomy in patients undergoing sub-total thyroidectomy and if yes, the optimum activity of 131I and frequency of ablation. A total of 85 patients (F--63; M--22) with mean age of 37.9+/-12.3 years were recruited in this study. The pre-ablation mean 24 hour radioiodine neck uptake, effective half-life, residual thyroid tissue weight and TSH values were 13.9+/-8.5%, 4.5+/-0.9 days, 9.6+/-3.6 g and 11.7+/-6.4 microIU/ml, respectively. Thyroid tissue was completely ablated in 50 patients (58.8%, 95% CI:50-68%) after mean 1st administered activity of 32.3+/-10.7 mCi of 131I and the cumulative ablation rate was 91.8% after two doses of 131I. During mean follow-up duration of 49 months no local/distant recurrence has been observed so far in this cohort. It appears that radioiodine ablation may be an attractive alternative to completion thyroidectomy and an activity as low as 35 mCi may achieve reasonable ablation.

Total thyroidectomy for the treatment of thyroid diseases in an endemic area

INTRODUCTION

Thyroidectomy is a common operation with very low mortality and an acceptable morbidity rate. Total thyroidectomy has become the predominant type of surgery used today for the treatment of thyroid diseases. In this retrospective study, we analyzed the complications of thyroid surgery according to the operative technique used in our department.

MATERIAL AND METHODS

A retrospective analysis was performed for all patients who underwent thyroid surgery during the previous 11 years. The period under study was divided into two sections: phase A (1995-1999) and phase B (2000-2005). Patient characteristics, type of operation, histologic diagnoses and postoperative complications were compared in the two study periods according to the type of surgery.

RESULTS

A total of 264 patients between the ages of 18 and 89 underwent thyroid surgery during the study period (133 in phase A and 131 in phase B). Overall histopathological diagnoses were nodular goiter (54.9%), hyperplastic nodules (14.7%), adenoma (8.3%), thyroid cancer (18.2%), and Hashimoto thyroiditis (3.8%). Total thyroidectomy was performed in 91 patients in phase A versus 115 patients in phase B (P < 0.001), whereas the use of subtotal thyroidectomy and lobectomy decreased over time. A trend toward increased morbidity was noted in phase B. Seven patients had hypocalcemia in phase A, whereas 11 patients had hypocalcemia in phase B. Similarly, 5 patients had some degree of vocal cord paralysis in phase A, compared with 7 in phase B (P > 0.05). Morbidity was significantly increased in the case of cancer or reoperation.

CONCLUSION

Despite the slightly higher risk of complication associated with total thyroidectomy, this has gradually replaced more conservative approaches for the treatment of both benign and malignant thyroid diseases. Reoperations and surgery for thyroid cancer carried a higher risk of complications.

Surgical Treatment of Solitary Thyroid Nodules Via Fine-Needle Aspiration Biopsy and Frozen-Section Analysis

BACKGROUND

Fine-needle aspiration biopsy (FNAB) and frozen-section analysis of managing solitary thyroid nodules continue to generate considerable controversy.

METHODS

This study was a retrospective review of 619 patients with solitary thyroid nodules who underwent thyroidectomy.

RESULTS

Of 540 FNABs, 35 (6.5%) were positive for malignancy, 276 (51.1%) were benign, and 229 (42.4%) were suspicious. Only 5.1% were false negative, and 11.4% were false positive. Diagnostic FNAB sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for malignancy were 86.1%, 59.7%, 33.0%, 94.9%, and 64.6%, respectively. Of 569 patients analyzed by frozen section, diagnosis was deferred in 86 (15.1%) patients, and results were positive for malignancy in 92 (16.2%) and benign in 391 (68.7%). No false-positive results were noted, but 2.3% (391) were false negative. Of 86 deferred frozen sections, 11 (12.8%) patients had malignant tumors confirmed by permanent section. Diagnostic frozen-section sensitivity, specificity, PPV, NPV, and accuracy for carcinoma were 82.1%, 100%, 100%, 95.8%, and 96.5%, respectively. Sensitivity, specificity, PPV, NPV, and accuracy for frozen-section analysis for diagnosis of carcinoma in patients with suspicious FNAB were 83.9%, 100%, 100%, 94.9%, and 96.0%, respectively.

CONCLUSIONS

FNAB is a sensitive diagnostic modality in selecting patients who require surgery. Routine use of frozen-section analysis is unwarranted for benign FNAB results. Frozen section is specific and cost-effective in determining the extent of surgery in patients with suspicious or malignant FNABs.

Papillary microcarcinomas of the thyroid gland and immunohistochemical analysis of expression of p53 protein in papillary microcarcinomas

Background

Thyroid papillary microcarcinoma (TPM) is defined according to WHO criteria as a thyroid tumor smaller than 1–1.5 cm. TPMs are encountered in 0.5–35.6 % of autopsies or surgical specimens where carcinoma had been unsuspected. The purpose of the present study was to evaluate patients who had TPMs in terms of clinical findings, histopathological features and immunohistochemical evidence of expression of the tumor suppressor gene p53.

Methods

A total of 44 patients with TPMs less than 1.0 cm in diameter were included in the study. The patients were evaluated clinically and the tumors were evaluated in terms of their histopathological and immunohistochemical features, including expression of p53.

