Treatment of intrathyroidal papillary carcinoma of the thyroid

Changing trends in the management of well-differentiated thyroid carcinoma in Korea

A questionnaire administered in 2009 found that members of the Korean Association of Thyroid-Endocrine Surgeons (KATES) favored more aggressive treatment of well-differentiated thyroid carcinoma (WDTC) than physicians from other countries. This study assessed the changes in practical management of WDTC in Korea from the previous survey. Questionnaires were sent by e-mail to KATES members. A total of 101 members completed the questionnaire. Their responses were compared with response for the 2009 survey. Of the respondents, 53.5% and 80.2% indicated that they would perform fine-needle aspiration cytology on nodules that were <0.5 cm and 0.5-1.0 cm in diameter, respectively. If the cytology was positive, a large number of respondents favored surgical treatment, regardless of tumor size. Compared with the 2009 survey, a slightly higher percentage favored observation for patients with tumors that were <0.5 cm in diameter, and a larger percentage recommended less-than-total thyroidectomy for patients with T1 cancers. Respondents in 2014 favored aggressive lymph node dissection less, irrespective of tumor size, preferring short-term treatment with thyroid stimulating hormone suppressors. The percentage preferring postoperative high-dose radioactive iodine therapy slightly increased, whereas the percentage favoring external irradiation decreased, in 2014 compared with 2009. The management of Korean patients with WDTC changed from 2009 to 2014. In 2009, Korean respondents favored more aggressive treatment of WDTC compared with respondents from other countries. In 2014, however, Korean respondents favored a more conservative approach, especially in patients with microcarcinomas.

Predictive factors for occult contralateral carcinoma in patients with unilateral papillary thyroid microcarcinoma by preoperative ultrasonographic and pathological features

BACKGROUND

The surgical extent and indication for treatment in patients with papillary thyroid microcarcinoma (PTMC) remain a controversial issue. The aim of this study was to investigate the predictive factor for contralateral occult carcinoma in patients with unilateral PTMC by preoperative ultrasonographic and pathological features.

METHODS

Of the total patients who underwent thyroidectomy, 455 patients with PTMC confined to one unilateral lobe as diagnosed using preoperative ultrasonography (US) were enrolled in the study. Occult contralateral carcinoma was defined as tumor foci in the contralateral lobe that was not detected preoperatively, but was detected pathologically. All patients underwent preoperative US review to investigate the US features of PTMC such as laterality, location, size, internal component, echogenicity, margin, calcification shape, multifocality, bilaterality, extrathyroidal extension, and location with respect to the trachea. Clinicopathological data were also analyzed.

RESULTS

Of the total of 455 patients who underwent total thyroidectomy for preoperatively detected unilateral PTMC, 71 patients (15.6 %) had contralateral occult carcinoma. Clinicopathological characteristics did not significantly differ between patients with and without contralateral occult carcinoma. Multivariate analysis showed that the absence of a well-defined margin and the presence of a probably benign nodule in the contralateral lobe were independent predictive factors for contralateral occult carcinoma in patients with unilateral PTMC in preoperative US images.

CONCLUSION

We demonstrated that an absence of a well-defined margin and the presence of a probably benign nodule in the contralateral lobe were independent predictive factors for contralateral occult carcinoma in patients with unilateral PTMC in preoperative US. The prediction of contralateral occult carcinoma in unilateral PTMC using preoperative US features could be useful for determining the optical extent of surgery.

Total versus hemithyroidectomy for microscopic papillary thyroid cancer

BACKGROUND

No increased mortality has been reported in patients with thyroid papillary microcarcinoma (PMC); however, neck recurrences and distant metastases have been described. In this study, we compare patients' outcomes after total thyroidectomy vs hemithyroidectomy for treatment of thyroid PMC.

METHODS

Two hundred and ninety-three patients from two major medical centers in Israel were included. The mean follow-up period was 7.2±6.8 yr.

RESULTS

Total thyroidectomy was performed in 214 patients and hemithyroidectomy in 79 patients. Mean tumor size was 6.3±3 mm. Lymph-node (LN) metastases and extraglandular extension were more frequent in the total thyroidectomy group than in the hemithyroidectomy group, 24.8% vs 1.3% (p<0.001) and 11.7% vs 3.8% (p=0.042), respectively. The cumulative incidence of recurrence at the end of follow-up was 13.2% in the total thyroidectomy group and 14.3% in the hemithyroidectomy group (p=ns). The incidence of recurrence was higher in patients with LN involvement in both groups. Considering low risk patients only (monofocal tumors, no LN involvement, no extraglandular extension; no.=63 in the total thyroidectomy group vs no.=60 in the hemithyroidectomy group) neck recurrence was found in 10% of patients in the hemithyroidectomy group but none in the total thyroidectomy group. In the hemithyroidectomy group, all locoregional recurrences were diagnosed using ultrasonography, compared to 47.6% in the total thyroidectomy group.

CONCLUSION

For patients with monofocal disease within the thyroid gland and no LN involvement, hemithyroidectomy can be considered an option, bearing in mind a higher risk for recurrence. For all other patients with PMC, we propose total thyroidectomy as initial treatment.

Practical management of well differentiated thyroid carcinoma in Korea

OBJECTIVES

The optimal extent of surgery and postoperative management of patients with well differentiated thyroid carcinoma (WDTC) vary among countries and institutions. We assessed the practical management of WDTC in Korea by questionnaire and compared these results with those obtained in similar surveys of members of the Japanese Society of Thyroid Surgery (JSTS) and the International Association of Endocrine Surgeons (IAES).

MATERIALS AND METHODS

Questionnaires were sent by mail or e-mail to 266 members of the Korean Association of Endocrine Surgeons (KAES). Ninety members (33.8%) completed the questionnaire; their responses were compared with those of the JSTS and IAES surveys.

RESULTS

Total thyroidectomy was more prevalent in the KAES and IAES than in the JSTS, irrespective of tumor size in the low-risk group. Patients with papillary microcarcinoma were more likely to undergo aggressive central compartment node dissection in the KAES than in the IAES or JSTS. Thyroid stimulating hormone suppression therapy was administered to a higher proportion of patients and for longer times in the KAES and IAES than in the JSTS. Postoperative radioactive iodine treatment was more prevalent in the KAES than in the JSTS. There were no differences between the KAES and the JSTS in the treatment of patients with locally advanced thyroid carcinoma. External irradiation and radioactive iodine treatment for recurrent papillary thyroid carcinoma were favored more by the KAES than the IAES and JSTS.

CONCLUSIONS

The actual practices of members of the KAES were almost similar to those of the IAES, but differed from those in Japan in some aspects. In general, however, members of the KAES favored more aggressive treatment of WDTC than did physicians in other countries.

Unique treatment policy for well-differentiated thyroid cancer in Japan: results of a questionnaire distributed to members of the Japanese Society of Thyroid Surgery and the International Association of Endocrine Surgeons

Although surgery has been the mainstay of treatment for patients with well-differentiated thyroid cancer, the extents of thyroid resection and lymph node dissection adopted in Japan differ from those in other countries. Furthermore, regarding the indications for postoperative radiation therapy and hormonal therapy, and treatment modalities for cancer recurrence, there are marked discrepancies between Japan and other countries. A questionnaire survey was thus conducted among domestic and overseas thyroid surgeons to ascertain the actual treatment policy for well-differentiated thyroid cancer in Japan and various foreign countries. For small papillary carcinomas of 2.0 cm or less (T1), thyroid resection was more extensive in foreign countries than in Japan, although the extent of lymph node dissection was limited in the former. For large papillary carcinomas exceeding 3.0 cm (T2), on the other hand, total thyroidectomy was the treatment of first choice for all overseas respondents, but of only 20% in Japan, despite lymph node dissection being more extensive in Japan than in other countries. Overseas surgeons were much more likely to favor postoperative TSH suppression therapy and high-dose (131)I therapy. For recurrence following surgery for papillary thyroid cancer, both domestic and overseas respondents indicated surgical resection to be the most common treatment option, and favored high-dose (131)I therapy as well. In Japan, however, high-dose (131)I therapy is available only in a few institutions. Such limited indications for high-dose (131)I therapy in Japan may reflect a discrepancy in the frequency of total thyroidectomy, a prerequisite for postoperative high-dose (131)I therapy, between Japan and other countries. This is the first questionnaire study conducted in both Japan and other countries in relation to treatment modalities for thyroid cancer. The results reveal that there is a clear disparity in treatment policies between Japan and foreign countries.

Papillary thyroid microcarcinoma (PTMC): prognostic factors, management and outcome in 403 patients

AIM

To investigate an "optimal" therapeutic management of patients with papillary thyroid microcarcinoma (PTMC).

METHODS

We evaluated a group of 403 consecutive patients affected by PTMC operated on by the same surgeon. Prognostic factors were evaluated by uni- and multivariate statistical analysis.

RESULTS

After a mean follow-up of 8.5 years, 372 patients were living without disease (undetectable serum thyroglobulin levels), 24 patients were living with disease (increased serum thyroglobulin levels), 6 patients were deceased due to causes different from thyroid cancer, and 1 patient was deceased due to metastatic thyroid cancer. No statistically significant prognostic factor was found at uni- and multivariate analysis. However, it is worth noting that in patients with a larger primary tumour (size> or =5mm) and treated by partial thyroidectomy alone, the prevalence of recurrent disease was higher than in patients treated by total thyroidectomy and (131)I administration.

CONCLUSION

It appears reasonable to perform total thyroidectomy (possibly associated with central compartment node dissection), (131)I whole body scan (followed by (131)I therapy when necessary) and TSH-suppressive hormonal therapy in patients with PTMC.

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.

Nationwide survey on the treatment policy for well-differentiated thyroid cancer -- results of a questionnaire distributed at the 37th meeting of the Japanese Society of Thyroid Surgery

The treatment policy for patients with well-differentiated thyroid cancer varies among institutions. Although surgery has been the mainstay of treatment for this cancer, there is no consensus concerning the optimal extent of thyroid resection or the extent of lymph node dissection. Furthermore, controversy remains with regard to the indications for radiation therapy and hormonal therapy in surgical or non-surgical cases and the treatment modalities for cancer recurrence. To determine the actual status of treatment policies for thyroid cancer in Japan, a questionnaire was distributed to all physicians who participated in the 37th meeting of the Japanese Society of Thyroid Surgery, to inquire into treatment options for well-differentiated thyroid cancer in relation to clinical stages in actual situations. The replies to this questionnaire were analyzed in this study.

Thyroid microcarcinoma: prevalence, prognosis, and management

OBJECTIVE

To review the usual course of thyroid microcarcinoma (TMC) and the associated prognosis and treatment of affected patients.

METHODS

We discuss predisposing factors in the formation of TMC and the modulation of its behavior, diagnostic evaluation, and management options.