Results

The female/male ratio was 2.8/1, and the median age at time of diagnosis was 49 years (range 20–71 years). The maximum diameter of the smallest focus was 0.1 mm, and that of the largest was 10 mm microscopically. The mean diameter of all tumors was 5.7 mm. There was no correlation between tumor size and age or gender. Of the TPMs, 72 % were found in the right lobe, 24 % in the left lobe and 4 % in the isthmus. Fine-needle aspiration biopsy provided the diagnosis of TPM in only 43.2 % of the patients. All patients were treated with surgery, with 20 undergoing conservative surgery, i.e. lobectomy or isthmusectomy, and 24 undergoing total thyroidectomy. Frozen section provided the diagnosis of TPM in only 56.8 % of the patients. We found lymphocytic thyroiditis in 13.6% of patients, follicular variants in 11.9%, capsular invasion in 26.8%, lymph node involvement in 11.9%, soft tissue metastases in the neck in 12.1% and multifocality in 31.7 %, and none of these were related to age or gender (p > 0.05). No distant metastases were observed during approximately 10 years of follow up. We found p53 positivity in 34.5 % of TPM tumors. However, p53 expression was not statistically related to age or gender.

Conclusion

Our findings imply that TPMs may not be entirely innocent since they are associated with signs of poor prognosis such as capsular invasion, multifocal presentation, lymph node involvement and p53 positivity. Therefore, TPMs should be evaluated and followed like classical papillary cancers.

Papillary thyroid microcarcinoma: A surgical perspective

Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid cancer measuring less than 10mm in its greatest diameter. It is the most common form of thyroid cancer, detected in up to 36% in autopsy studies. The wide availability and use of neck ultrasonography in the evaluation of carotid arteries and of the thyroid resulted in an increased detection of PTMC. PTMC is often multifocal. The diagnosis is usually based on a combination of clinical examination, laboratory investigations, and specialized radiological techniques (mainly neck ultrasonography combined with fine-needle aspiration cytology). A common scenario is the diagnosis of PTMC as an incidental finding following thyroidectomy for a presumably benign thyroid disease. Despite some controversy, most authors agree that PTMC should be treated by total or near-total thyroidectomy, provided it can be performed safely. Because of its many and major advantages, in our clinical practice, total or near-total thyroidectomy is the procedure of choice for the management of PTMC. Given the high incidence of PTMC as an incidental finding and the frequent multi-focality, we also favor total or near-total thyroidectomy for the surgical management of nodular thyroid disease (multinodular goiter or dominant presumably benign thyroid nodule/s). Despite some controversy, we perform central neck lymph node dissection electively, in the presence of cervical lymphadenopathy. Radioiodine ablation therapy may be used as an adjuvant therapy. Prognostic factors (such as tumor multicentricity, positive lymph nodes, capsular or vascular invasion) or scoring systems (such as the AMES) can be used to select patients for radioiodine adjuvant therapy. Suppression therapy is needed after surgical management. Despite the potential for neck lymph node and even distant metastases, the biological behavior of PTMC is in general benign and the prognosis is very good.

Large remnant 131I ablation as an alternative to completion/total thyroidectomy in the treatment of well-differentiated thyroid cancer

BACKGROUND

An alternative to completion thyroidectomy for well-differentiated thyroid carcinoma is to ablate the remnant lobe with 131 I. The purpose of this study is to review our own experience with large remnant ablation.

METHODS

A retrospective review of 169 patients with well-differentiated thyroid cancer treated at one institution over a 14-year period was undertaken. Seventy-one patients who underwent partial thyroidectomy (PT) followed by 131 I ablation were identified. This group was compared to 98 patients treated with total thyroidectomy (TT).

RESULTS

Mean follow-up was 6.2 years for the 71 PT + 131 I versus 4.7 years for the 98 TT patients (P = .184). Recurrence occurred in 4 of 71 PT + I 131 patients (5.6%) versus 9 of 98 TT patients (9.2%) (P = .393). Other than a tendency for the size of the primary to be slightly larger and for the histology to be follicular carcinoma in the PT + 131 I patients, the 2 groups were nearly identical in age, gender, and other prognostic factors such as capsular invasion and metastases.

CONCLUSIONS

Large-dose ablation with 131 I is a viable alternative to completion thyroidectomy. Recurrence rates over an average 6-year period are similar to TT. Long-term monitoring of these cohorts is required.

Surgical Treatment of Thyroid Cancers With Concurrent Graves Disease

BACKGROUND

Thyroid cancers with concurrent Graves disease are relatively rare. Accordingly, the natural history and optimal surgical treatment of thyroid cancers with Graves disease are controversial.

METHODS

Sixty-one thyroid cancers with concurrent Graves disease were retrospectively reviewed. Histopathologic diagnoses included 58 papillary thyroid carcinomas (95.1%), 1 follicular carcinoma (1.6%), 1 medullary carcinoma (1.6%), and 1 Hürthle cell carcinoma (1.6%).

RESULTS

The sample included 54 females and seven males. Subjects' ages ranged from 20 to 73 years (mean +/- SD, 35.9 +/- 10.6 years; median, 37 years). Average tumor size was 10.7 +/- 15.9 mm (range, 1-70 mm). Forty-nine tumors (80.3%) were 10 mm or smaller. Surgical procedures included subtotal thyroidectomy (40 patients), total thyroidectomy (16 patients), total thyroidectomy plus neck dissection (2 patients), near-total thyroidectomy (1 patient), and lobectomy with contralateral subtotal lobectomy (1 patient). Thirty-seven patients (60.7%) underwent postoperative 131I ablation for thyroid remnant. Neck lymph node metastases occurred in three patients and lung metastases in two patients. Patients who developed metastases were younger and had significantly larger tumors and higher pretreatment serum T3 level than those who did not develop metastases. No deaths occurred during the 6.2 +/- 4.1 year follow-up period (range, 1 year and 2 months to 18 years and 11 months).