RESULTS

TMC, generally defined as a well-differentiated thyroid cancer less than or equal to 15 mm in diameter, has an estimated prevalence (based on autopsy studies) of about 5 to 10%. Studies, however, have shown that most of these cancers are smaller than 5 mm in diameter. The high prevalence of TMC in the general population contrasts with the rarity of thyroid cancers of greater size, which constitute less than 1% of malignant neoplasms in the United States. The frequent detection of TMC as a result of routine imaging of the neck for unrelated reasons and as a incidental finding in surgical specimens has raised a question about whether the management of TMC should differ from that for thyroid cancer of appreciable size. The uncertainty about optimal management of TMC is attributable to the small number of long-term follow-up studies as well as the common observation that patients usually have an excellent prognosis. Although in most patients harboring a TMC the cancer remains quiescent and never becomes clinically significant, in some cases TMC can demonstrate an aggressive course. Several variables, such as older age, multifocality, bilateral disease, and extrathyroidal spread at initial assessment, may have some adverse prognostic significance. After a partial surgical removal of the thyroid gland for TMC, the recurrence rate may be as high as 11%. Therefore, a treatment dilemma is caused by the low propensity of TMC for progression to clinically significant disease, yet the potential for recurrence and aggressive behavior in some cases.

CONCLUSION

In general, surgical resection of TMC is based on results of fine-needle aspiration biopsy and the rate of growth of the nodule. Aggressive management seems indicated in high-risk patients, particularly older patients, those with a history of radiation exposure, and those with multifocal disease, bilateral disease, or lymph node involvement.

Long-Term Follow-Up of a Patient With Papillary Thyroid Carcinoma, Elevated Thyroglobulin Levels, and Negative Imaging Studies

OBJECTIVE

To describe a patient with papillary thyroid carcinoma who had measurable thyroglobulin (Tg) levels for 20 years without clinical or imaging evidence of a malignant lesion.

METHODS

We reviewed the clinical course, pathologic findings, Tg measurements, and results of various imaging studies in our patient and reviewed the literature regarding Tg-positive, diagnostic total-body radioiodine scan-negative patients with thyroid cancer.

RESULTS

Four months after a 3.5- by 3.5-cm follicular thyroid cancer was removed from the anterior neck area of a 5-year-old girl, a bilateral subtotal thyroidectomy was performed. At age 12 years, she presented with a 2-cm mass on the right side of the neck. After a completion thyroidectomy, recurrent mixed papillary-follicular thyroid cancer was found scattered throughout the remaining thyroid parenchyma. Although a postoperative diagnostic total-body radioiodine scan did not reveal uptake of (131)I, the Tg level was 58 ng/mL. Despite Tg levels as high as 2,528 ng/mL, the patient had no clinical evidence of thyroid cancer during a 20-year period of follow-up. Moreover, numerous imaging studies, including total-body scanning after the administration of 150 mCi of (131)I and [(18)F]fluorodeoxyglucose positron emission tomography, were negative. Review of pathologic specimens from both operations with use of updated diagnostic criteria indicated that the tumor was a papillary thyroid carcinoma.

CONCLUSION

Our observations and the observations of other investigators indicate that some thyroid cancers produce Tg so efficiently that high levels of Tg may be associated with tumors that remain too small to be detected by imaging studies. The Tg levels may remain stable, decline, or even disappear over time without treatment.

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.

Incidental association of thyroid carcinoma and squamous cell carcinoma of head and neck

PURPOSE

This study was carried out to address the dilemma of managing incidentally associated squamous cell carcinoma of the head and neck and thyroid carcinoma.

MATERIALS AND METHODS

The patient group consists of 229 consecutive cases of squamous cell carcinoma of the head and neck and who were treated surgically at the Uludag University School of Medicine Department of Otolaryngology over a four-year period between 1997 and 2000.

RESULTS

Among these patients, 3 had additional thyroid papillary carcinoma metastases (1.3%, 3/229) within the surgical specimens of the surgical procedures performed for squamous cell carcinoma of the head and neck. Complementary thyroidectomy was recommended but could not be performed in one of three cases because of the patient's refusal, and the primary focus of thyroid carcinoma could be found in only one of these two cases who had undergone complementary thyroidectomy. All three patients received postoperative radioactive iodine and thyroid hormone suppression, and all are free of disease after 49, 46, and 19 months of follow-up, respectively.

CONCLUSIONS

Management of thyroid carcinoma found incidentally during treatment of squamous cell carcinoma of the head and neck is still debatable, and all patients must be evaluated individually with regard to its benefit. Our limited experience suggests that total thyroidectomy may not be regarded as mandatory in managing these patients.

Sentinel lymph node biopsy in patients with papillary thyroid carcinoma

BACKGROUND

It remains controversial whether modified radical neck dissection (MRND) for patients with papillary thyroid carcinoma improves prognosis. However, it is highly probable that the incidence of local recurrence is reduced by lymph node dissection. Sentinel lymph node (SLN) biopsy (SLNB) for patients with melanoma and breast carcinoma has been validated as an accurate method for assessing lymph node status. The objective of this study was to determine the feasibility of SLNB for the evaluation of cervical lymph node status in patients with papillary thyroid carcinoma.

METHODS

After injection of methylene blue around the tumor in 22 patients with papillary thyroid carcinoma, blue-stained lymph nodes were dissected as SLNs. After the SLNB, all patients also underwent subtotal thyroidectomy and MRND. SLNs and other lymph nodes were investigated with regard to their number, distribution, size, lymph node status, and ratio of metastatic area.

RESULTS

There was concordance between the SLN findings and the regional lymph node status in 19 of 21 patients (90.5%; 7 patients had both positive SLN and regional lymph node results, and 12 patients had both negative SLN and regional lymph node results). Two patients had negative SLN results but, in the end, had positive nonsentinel lymph nodes (NSLNs). The overall reliability rate of SLNB was 86.3% (19 of 22 patients). The authors experienced no complications with the use of methylene blue for the detection of SLNs.

CONCLUSIONS

SLNB using methylene blue is feasible technically and is safe, and the findings correlate with cervical lymph node status. Therefore, SLNB is a good technique for estimating the status of cervical lymph nodes in patients with papillary thyroid carcinoma.

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.

Extent of surgery for intermediate-risk well-differentiated thyroid cancer

BACKGROUND

Methods of assigning patients with papillary or follicular thyroid cancer (well-differentiated thyroid cancer) to risk groups for the purpose of determining appropriate therapy have been developed. Despite these efforts, the optimal extent of surgery for intermediate-risk patients remains controversial.

METHODS

A retrospective study was conducted of 208 patients with well-differentiated thyroid cancer (DTC) from two institutions. Univariate and multivariate analysis of patient- and tumor-related variables was performed. A regression model was obtained, three risk groups (low, intermediate, and high) were defined, and survival curves were generated.

RESULTS

Prognostic variables were age (P <0.001), distant metastases (P <0.001), tumor size (P <0.001) and an aggressive growth pattern (P = 0.03) by univariate analysis and age (P <0.001) and distant metastases (P <0.001) by multivariate analysis. Tumor size (P = 0.07) was included in the regression model. Total thyroidectomy appeared to provide a survival advantage for intermediate risk patients. High-risk patients treated by lobectomy had a poorer prognosis.

CONCLUSIONS

Total thyroidectomy may provide a survival advantage for intermediate-risk patients with DTC. A prospective randomized trial with 200 such patients is required to confirm this finding.

Thyroid nodules in Graves' disease: classification, characterization, and response to treatment

Thyroid nodules in patients with Graves' disease are common and raise concern about coexistent thyroid malignancy. Alternative etiologies for such nodules are more frequent, and separation from thyroid malignancy is important for rational management. To characterize the types of thyroid nodules present in patients with Graves' disease, evaluate the response of these nodules to treatment, and stratify the risk of thyroid malignancy, we report on a retrospective single center study in an ambulatory setting of 468 Graves' patients ages (12-75) followed for 1-31 years (mean = 5.1) treated with radioiodine (n = 345), near total thyroidectomy (n = 19), thionamide antithyroid drugs (n = 88) or observation (n = 18). Sixty patients (12.8% of the total) had nodules and were classified as: (1) Graves' disease with a solitary hypofunctional nodule (n = 27, 5.8%); (2) Graves' disease with multiple nodules (n = 21, 4.5%); (3) Graves' disease with autonomous nodule (n = 4, 1%); or (4) patchy Graves' disease (n = 8, 1.7%). Six patients (1.3% of total or 10% of nodule patients) had cancer: 5 in group 1 and 1 in group 4. Based on the response to therapy or surgical and fine-needle aspirate pathology, the remaining patients demonstrated pseudo-nodules of autoimmune thyroid disease, autonomous nodules of Marine-Lenhart syndrome, colloid goiter, hyperplastic adenomatous disease, and Hashitoxicosis. In conclusion, Graves' patients present with or may develop nodules commonly (12.6%) and the majority of these are benign expressions of autoimmune changes and coexistent nodular goiter. Thyroid cancer occurs in 10% of all nodules, 19% of palpable solitary cold nodules and 1.3% of the total patients. If the fine-needle aspiration biopsy (FNAB) cytology is benign, it is reasonable to use nonsurgical therapy. Any single cold nodule that remains or develops after treatment needs careful re-examination due to the high risk of malignancy.

Microcarcinoma of the thyroid gland: the Gustave-Roussy Institute experience

BACKGROUND

Patients with thyroid microcarcinoma (TMC) have favorable long term prognoses. However, recurrences in the neck and distant metastases have been reported. The authors investigated independent factors associated with recurrence in an effort to define therapeutic guidelines.

METHODS

Two hundred eighty-one patients (207 females, 74 males; mean age, 41.9 years) with a differentiated thyroid carcinoma < or = 1 cm in greatest dimension (mean size +/- standard deviation, 5.9+/-3.3 mm) were analyzed. The median follow-up time was 7.3 years.

RESULTS

TMC diagnosis was incidental in 189 patients, and metastases were the first manifestation of the disease in the other 92 patients. Therapy included near-total thyroidectomy for 195 patients, lymph node dissection for 195, and therapeutic administration of radioiodine for 124. Eleven recurrences (3.9%) were observed 4.3+/-2.7 years (mean +/- standard deviation) after initial treatment: all had locoregional recurrence (4 in the thyroid bed and 7 in the lymph nodes), and in one of these the local recurrence was associated with lung metastases. Multivariate analysis showed that two parameters significantly influenced TMC recurrence, namely, the number of histologic foci (P < 0.002) and the extent of initial thyroid surgery (P < 0.01). Only 3.3% of patients with unifocal TMC treated with loboisthmusectomy had tumor recurrence.

CONCLUSIONS

The recurrence rate for TMC appears to be low (3.9%). In the authors' view, loboisthmusectomy is the treatment of choice for patients with TMC when only one focus of cancer is found histologically, and total thyroidectomy is the optimal treatment for patients with multiple foci.