CONCLUSIONS

Most thyroid cancers with concurrent Graves disease were 10 mm or smaller. Subtotal thyroidectomy is adequate for patients with Graves disease with concurrent carcinoma 10 mm or smaller.

Differentiated thyroid cancer: radioiodine following lobectomy — a clinical feasibility study

The surgical management of differentiated thyroid cancer remains controversial. Total thyroidectomy has been associated with higher rates of post-operative morbidity than more conservative surgery, but radioiodine ablation of residual thyroid tissue is considered to be particularly difficult after lobectomy. The purpose of this retrospective study was to assess the feasibility of 131I ablation after lobectomy, compared with total thyroidectomy, in patients who had undergone surgery for differentiated thyroid carcinoma. A retrospective analysis was performed of 225 post-surgical thyroid cancer patients treated with 3500 MBq 131I for the ablation of thyroid remnants. One hundred and sixty-five patients (73%) had previously undergone total thyroidectomy, whilst 60 patients (27%) had been treated by lobectomy. All patients underwent diagnostic scintigraphy, with 40 MBq 131I, 2 days prior to ablative therapy and at 3 months post-ablation. The median pre-ablative 131I neck uptake values were 3.3% and 20.1% in patients treated by total thyroidectomy and lobectomy, respectively (P < 0.001). Pre-ablation neck uptake correlated strongly with the whole-body 131I burden 2 days after 131I therapy (P < 0.001), and the biological half-life of the radioiodine was markedly longer after lobectomy than after total thyroidectomy. Ninety-eight per cent of patients treated by total thyroidectomy were successfully ablated by one 131I treatment, compared with 90% after lobectomy (P < 0.05). There were no significant differences in 131I neck uptake or serum thyroglobulin levels between the two patient groups at 3 months post-ablation. These data show that high rates of thyroid ablation can be achieved with a single fixed dose of 131I after thyroid lobectomy. The use of this surgical procedure may result in a longer period of patient isolation than that required after total thyroidectomy. However, the clear correlation between pre-ablation neck uptake and 131I burden at 2 days post-therapy enables effective treatment scheduling, so making lobectomy followed by 131I ablation a practical option for the management of differentiated thyroid cancer.

Radioiodine lobar ablation as an alternative to completion thyroidectomy in patients with differentiated thyroid cancer

This study seeks to evaluate the role of radioiodine in the ablation of the remaining thyroid lobe, following a histopathological diagnosis of minimally invasive follicular carcinoma or papillary carcinoma of > or =1.5 cm size in patients undergoing hemithyroidectomy. There were 93 patients (69 females and 24 males) with an average age of 37.3+/-12.5 years (range, 16-70 years) and a mean follow-up duration of 46 months. Sixty-six of the patients had papillary cancer and remaining 27 had follicular thyroid cancer. The mean 24 h radioiodine neck uptake at the first visit was 17.2+/-7.3% (4.4-34%). In view of the large amount of thyroid tissue to be ablated, which may produce radiation induced thyroiditis, low doses of radioiodine (15-60 mCi) were administered to the patients. The patients were evaluated 6 months after radioiodine therapy with a 131I whole-body scan and 48 h radioiodine neck uptake, and a thyroglobulin assay after 4-6 weeks of levothyroxine withdrawal. The thyroid lobe was completely ablated in 53 patients (56.9%) after one dose of I and the remaining patients had partial thyroid ablation, with the mean radioiodine neck uptake being reduced to 3.1+/-2.4%. The mean first dose of 131I was 31.8+/-11.7 mCi; the estimated mean absorbed dose was 251.3+/-149.3 Gy (range, 120-790 Gy). Around 30% patients, in each of whom a remnant thyroid lobe was ablated with a single dose of radioiodine, received < or =200 Gy. The cumulative ablation rate was 92.1% after two doses of 131I. Only seven patients needed a third dose of 131I. In our cohort, 15 patients (16.1%) complained of throat discomfort and neck pain. All of them were managed with mild analgesics except three patients who needed additional oral prednisolone for 7-10 days to overcome neck oedema. We conclude that, although completion thyroidectomy remains the standard treatment after hemithyroidectomy in cases of differentiated thyroid cancer, radioiodine ablation of an intact thyroid lobe is possible and it can be achieved with much smaller doses of radioiodine than previously believed. Lobar ablation is an attractive alternative to surgery for those who refuse to undergo completion thyroidectomy or had complications during initial surgery. However, the long-term outcome in this subset of patients remains to be determined.

Safety of completion thyroidectomy following unilateral lobectomy for well-differentiated thyroid cancer

OBJECTIVES

When a diagnosis of thyroid cancer is returned following unilateral lobectomy, removal of the contralateral lobe is frequently necessary. Morbidity for completion thyroidectomy includes a reported 2% to 5% risk of recurrent laryngeal nerve (RLN) injury and an 8% to 15% incidence of hypoparathyroidism. In this study, to determine morbidity following completion thyroidectomy, we reviewed our results of reoperative surgery among patients with thyroid cancer.

STUDY DESIGN

Retrospective chart review.

METHODS

Between 1997 and 2000, 36 consecutive patients, 32 females and 4 males, with a mean age of 43.6 years (range, 19-59 y), underwent completion thyroidectomy. Preoperative fine-needle aspiration revealed follicular derived neoplasm in 32 patients (88.9%), indeterminate in 3 patients (8.3%), and Hürthle cell neoplasm in 1 patient (2.8%). The interval between the first and second operation was a mean of 43.3 days (range, 2-103 d).