Thyroid nodules in Graves' disease: classification, characterization, and response to treatment

Thyroid nodules in patients with Graves' disease are common and raise concern about coexistent thyroid malignancy. Alternative etiologies for such nodules are more frequent, and separation from thyroid malignancy is important for rational management. To characterize the types of thyroid nodules present in patients with Graves' disease, evaluate the response of these nodules to treatment, and stratify the risk of thyroid malignancy, we report on a retrospective single center study in an ambulatory setting of 468 Graves' patients ages (12-75) followed for 1-31 years (mean = 5.1) treated with radioiodine (n = 345), near-total thyroidectomy (n = 19), thionamide antithyroid drugs (n = 88), or observation (n = 18). Sixty patients (12.8% of the total) had nodules and were classified as: (1) Graves' disease with a solitary hypofunctional nodule (n = 27, 5.8%); (2) Graves' disease with multiple nodules (n = 21, 4.5%); (3) Graves' disease with autonomous nodule (n = 4, 1%); or (4) patchy Graves' disease (n = 8, 1.7%). Six patients (1.3% of total or 10% of nodule patients) had cancer: five in group 1 and and one in Group 4. Based on the response to therapy or surgical and fine-needle aspirate pathology, the remaining patients demonstrated pseudo-nodules of autoimmune thyroid disease, autonomous nodules of Marine-Lenhart syndrome, colloid goiter, hyperplastic adenomatous disease, and Hashitoxicosis. In conclusion, Graves, patients commonly present with or may develop nodules (12.6%) and the majority of these are benign expressions of autoimmune changes and coexistent nodular goiter. Thyroid cancer occurs in 10% of all nodules, 19% of palpable solitary cold nodules, and 1.3% of the total patients. If the fine-needle aspiration biopsy (FNAB) cytology is benign, it is reasonable to use nonsurgical therapy. Any single cold nodule that remains or develops after treatment needs careful re-examination due to the high risk of malignancy.

Therapeutic strategies and long-term results in differentiated thyroid cancer

Differentiated thyroid carcinoma (DTC) is usually an indolent tumor associated with a low mortality. However, DTC, particularly papillary thyroid carcinoma, happens to be a multicentric tumor and tends to spread to the regional lymph nodes in the early stage of the disease; some patients with DTC do die from metastatic or recurrent disease. Despite the small number of these patients, therapeutic strategies designed to prevent such outcomes should be pursued. In this review, we attempt to evaluate the impact of different therapeutic strategies on survival and recurrence. Consequently, we conclude that the surgical approach to DIC should be individualized on the basis of the biologic behavior of the tumor, rather than on the extent of cancer involvement in the thyroid and regional lymph nodes. It is mandatory to expand our efforts to identify high-risk patients more accurately, thereby facilitating more rational approaches to treatment.

Postoperative outcome of insufficient surgery for small differentiated thyroid carcinoma

We performed conservative surgery for small differentiated thyroid carcinoma, but also inadvertently carried out minimal insufficient surgery, such as enucleation (Ex) or partial lobectomy (pLx) without regional node dissection for malignant thyroid nodules. In this study, the long-term postoperative outcome after such insufficient surgical treatment was evaluated. Of 348 patients with differentiated thyroid carcinoma who underwent initial surgery between 1953 and 1976, 84 underwent either Ex or pLx and their records are herein reviewed. The frequency of recurrence from the remnant gland or regional lymph nodes was examined in relation to the tumor diameter (< or = 1.0 cm, tis; 1.0 cm-2.0 cm, t1; > 2.0 cm, t2). After Ex/pLx, the recurrence rate in the tis group was 13.3% and not significantly different from that (13.6%) in the t1 group. The recurrence rate was notably increased in the t2 group. Moreover, there was no significant difference between the recurrence rate in the tis and t1 groups after Ex/pLx and that after lobectomy with nodal dissection. These results suggest that a reoperative procedure with a more extensive thyroidectomy and neck dissection might not necessarily be required immediately after minimal insufficient surgery is inadvertently carried out in patients with small differentiated thyroid carcinoma measuring 2.0 cm in diameter or less.

Papillary microcarcinoma of the thyroid gland

Papillary microcarcinomas are a specific subgroup of papillary thyroid cancer. They have the same histological features as papillary thyroid cancer but are 1.0 cm or less in diameter. These tumours are a common incidental finding at autopsy and in thyroid glands excised for other pathology. This tumour can metastasize to regional lymph nodes but its ability to cause significant morbidity and mortality has been questioned. As papillary microcarcinomas can represent up to 30 per cent of all papillary cancers seen in a thyroid surgeon's practice, they are an important group. The aim of this review article is to outline the natural history of papillary microcarcinoma and to offer therapeutic management strategies.

Overexpression of p53 in tall cell variants of papillary thyroid carcinoma

BACKGROUND

The tall cell variant (TCV) is a clinically aggressive subtype of papillary thyroid cancer. The aim of this study was to discover the prevalence of mutant forms of p53 protein in this subtype and relate it to clinical outcome.

METHODS

Eighteen patients with TCV and a control group with common papillary cancers, matched for age and gender, were studied. The p53 mutations were identified by means of immunohistochemical staining. Data reviewed were overall survival, recurrence, TNM stage, and p53 positivity.

RESULTS

p53 mutations occurred in 11 (61%) patients with TCV compared with two (11%) in control group (p = 0.05). In the TCV group two patients died of the disease (11%) and eight (44%) had local recurrences or distant metastases compared with none in the control group. All deaths and 70% of the recurrences occurred in patients with stage III or IV disease. p53 positivity did not correlate with any reduction in survival (7% compared with 9%) but with increased rate of local (23% compared with 4%) and distant (23% compared with 13%) recurrences.

CONCLUSIONS

TCV was associated with a significantly higher rate of p53 positivity than common papillary carcinoma. The stage of the disease seemed to be a better prognostic indicator than p53 positivity for overall survival.

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.

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.