RESULTS

At the primary surgery, 29 patients (80.6%) had a follicular variant of papillary carcinoma, 6 (16.7%) had follicular carcinoma, and 1 (2.8%) had Hürthle cell carcinoma. Of these, 14 had multifocal disease. In the completion lobe, 20 patients (55.6%) had evidence of thyroid carcinoma. There was a 0% incidence of RLN injury, and the mean pre- and post-completion thyroidectomy serum calcium was 8.9 mg/dL and 8.6 mg/dL, respectively. There was one postoperative hematoma, requiring re-exploration. Five patients (13.9%) had a transient postoperative serum calcium (Ca) <8.0 mg/dL, with one being symptomatic. None required vitamin D or prolonged calcium supplementation.

CONCLUSIONS

When completion thyroidectomy is necessary for the treatment of thyroid malignancy, the procedure can be performed safely with low morbidity and is effective for diagnosing and removing occult disease in the remaining thyroid.

Conservative management of patients with intrathyroidal well-differentiated follicular thyroid carcinoma

BACKGROUND

Total or near-total thyroidectomy for the treatment of follicular thyroid carcinoma (FTC). The prognosis of patients with low-risk FTC, however, is excellent, and thus total thyroidectomy may not be justifiable in such patients.

METHODS

A retrospective review identified 61 patients diagnosed with intrathyroidal well-differentiated FTC between 1958 and 1991.

RESULTS

Median age at diagnosis was 42 years (range, 15-78 years). Most patients (90.2%) had a lobectomy or subtotal thyroidectomy. Median tumor size was 3.0 cm (range, 0.9-9.5 cm). Fifty-eight patients (95.1%) received thyroid hormone supplementation, and 5 (8.2%) received radioactive iodine ablation postoperatively. Median follow-up was 11 years (range, 3-35 years). Local recurrence, metastasis, or both developed in 3 patients (4.9%), and all subsequently died of thyroid cancer. The cumulative 10- and 15-year cancer-specific survival rate was 96.5%. Factors significantly related to worse survival were oxyphilic histology (log-rank, P =.00) and tumor size of more than 4 cm (P =.001). However, neither was found to be an independent predictor of outcome by Cox multivariate analyses (P =.7 and.9, respectively). The extent of initial operation (unilateral versus bilateral procedure) was not significantly related to survival (P =.52).

CONCLUSION

Conservative management consisting mainly of lobectomy or subtotal thyroidectomy and thyroid hormone supplementation is associated with favorable outcome of patients with intrathyroidal well-differentiated FTC.

Differentiated thyroid carcinoma in the elderly

The overall prognosis of patients with differentiated thyroid cancer is excellent, but the prognosis is rapidly worsening, when the disease is diagnosed in elderly patients. Old patients more often present with poor prognostic features, such as large tumors, follicular or Hürthle cell subtypes, extrathyroidal growth and distant metastases. Therefore, an optimal therapeutic approach is recommended. Current therapy includes a total thyroidectomy, if necessary combined with a lymph node dissection and followed by high dose radioiodine ablation. Radioiodine therapy in elderly patients meets specific problems, concerning thyroid hormone withdrawal, side effects of 131I and nursing problems. Additional treatment of residual, recurrent or metastatic disease must be tailored, according to the stage of the disease, and should not be denied on the basis of chronological age. Lifelong treatment with suppressive thyroid hormone therapy does not lead to important long-term side effects at old age.

Factors related to nerve injury and hypocalcemia in thyroid gland surgery

To identify potential risk factors related to complications after thyroidectomy, a study was designed that included 675 patients. Recurrent laryngeal nerve (RLN) paralysis, hypocalcemia, serohematoma, wound infection, and postoperative hemorrhage were evaluated. The rate of paralysis of the RLN was calculated on nerves at risk for hypocalcemia (n = 890) in patients undergoing bilateral procedures or unilateral procedures if they had previously undergone a contralateral operation (n = 321). Multivariate analysis was used to identify the relationships between the variables included in the study. All statistical tests received the same level of significance of 0.05. Permanent hypocalcemia occurred in 2.2% of the patients, whereas unilateral paralysis of the RLN developed in 0.9%. Mortality was 0.1% in this series. The RLN paralysis had a significant relationship with preoperative diagnosis of malignancy (P < 0.03). Likewise, hypocalcemia was related to sex and surgical procedure (P < 0.03). Serohematoma was linked with age (P < 0.001), and hemorrhage was associated with previous radiation of the neck (P < 0.03).

Surgical management of thyroid cancer

OBJECTIVE

To present an overview of surgical management of differentiated thyroid cancer.

METHODS

Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed.

RESULTS

In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma.

CONCLUSION

Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.

Papillary thyroid cancer

Papillary thyroid cancer is the most common neoplasm of the thyroid gland. Surgical resection is the cornerstone of therapy. There is controversy regarding the extent of resection, ranging from thyroid lobectomy plus isthmusectomy to total thyroidectomy, but in experienced hands total thyroidectomy has many significant advantages over a lesser operation. Nonoperative therapy has no role as primary therapy for papillary thyroid cancer, but can be used in conjunction with surgery to improve outcome. Radioiodine in patients who have received total thyroidectomy can be used to identify residual occult tumor, recurrence, and metastasis, and can also be used to ablate the neoplasm, resulting in a substantial cure rate. Thyroid hormone is needed as replacement after total thyroidectomy, but can also be given as thyroid-stimulating hormone suppression, which may have an adjunctive benefit after resection.