Primary thyroid carcinoma in children: a retrospective study of 20 patients

A total of 20 children (median age 11 years) were treated for primary thyroid carcinoma from 1976 to 1990. Papillary adenocarcinoma was diagnosed in 19 and follicular in one case. Nineteen of 20 patients were considered amenable to surgery, which consisted of total thyroidectomy in 14 and partial thyroidectomy in 5. Only one patient with extensive perithyroid soft tissue infiltration was treated with external beam radiotherapy. Monolateral or bilateral cervical nodal dissection was performed in eight and six children, respectively; in nine cases without clinical evidence of metastatic nodes. Pathological examination showed that tumor extent was greater than that clinically assessed: Multiple tumor foci within the thyroid were assessed in 8/19, unilateral positive nodes in 8, and bilateral in 6, and soft tissue infiltration in 7. Subsequently 10 patients received thyroid-stimulating hormone (TSH) suppressive hormonotherapy. Relapses occurred in 7/20 at 2-48 months (median 18) from primary treatment: Four in cervical nodes, two in cervical nodes and lungs, and one in lungs. These seven patients were salvaged with node dissection and radioiodine therapy for lung metastases. All the 20 children are alive and disease-free after a median follow-up of longer than 10 years. The incidence of relapse was greater in the group of patients not given TSH-suppressive hormonotherapy. Total thyroidectomy produced permanent hypoparathyroidism in 5/14 (36%). Thyroid carcinoma in children of this series frequently presented with multiple tumor foci within the thyroid and cervical node metastases. Prognosis was favourable even after relapse and was not related to the extent of surgical treatment. Limited surgery and suppressive hormonotherapy may be adequate therapy for thyroid carcinoma in children.

Utility of frozen section analysis on follicular lesions of the thyroid

The experience of one surgeon (R.H.) with intraoperative frozen sections (FS) performed on thyroid nodules over a 10-year period was studied to assess the utility of FS in follicular thyroid lesions. One hundred and ten patients with dominant or solitary nodules demonstrating a follicular growth pattern were evaluated. The FS slides and subsequently the permanent sections of the nodules were reviewed by the pathologists in the study (M.P.B., VAL.) without knowledge of the original diagnoses. Our results indicate: (1) if the FS was definitively benign (58 patients), the final diagnosis was benign [these lesions consisted of adenomatous nodule, nodular goiter, follicular adenoma, and Hürthle cell adenoma); (2) if an FS diagnosis of malignancy was rendered (4 patients), it was confirmed on permanent sections (follicular variant of papillary carcinoma in all 4); and (3) if the FS diagnosis was deferred (48 patients), the final diagnosis was benign in all but 10 (21 %) (of these 10, 6 had minimally invasive follicular carcinoma [2 of the Hürthle cell type], and 4 had follicular variants of papillary carcinoma). Overall, sensitivity, specificity, and accuracy rates for FS diagnoses were 29, 100, and 91%. Because unilateral lobectomy may be acceptable therapy for well-differentiated thyroid cancers, and because the efficiency of FS evaluation in diagnosing malignancy is low (only 4 malignancies of 110 total patients were diagnosed at FS, or 3.6% overall), we conclude that in this era of cost-containment, FS is not useful in the evaluation of follicular thyroid nodules identified preoperatively as follicular lesions by fine-needle aspiration cytology. Several recommendations concerning the 3 categories of FS diagnosis (i.e., definitively benign, definitively malignant-especially the follicular variant of papillary carcinoma-and deferred) are also put forward.

Multivariate analysis of risk factors influencing survival in 110 ethnic Chinese with papillary thyroid cancer

Data from 110 Chinese patients presenting with papillary thyroid cancer to a single institution up to December 1985 have been analyzed to evaluate the possible risk factors affecting survival. There were 83 women and 27 men with an age range of 15 to 78 years (mean 45 years, median 42 years). The longest follow-up period is 39 years and the median 10 years. Cervical lymph node recurrence more than 6 months after surgery developed in 12 patients, of whom 1 died with a concomitant distant metastasis. "Thyroid bed" tumor recurrence, after apparently complete surgery, presented in 10 patients and resulted in 5 deaths. Distant metastases were identified in 17 patients with 7 deaths. Another 4 patients died from advanced local disease incompletely resectable on presentation. The following seven risk factors for survival were selected for multivariate analysis: age, sex, tumor size, histologic evidence of extrathyroidal spread, lymph node recurrence, neck recurrence, and distant metastases. Age, size, neck recurrence, and distant metastases were all significant on univariate analysis. Using Cox proportional hazards regression in the multivariate analysis of these seven factors, only age (p < 0.0001) was shown to be significant. Age over 40 years on first diagnosis was a highly significant indicator of high risk (p = 0.0003, log-rank).

Classification of papillary cancer of the thyroid based on prognosis

Between 1965 and 1988 there were 2953 patients with papillary carcinoma treated at Noguchi Thyroid Clinic. Among them 761 patients were excluded because the primary tumor was < 10 mm in maximum diameter, the patient's age was > 80, or the patient underwent noncurative surgery. The remaining 2192 patients, 192 men and 2000 women, were analyzed. The mean follow-up period was 12.5 years. Total thyroidectomy, subtotal thyroidectomy, lobectomy with or without isthmectomy, and less than lobectomy were performed in 2.3%, 40.3%, 44.2%, and 13.2%, respectively. Modified radical neck dissection, partial node excision, and no node excision were performed in 77.8%, 6.4%, and 15.8%, respectively. Men and women were separately analyzed because their risk factors and prognosis were significantly different. Multivariate analysis was carried out according to Cox's regression hazard model. Independently significant factors affecting prognosis in men were aged and gross nodal metastasis; and age, gross nodal metastasis, tumor size, and number of adhered tissues or organs were the factors in women. Based on those risk factors patients were classified into three groups. For men, 65.6% were classified in the excellent group and their 10-year survival was 98.4%; 17.2% were classified as intermediate and 17.2% as poor with survival rates of 90.1% and 74.4%, respectively. For female patients 69.6% were classified in the excellent group, 18.6% in the intermediate group, and 11.9% in the poor group with 10-year survivals of 99.3%, 96.4%, and 88.8%, respectively.

Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer

We studied the records of 342 patients with papillary thyroid carcinoma out of a total of 728 thyroid cancer patients treated at the Medical School of Hannover (MHH) from 1972 through 1992. The comprehensive data-abstracting forms were designed, and the acquired information was coded, stored, maintained, and evaluated by the Clinical Cancer Registry of the MHH. A total of 160 patients (46.8%) initially had lymph node metastases (N1 status). The N status significantly influenced recurrence (p < 0.00001) and survival (p < 0.00001). Excluding other risk factors developed by univariate and multivariate analysis, such as high age (age > 45 years, p < 0.001), tumor invasion (T4 tumor, p < 0.005), and distant metastases (M1, p < 0.001), lymph node metastases remained an independent, highly significant prognostic marker for more aggressive papillary thyroid cancer. N1 status did not influence survival of patients with T4 tumor but did influence those with T1-T3 status (p < 0.001). The influence of N1 status remained significant in patients older (p < 0.001) and younger (p < 0.05) than 45 years of age. Systematic compartment-oriented dissection of lymph node metastases improved survival (p < 0.005, T1-T3) and recurrence (p < 0.00001, T1-T3) especially in patients with T1-T3 tumors. In conclusion, lymph node metastases with a significant incidence at a young age and male sex had a substantial effect on survival and recurrence especially in those with tumor status T1-T3. Systematic compartment-oriented dissection of the lymph node metastases results in better survival and a lower recurrence rate.

Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland

The preoperative and pathological findings of 38 cases of small papillary carcinoma of the thyroid gland measuring < or = 10 mm in diameter and 74 cases of large papillary carcinoma measuring more than 10 mm were compared. In the small carcinoma cases, the sensitivity of palpation, ultrasonography, and fine-needle aspiration biopsy (FNAB) was higher than that of computed tomography and soft tissue roentgenography of the neck. Therefore, palpation, US, and FNAB should be instituted as reliable diagnostic methods, but other examinations seem unsuitable as methods for preoperative qualitative diagnosis. No definite correlation was found between the intraglandular dissemination and the size of the carcinoma, and the frequency of metastasis was relatively high even in the small carcinoma cases. If the patient elects to undergo surgery, subtotal thyroidectomy with lymph node dissection should be performed for small thyroid carcinomas as well as large carcinomas.

Recurrence-associated mortality in patients with differentiated thyroid carcinoma

Differentiated thyroid carcinoma (DTC) is associated with prolonged natural history, and even recurrent tumor is not necessarily followed by increased mortality. Prognostic factors and different treatment strategies, therefore, are difficult to assess. One hundred and fifty-seven patients were followed in our clinic. In an attempt to predict mortality from this tumor, we evaluated the risk factors in 36 patients who presented with recurrent disease. Ten of these patients died. Age above 40 years at initial diagnosis was the predominant risk factor associated with 44% mortality after recurrence. Male sex, lack of radioiodine treatment, and distant site of initial recurrence were all associated with a trend towards increased mortality. Tumor histology and local invasion or extent of initial surgical treatment failed to affect mortality. In conclusion, this approach may be used to identify those patients who will die from their disease, despite currently available treatment. It remains to be seen, however, if new treatment protocols can be developed to improve the prognosis of these patients.

"Occult" papillary carcinoma of the thyroid: a questionable entity

A series of 72 cases of "occult" thyroid papillary cancer, i.e. tumours of less than 1.5 cm in diameter, was analysed. The patients--26 males and 46 females--were treated surgically, 25 by lobectomy and isthmusectomy and 47 by total thyroidectomy. In 51 cases nodal neck dissection was performed, bilateral in 2 cases. 9 thyroidectomised patients received radiometabolic therapy. Hormone therapy (T4) was continuously administered to 57 patients. The median duration of follow-up was 99 months (60-189). All the patients were alive (except one who died from other causes) and free of disease at last control. No relapses in the thyroid were observed in the conservatively treated patients. 2 patients of the 47 radically operated upon subsequently presented nodal metastasis and underwent neck dissection. The so-called "occult" thyroid papillary cancer does not differ from other papillary cancers with respect to morphological, clinical and prognostic factors--it differs only in size. Considering occult papillary tumours as an entity is questioned in this paper.

Metastatic thyroid cancer as an incidental finding during neck dissection: significance and management

Occult thyroid cancer is an occasional incidental finding during surgery for other indications and is usually considered of minor clinical significance; however, the appropriate approach for incidentally found metastatic thyroid cancer is less clear especially when it occurs in the context of another malignancy that has more aggressive potential. Among 2,855 patients treated for squamous cancer of the tongue at The University of Texas M. D. Anderson Cancer Center, eight patients had coexisting differentiated thyroid cancer metastatic to cervical lymph nodes which was found incidentally during regional lymph node dissection. The eight patients included three women and five men with a median age of 47 years (range, 32-62 years); tumors were of the papillary variety in four patients and follicular in the other four. In one patient, no gross or microscopic primary tumor could be identified after thyroidectomy; in another patient, no gross tumor was evident, but whole organ section revealed an area of fibrosis consistent with a primary lesion. Two patients had primary lesions less than 1 cm in maximal diameter. In four patients who had no surgery, physical exam and radiologic evaluation failed to show any intrathyroidal lesions. Clinically relevant thyroid cancer did not develop in any of those patients during the duration of documented follow-up (1-15 years). Three patients died of progressive tongue cancer, one patient of unrelated pulmonary disease, and four patients remain alive without evidence of disease for 1 to 15 years of available follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in papillary carcinoma of the thyroid

In a retrospective study of 119 patients, followed for 1 to 30 years after treatment of a papillary carcinoma of the thyroid, the authors searched for possible prognostic factors of the risk of recurrence. Microcarcinomas, anaplastic tumors and Hürthle cell carcinomas were excluded from the study. In a univariate analysis, age (greater than 45 years), sex (male), loss of histologic differentiation, size (greater than 3 cm), presence of carcinomatous lymphangitis, extrathyroid extension, and presence of metastasis at diagnosis were associated with a higher recurrence rate; type of growth and multifocality were not significant. In a multivariate analysis (logistic regression), age, size, and carcinomatous lymphangitis were significant predictors for women, whereas metastasis at diagnosis and cystic growth were significant for men.