Characteristics and prognostic factors in patients with differentiated thyroid cancer who underwent a total or subtotal thyroidectomy: surgical approach for high-risk patients

Differentiated thyroid cancer grows slowly in general. But some patients repeat recurrence and progress finally to death. To clarify the difference of their prognosis and establish the appropriate thyroid surgery, we studied 105 patients with differentiated thyroid cancer who were treated with total or subtotal thyroidectomy, excluding those with small tumors, under uniform conditions regarding thyroidectomy. There were 77 women and 28 men aged 19 to 76 years (mean 54.7 years). More than 60% (alive) were followed up for longer than 10 years. Thirty-eight (36%) patients had recurrences. There were 19 deaths. Twelve of 31 patients with locoregional recurrence died and 7 of these 12 died of locoregional control failure (neck and mediastinum). Age at first operation, tumor size, and local tumor extension increased the rate of recurrence significantly. Multivariate analysis confirmed that age, locoregional recurrence, and distant metastasis significantly affected survival. Although lymph node metastases were not a prognostic factor, for patients at high risk for recurrence who are older, and have large tumors with invasion, complete resection of cervical lymph nodes is advised to prevent local recurrence and prolong the disease-free interval. Prolongation of the disease-free interval may lead to prolonged survival time.

[Prognostic factors and the effect of radiotherapy in the treatment of differentiated thyroid carcinomas]

PURPOSE

In the treatment of differentiated thyroid carcinomas the indication for adjuvant radiotherapy is discussed contradictory. The following study analyzes the long-term survival rates of patients with follicular and papillar thyroid carcinomas after percutaneous radiotherapy.

PATIENTS AND METHOD

Records of 178 patients with differentiated thyroid carcinomas (132 female, median age 46 years; 46 male, median age 47 years) were evaluated. Following thyroid-resection and radioiodine therapy external beam irradiation was performed with a telecobalt device and high energy electrons (mean reference dose 54.7 Gy). Hundred and twenty patients (67.4%) had a histologically confirmed papillary carcinoma, 58 (32.6%) patients had follicular carcinoma. In the group with papillary carcinoma 57 patients (47.5%) were classified as stage I, 11 patients (9.2%) as stage II, 48 patients (40.0%) as stage III, 4 patients (3.3%) as stage IV, respectively, in the group with follicular carcinoma 21 patients (36.2%) were classified as stage I, 4 patients (6.9%) as stage II, 28 patients (48.3%) as stage III and 5 patients (8.6%) as stage IV. Survival, recurrence rate and prognostic factors were analyzed.

Total thyroidectomy for differentiated thyroid carcinoma: primary and secondary operations

AIMS

There is considerable controversy concerning the most appropriate surgical treatment of patients with differentiated thyroid carcinoma (DTC). Although some authors have advocated subtotal thyroidectomy because of the decreased surgical morbidity and the lack of improved survival with a more extensive procedure, total thyroidectomy has been defended by others as a treatment of choice with lower morbidity.

METHODS

We reviewed 106 consecutive patients who had been treated with total thyroidectomy for DTC to determine the complication rate. Forty-seven patients had primary operations and 59 had reoperations with completion of total thyroidectomy.

RESULTS

Residual tumour in the remnant thyroid tissue was found in 53.8% of patients who underwent prophylactic completion thyroidectomy. Permanent hypoparathyroidism was present in one (0.9%) patient and accidental transient unilateral recurrent laryngeal nerve injury occurred in 2.8% of the entire series. No patient had permanent bilateral recurrent nerve palsy. Furthermore, the risk of complication was not significantly different when comparing primary total thyroidectomy or completion surgery.

CONCLUSIONS

We recommend total thyroidectomy as a safe treatment for DTC with a low rate of morbidity.

Completion thyroidectomy for differentiated thyroid carcinoma

Completion thyroidectomy is performed because of a deferred diagnosis of differentiated carcinoma of the thyroid or a significant thyroid remnant after initial operation. During a period of 6 years, data from 40 patients with differentiated thyroid carcinoma undergoing completion thyroidectomy were retrospectively reviewed. There were 4 men and 36 women (1:9), and the average age was 39.6+/-1.9 years (range, 20 to 62 years). The indications for the initial surgery were a solitary thyroid nodule in 36 (90%) patients, multinodular goiter in 3 (7.5%) patients, and Graves' disease in 1 (2.5%) patient. Three patients underwent completion thyroidectomy during the same hospital stay. In the remaining 37 patients, completion thyroidectomy was performed 4 to 252 days (44.1+/-7.8 days) after the initial operation. The length of hospital stay for the initial operation was not different from that for completion thyroidectomy (5.1+/-0.3 days vs. 5.2+/-0.3 days). The length of time needed to accomplish the initial operation was not different from that required for the completion thyroidectomy (122+/-7.5 minutes vs. 110.8+/-5.9 minutes). There was no 30-day perioperative mortality. The postoperative morbidity in completion thyroidectomy consisted of transient hypoparathyroidism in 3 (7.5%) patients, permanent hypoparathyroidism in 1 (2.5%) patient, transient recurrent laryngeal nerve palsy in 1 (2.5%) patient, and permanent recurrent laryngeal nerve palsy in 1 (2.5%) patient. On the other hand, one transient recurrent laryngeal nerve palsy and one transient hypoparathyroidism occurred at the initial operation. Completion thyroidectomy is a safe procedure to remove the thyroid remnant.

Differentiated thyroid cancer: determinants of disease progression in patients <21 years of age at diagnosis: a report from the Surgical Discipline Committee of the Children's Cancer Group

OBJECTIVE

This study was done to define the extent of disease and evaluate the effect of staging and treatment variables on progression-free survival in patients with differentiated thyroid carcinoma who were less than 21 years of age at diagnosis.