Occult papillary microcarcinoma of the thyroid--a potential pitfall of fine needle aspiration cytology?

The use of fine needle aspiration cytology detected papillary carcinoma in two patients with multinodular goitre measuring 0.7 cm and 0.9 cm in diameter, respectively. Like most of the cases from previous large series, the tumours progressed slowly as shown by absence of enlarged glands on surgical exploration and no clinical signs of metastasis after two and five years of follow up. This study shows that aspiration cytology can detect a virtually harmless occult papillary carcinoma that will oblige patients to have surgery. This very occasional "pitfall" of fine needle aspiration should not preclude this well known beneficial method from being used in the management of thyroid disease.

Distant metastases in differentiated thyroid carcinomas: a clinical and pathologic study

Of 514 patients with differentiated thyroid carcinoma treated between 1970 and 1987, 34 (6.6%) had distant metastases. Twelve patients died of their distant metastases; eight of these patients died within 5 years from the time of initial diagnosis. Death from cancer was most frequent in the seventh decade. The metastases were most often found in the lungs and bones. In the fatal group, pleural, brain, and pericardial metastases were noted. Local recurrences were found only in 24% of these 34 patients. Histologic types of primary thyroid tumors and metastatic tumors were reexamined and classified using our criteria, which were mainly based on the World Health Organization nomenclature and currently obtained pathologic observations of thyroid tumors. In 31 thyroid tumors, the surgical specimens were available for review. Twenty-four tumors were papillary and seven were follicular. Of the 24 papillary carcinomas, nine were follicular, eight were well-differentiated, and seven were trabecular. On the other hand, the seven follicular carcinomas consisted of four well-differentiated, two solid, and one oxyphilic. The majority of the thyroid tumors showed an extrathyroidal extension; however, two were intrathyroidal carcinomas and two were encapsulated carcinomas, larger than 5 cm in diameter. Distant metastases were confirmed morphologically in 18 patients (11 by surgical or biopsy material, five by autopsy, and two by cytology). The histologic types of metastatic tumors were consistent with those of primary thyroid tumors. Diagnostic 131I uptake was examined in 32 patients and absorption of diagnostic 131I in metastatic tumors was demonstrated in 21 patients. The 10-year survival rate of patients with 131I accumulating metastases (70%) was significantly better than that of patients with metastases lacking such uptake (40%). Immunoreactivity for thyroglobulin in metastatic tumors was correlated with the 131I absorption. This finding indicated that immunostaining of thyroglobulin in metastatic tumors might be useful in the prediction of the effectiveness of 131I therapy.

Prognosis and morbidity after total thyroidectomy for papillary, follicular and medullary thyroid cancer

The prognosis and the morbidity results after total thyroidectomy are reported for 148 patients with differentiated thyroid cancer. Ninety-two patients (62%) had papillary cancer, 27 (18%) had follicular cancer and 29 (20%) had medullary cancer. In the latter group, 16 patients had no clinical signs of a tumour and underwent total thyroidectomy after elevated calcitonin levels were found in a family screening programme. The mean follow-up period was 9.7 years in the present series. The 5- and 10-year overall survival in the patient group with papillary cancer was 97% and 95% respectively, in the group with follicular cancer it was 78% and 50% respectively and in the group with medullary cancer it was 91% and 82% respectively. Significantly associated with reduced disease-free survival were: extrathyroidal growth (P less than 0.0001), distant metastases at diagnosis (P less than 0.0001), follicular histology (P less than 0.0001), age over 40 (P less than 0.001) and male sex (P less than 0.05). In patients with papillary cancer, recurrences were in most cases located in the neck, while recurrences at distant sites were encountered more frequently in patients with follicular or medullary cancer. Accidental permanent unilateral recurrent laryngeal nerve palsy were registered in 1.4% of the nerves at risk; all on the side of the tumour. Permanent hypoparathyroidism was present in 4% of the patients.

Prognostic value of morphometry in papillary thyroid carcinoma

The value of morphometric analysis in addition to standard prognostic indicators was studied in 28 cases of papillary thyroid carcinoma. Standard features included age, sex, lymph node status, tumor size, and encapsulation. The mean follow-up was 47 months (maximum, 140 months). Recurrences were documented in six patients at a mean time of 34 months; five patients recurred with distal metastases and one patient recurred with local disease. Univariate analysis most closely associated tumor recurrence with nuclear anisotropism (the standard deviation of the estimated nuclear area [ENASD]) and tumor size. With forward stepwise incremental analysis, the value of tumor size was lost and only the ENASD and the cellularity mean index (CMI), defined as the percentage of tumor volume composed of tumor cells, significantly correlated with recurrence. Fifty-five percent of patients with an ENASD greater than 17 microns2 and a CMI greater than 40% developed recurrence as compared with 5% of patients with lesser values (P = .0001). Morphometric analysis may significantly contribute to the role of histopathology in the evaluation of papillary thyroid carcinoma and may also provide information regarding prognosis not obtained by standard methods.