SUMMARY BACKGROUND DATA

Differentiated thyroid cancer in young patients is associated with early regional lymph node involvement and distant parenchymal metastases. Despite this, the overall long-term survival rate is greater than 90%, which suggests that biologic rather than treatment factors have a greater effect on outcome.

METHODS

Variables analyzed for their impact on progression-free survival in a multi-institutional cohort of 329 patients included age, antecedent thyroid irradiation, extrathyroidal tumor extension, size, nodal involvement, distant metastases, technique of thyroid surgery and lymphatic dissection, initial treatment with 131Iodine, residual cervical disease, and histopathologic subtype. Surgical complications were correlated with the specific procedures completed on the thyroid gland or cervical lymphatics.

RESULTS

The overall progression-free survival rate was 67% (95%, CI: 61%-73%) at 10 years with 2 disease-related deaths. Regional lymph node and distant metastases were present in 74% and 25% of patients, respectively. Progression-free survival was less in younger patients (p = 0.009) and those with residual cervical disease after thyroid surgery (p = 0.001). Permanent hypocalcemia was more frequent after total or subtotal thyroidectomy (p = 0.001) while wound complications increased after radical neck dissections (p < 0.00001).

CONCLUSIONS

The progression-free survival rate was better after a complete resection and in older patients. Progression-free survival rate was the same after lobectomy or more extensive thyroid procedures, but comparison was confounded by the increased use of total or subtotal thyroidectomy in patients with advanced disease. The risk of permanent hypocalcemia increased when total or subtotal thyroidectomy was done. Thyroid lobectomy alone may be appropriate for patients with small localized lesions while total or subtotal thyroidectomy should be considered for more extensive tumors.

Carcinoma of the thyroid in children: a 25-year experience

Over the past 25 years, 23 children with carcinoma of the thyroid have been treated at the Christie Hospital, Manchester. Twenty-one cases were well-differentiated carcinoma, and two were medullary carcinoma. They were all treated by resection, 14 with total thyroidectomy and 9 with lobectomy or subtotal thyroidectomy. Sixteen children also had surgery for nodal disease. Two children presented with lung metastases. Sixteen children received post-operative radiotherapy (4 external beam, 12 131I). Median follow-up of 67 months (range 7-233), was the same for the 21 well-differentiated carcinomas and the whole group including the two medullary carcinomas. All 21 children with well-differentiated carcinomas are alive with no evidence of progressive disease. Two relapsed after total thyroidectomy, but both were salvaged, one with external beam radiotherapy, one with 131I. One child with medullary carcinoma died with progressive disease after 43 months, the other is alive, but with slowly progressive disease 145 months after diagnosis. Ten of 14 children experienced post-operative hypocalcaemia following total thyroidectomy, in 7 cases it persisted long-term. 131I and external beam radiotherapy were both well tolerated. The long-term results of treatment of well-differentiated carcinoma of the thyroid are excellent, but there remains disagreement over the extent of treatment required. Some authors believe the condition is multifocal and requires total thyroidectomy, others argue that lobectomy or subtotal thyroidectomy avoids the possible post-operative complications of total thyroidectomy and gives equal long-term cure rates. We agree with the latter view. Although a small series cannot be conclusive, we feel that our results are consistent with this. We also believe, that for children, radiotherapy can be reserved for relapse only, as long as regular follow-up is available.

Prognostic factors in patients with recurrent differentiated thyroid carcinoma

BACKGROUND

Approximately 20% of patients with thyroid carcinoma have relapse. To evaluate the factors affecting their disease-free survival and prognosis, we studied 68 patients with recurrent differentiated thyroid carcinoma, ranging in age from 5 to 73 years (mean: 47.6 years). Three-fourths of patients were followed for >10 years. Thirty-nine patients were treated with total or subtotal thyroidectomy at first operation; the remainder underwent lesser operations. Fifty-six patients had local recurrence, mostly lymph node infiltration. Twenty-six patients died.

METHODS

Survival curves were constructed using the Kaplan-Meier method. Factors affecting relapse and survival were tested by univariate or multivariate analysis.

RESULTS

Univariate analysis identified age at diagnosis, local tumor extension, and surgical method as significant factors for disease-free survival. These three factors and histology were significant prognostic factors. Multivariate analysis showed age, histology, and disease-free interval as significant and independent variables.

CONCLUSIONS

In high-risk patients, complete resection of thyroid tissue and cervical lymph nodes is critical.

Problems in diagnosis and management of goitre in childhood and adolescence

This study is a retrospective review of 17 patients aged 16 and under with a total of 18 goitres, who were investigated and treated at Bristol Children's Hospital and Bristol Royal Infirmary between 1967 and 1994. There were five neoplasms, comprising follicular adenoma (three) and papillary carcinoma (two). Other benign causes of goitre included nodular goitre (four), non-toxic hyperplasia (three) and chronic lymphocytic thyroiditis (three). The authors suggest some guidelines to help in the diagnosis and management of goitre in young patients, as a consequence of significant difficulties encountered in 12 of the 17 patients in this series.

Well-differentiated thyroid carcinoma

PURPOSE

This study presents our experience with 728 patients treated in our department for well-differentiated thyroid carcinoma between 1954-1994.

MATERIALS AND METHODS

The retrospective evaluation of the prognostic implications of the clinical and pathological findings was performed. Age, sex, histological variants, tumor size, and locoregional and distant spread were evaluated as risk factors in relation to the prognosis.

RESULTS

During follow-up, which ranged from 1 to 31 years, 125 locoregional and/or distant metastases developed (17.2% of the patients), 87 of which occurred in the first 10 years after initial therapy. Thirty-two patients with papillary cancer and 20 with follicular cancer died of causes related to malignancy of the thyroid.

CONCLUSION

The experience gained in our department has led us to adopt an aggressive approach in the treatment of patients with well-differentiated carcinoma of the thyroid gland.

Surgery for thyroid cancer

What operation to perform in the case of a patient with thyroid cancer is a controversial issue, because there are few trials of treatments on which to base decisions. Small papillary tumours in young patients can be adequately treated by less than total thyroidectomy as can some variants of follicular carcinoma, but outwith these settings total thyroidectomy is recommended.

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up

SUMMARY BACKGROUND DATA

Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy.

METHODS

An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function.

RESULTS

Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series.

CONCLUSIONS

Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.

Surgical considerations and approach to thyroid cancer

Patients with thyroid cancer can be safely treated by an experienced endocrine surgeon. More extensive initial surgery such as total or near-total thyroidectomy seems to decrease tumor recurrence and prolong life. When such operations can be done with minimal complications, we believe it is the treatment of choice because even low-risk patients have a 4% or 5% risk of eventually dying of thyroid cancer. If this risk of death from thyroid cancer can be decreased to 1% or 2% and the rate of serious complications is 1% or 2%, the authors believe total thyroidectomy is indicated. Most patients can be discharged within 1 day of total thyroidectomy.

Total thyroidectomy in the treatment of thyroid cancer

Considerable controversy exists about the most appropriate treatment for thyroid cancer. In this report the authors present their experience of 189 patients, all of whom had a total thyroidectomy between June 1980 and December 1993. The age of the patients ranged from 11 to 78 years (mean age: 42 years), there were 144 women and 45 men. Histological types were: 146 papillary, 16 medullary, 10 follicular, eight Hurtle, six insular and three undifferentiated. Coexistent lesions included: 22 thyroiditis, 17 adenomas, one Graves' disease and 22 benign goitre. Fifty-six (29.6%) patients had multifocal papillary cancer (bilateral in 45 cases). Surgical complications included 20 cases of transient recurrent laryngeal nerve palsy, 16 cases of transient and one of permanent hypoparathyroidism, and one respiratory obstruction due to bilateral recurrent laryngeal nerve palsy that required temporary tracheostomy. Two patients were reoperated on due to bleeding. Ninety per cent of patients were discharged within 3 days of thyroidectomy. One hundred and fifty patients were evaluated for 131I treatment by a standardized dosimetry procedure 4 weeks after surgery. Dosimetry was also used to calculate therapeutic 131I doses. Seventy-six patients did not show a 131I uptake above background levels, 56 underwent therapeutic 131I, while in the 18 patients who showed an abnormal uptake of 131I it was decided not to give the therapeutic dose. The authors conclude that total thyroidectomy can be performed with a minimum of permanent disability in patients with malignant thyroid tumours. The theoretical and practical advantages of this kind of surgical strategy make it the treatment of choice for thyroid cancer.

Multivariate analysis of histopathological features as prognostic factors in patients with papillary thyroid carcinoma

A retrospective analysis of 121 papillary thyroid carcinomas was made to assess prognostic factors including histological variants which might be related to survival. The mean follow-up period was 10 years and clinical, surgical and histopathological data were studied. The survival curves were analysed by the Kaplan-Meier method and the multivariate analysis used Cox's regression model. Eighty-seven patients had well differentiated papillary cancers. The survival rate for papillary thyroid cancer was 86 per cent at 5 years and 72 per cent at 10 years. Factors showing prognostic significance for survival were tumour size, extrathyroid extension and histological type. Disease-free survival was influenced by sex, existence of a capsule and nodal metastases. Factors showing a favourable prognosis were: age under 45 years, size less than 4 cm, no extrathyroid extension and well differentiated histological type (P < 0.001). Histological subtype was one of the most important prognostic factors.

Completion thyroidectomy for differentiated thyroid carcinoma

Completion thyroidectomy is defined as the surgical removal of the remnant thyroid tissue following procedures less than total or near-total thyroidectomy. The extent of surgical management for differentiated thyroid carcinoma (DTC) is controversial. Although some authors advocate subtotal thyroidectomy with lower complication rates, total or near-total thyroidectomy and completion thyroidectomy have been defended by others because of the improved survival and lower morbidity that is comparable with subtotal thyroidectomy. In this study, the incidence of residual tumor and surgical complication rates in patients who underwent completion thyroidectomy were investigated. The medical records of 165 patients undergoing completion thyroidectomy for DTC were reviewed. Seventy-seven (46.6%) of these patients were found to have residual tumor in the remaining thyroid tissue. Anaplastic transformation developed in two of these patients. Permanent bilateral recurrent laryngeal nerve palsy occurred in three patients, and permanent hypoparathyroidism was seen in one patient. We recommend completion thyroidectomy as an efficient and safe method of surgical treatment with a low complication rate for DTC.

Palliative operations for patients with unresectable endocrine neoplasia

No good randomized studies exist for many types of endocrine tumors to prove that surgery increases the survival of patients with these tumors. However, many case reports and our own experience suggest that it does. Therefore, surgery may be performed to potentially increase the survival of patients with metastatic and localized malignant endocrine tumors. Subsequently, these tumors may still recur locally or distantly. Therefore, surgery is usually a palliative procedure but is occasionally curative. Because endocrine tumors secrete hormonal substances resulting in particular syndromes, debulking surgery may be necessary to control hormonal syndromes. The location of a tumor may cause mass symptoms that can also be relieved by surgery. Thus, many patients with malignant endocrine neoplasia benefit from aggressive surgery. The surgeon must determine the resectability of the tumor as well as the operative morbidity and benefit to the patient before proceeding.

Surgical management of the patient with papillary cancer

Papillary cancer is the most common thyroid cancer occurring in all age groups and is usually an indolent tumor, and patients have an excellent prognosis. The majority of patients with papillary cancer do well. It is for the small number of patients who do poorly that it is critical to carry out the appropriate initial operation. The recognized primary treatment of papillary cancer is surgical excision, and the controversy regarding lobectomy versus total thyroidectomy continues. We favor total thyroidectomy because it eradicates multicentric disease, facilitates postoperative radioactive iodine ablation, and allows thyroglobulin levels to be used as a tumor marker for follow-up. Total thyroidectomy should be done by an experienced surgeon to decrease morbidity. Otherwise a total lobectomy on the side of the nodule with subtotal removal on the opposite side is preferred to avoid serious postoperative complications.

Metastases to the regional lymph nodes, lymph node recurrence, and distant metastases in nonadvanced papillary thyroid carcinoma

To investigate the biological characteristics of papillary thyroid carcinoma from the perspectives of lymph node metastasis, lymph node recurrence, and distant metastasis, 746 patients with nonadvanced papillary thyroid carcinoma were retrospectively studied. There were 76 men and 670 women with a mean age of 42.7 years. The rate of lymph node metastasis was significantly higher in young patients (aged less than 30 years). Lymph node recurrence was observed in 80 patients and distant metastasis in 13, being seen with significant frequency in the young and elderly (aged over 50 years) patients and in the men. The frequency of distant metastasis was significantly greater in the elderly patients and in those with lymph node recurrence. These findings indicate that the role of regional lymph nodes and the clinical meaning of lymph node recurrence differ between young and elderly patients.

Complications of thyroid surgery

BACKGROUND

The morbidity of thyroid surgery is low. Despite this, some authors advocate a subtotal thyroidectomy instead of a total thyroidectomy, to avoid the higher morbidity associated with a total thyroidectomy.

METHODS

We retrospectively evaluated the complications of thyroid surgery in Leiden between January 1, 1982 and October 1, 1990. Three hundred forty-one patients--261 women and 80 men--had 356 operations; 15 patients were operated on twice; there were 152 total hemithyroidectomies, 3 subtotal hemithyroidectomies, 33 total thyroidectomies, 122 bilateral subtotal hemithyroidectomies, 12 combinations of total and subtotal hemithyroidectomies, and 34 other operations.

RESULTS

Calculated for the nerves at risk (n = 489), the percentage of permanent recurrent nerve lesions was 3.1 (in the 5 most recent years it was 1.2%). There was no significant difference between total or subtotal (hemi)thyroidectomies. Initial symptomatic hypocalcemia necessitating supplementation was encountered 42 times (12.5%). The occurrence of permanent symptomatic hypocalcemia (6%) was not significantly different between total and subtotal (hemi)thyroidectomies (p = 0.06). The duration of surgery was 137.8 min for bilateral subtotal thyroidectomies and 182.9 min for bilateral total thyroidectomies (p < 0.0001). There was no difference in blood loss between total and subtotal (hemi)thyroidectomies.

CONCLUSIONS

Because total thyroidectomy carries a risk of complications similar to that for subtotal thyroidectomy, it is not logical to avoid total resections. If the number of total resections were increased, it is anticipated that fewer reoperations, which involve a relatively high morbidity rate, would have to be performed.

Parathyroid autotransplantation in patients undergoing a total thyroidectomy: a review of 261 patients

Parathyroid autotransplantation was first described in 1907 by Halsted. However, this simple and effective method of preserving parathyroid function has been used with increasing frequency only during the past 25 years. Beginning in the late 1960s, our group has transplanted normal parathyroid tissue into the ipsilateral sternocleidomastoid muscle whenever these glands could not be preserved in situ with adequate blood supply. In addition, if the blood supply of all four parathyroid glands appeared compromised, cryopreservation of parathyroid tissue was performed in case the autotransplanted tissue did not function after surgery. Since 1970, 393 patients underwent a total thyroidectomy. Parathyroid glands that could not be saved in situ were biopsied to confirm their identity by frozen section and then autotransplanted. Of the 393 patients who underwent a total thyroidectomy, 261 patients required transplantation of one or more glands. Among those 261 patients who underwent selective parathyroid autotransplantation, 33 (13%) required temporary calcium and vitamin D supplementation. Of these 33 patients, 2 (less than 1%) had permanent hypoparathyroidism and are receiving long-term vitamin D therapy.

Analysis of risk of death from differentiated thyroid cancer

The records of 231 patients with differentiated thyroid cancer, treated at the University Hospital of Granada between 1972 and 1986, were reviewed to determine which factors were associated with a favourable response and prolonged survival. Radical surgery was the initial treatment in the large majority of the patients. During the postoperative period, 174 patients received 131I therapy and 12 patients were treated by external irradiation. All of them received hormone replacement therapy. Median follow up was over 5 years. Kaplan-Meier actuarial overall survival (S) and disease-free survival (DSF) at 10 years were used as end points for analysis. Survival and freedom from relapse at this time were 0.93 +/- 0.02 and 0.63 +/- 0.06, respectively. No flattening of the relapse curve was observed during the period of follow-up. Univariate analysis showed that the prognosis was significantly influenced by age, sex (papillary cancer only), histological type of tumour, clinical-pathological stage of disease and cervical lymph node status (entire group and papillary cancer). Using Cox's regression model, two groups of patients with low and moderate risk of death and moderate and high risk of recurrence could be identified.