Carcinoma of the thyroid in surgical and postmortem material. Analysis of 300 cases at autopsy and literature review

Adverse Histological Features of Differentiated Thyroid Cancer Are Commonly Found in Autopsy Studies: Implications for Treatment Guidelines

Background: While the popularity of lobectomy for differentiated thyroid cancer (DTC) has increased since the 2015 ATA (American Thyroid Association) guidelines, recent studies reported that adverse histological features (minimal extrathyroidal extension [mETE], multifocality, vascular invasion, and lymph node [LN] metastases) may be found in 30-60% of lobectomy specimens, questioning the validity of this approach. Aim: To assess the prevalence adverse histological features in occult DTC detected in autopsy studies. Methods: Meta-analysis of autopsy studies of the thyroid in subjects without known history of thyroid cancer. Results: Twenty-nine studies including 8750 subjects fulfilled the inclusion criteria, with incidentally discovered DTC in 740 autopsies (8.5%). Age was reported in 17 studies, with a median age of 61 years (range 41-68 years). Multifocality was reported in 27 studies with a calculated event rate of 28.2% ([CI 23.1-33.8], I² = 46.3%), with bilateral involvement in 18% [CI 12.6-25.1]. mETE was reported in 5 studies, with an event rate of 24.5% ([CI 9.3-50.7], I² = 88.5%), and the presence of LN metastases were reported in 13 studies with an event rate of 11% ([CI 6.1-19.1], I² = 69.5%). Vascular invasion was reported in seven studies with an event rate of 16% ([CI 4-47], I² = 86.8%). Of 25 studies with whole body autopsies (722 subjects), 3 cases of distant metastases were reported, of which 2 had fatal metastatic disease (where thyroid origin was not diagnosed before death), and 1 had occult disease. Conclusions: Adverse histological features including mETE, LN metastases, multifocality, and vascular invasion are common in occult DTC. When minimal in size, these adverse histological features do not seem to be markers of aggressive disease and may not be an indication for completion thyroidectomy or radioiodine therapy.

Breast cancer metastasis into thyroid papillary carcinoma: A case report

Both metastatic tumors and breast cancer metastases in the thyroid gland are rare. Tumor metastasis into a primary thyroid cancer is rarer. We present a case with breast cancer metastasis into a metachronous thyroid papillary carcinoma which is the only case in literature.

Metastasis to the thyroid gland: a single-institution 16-year experience

AIMS

Metastasis to the thyroid gland is a rare occurrence that may pose a diagnostic challenge. In this study, we aimed to report the clinicopathological features, immunoprofile, molecular alterations and outcome of 30 patients treated at our centre from 2003 to 2019.

METHODS AND RESULTS

The most common site of the primary tumour was the kidney, followed by the lung, lower gastrointestinal tract and breast. In seven (23%) patients, the thyroid metastases were resected prior to the diagnosis of the primary tumours. Six patients (20%) had thyroid as the sole metastatic site. Three (10%) patients harboured tumour-to-tumour metastasis; 71% had a unilateral unifocal thyroid mass, which might be mistaken for a primary thyroid tumour. Among the 13 cases that were initially diagnosed at an outside hospital, four (31%) were misinterpreted as a thyroid primary. An immunohistochemical panel of thyroid follicular cell markers was most useful to differentiate primary thyroid tumours from metastasis. Molecularly, the metastasis showed alterations characteristic of the primary tumour, which may be helpful in establishing the diagnosis and primary site. Although the prognosis was poor, with a 5-year disease specific survival of 58%, a long-term cure was possible in cases with oligometastasis successfully treated with surgery.

CONCLUSIONS

Metastasis to the thyroid gland is an uncommon phenomenon, with an incidence of 0.36% in all thyroid malignancies. It may present as a solitary thyroid mass before the discovery of the primary tumour, posing a diagnostic challenge. Although the overall prognosis is poor, a subset of patients with oligometastasis can be managed surgically.

Prevalencia de tumores metastásicos en la glándula tiroides. Revisión sistemática y metanálisis

Introducción y objetivo: Los tumores metastásicos en la glándula tiroides complican el diagnóstico, el tratamiento y el pronóstico del paciente. El objetivo es conocer la prevalencia de las metástasis en la glándula tiroides referida en la literatura médica y los tumores primarios que con más frecuencia metastatizan en la glándula tiroides. Método: Se realizó una revisión bibliográfica sistemática en las bases de datos de PubMed, La Biblioteca Cochrane y Scopus. Los artículos seleccionados se dividieron en dos grupos, series clínicas de pacientes en los que se hallaron metástasis en tiroides (grupo A) y series de hallazgos de metástasis en tiroides en autopsias (grupo B). Se realizó metanálisis de prevalencia para cada grupo de artículos siguiendo el modelo de efectos aleatorios. Resultados: La prevalencia en cada grupo con su índice de confianza al 95% fue 0.00479 (0.002-0.007) para el grupo A y 0.0362 (0.014-0.059) para el grupo B. La prevalencia de metástasis halladas en autopsias fue 7,58 veces mayor que en los estudios clínicos. En el grupo A la edad media fue 60.82 y en el grupo B 57.20. En ambos grupos las metástasis halladas en tiroides fueron más frecuentes en el sexo femenino. La localización del tumor primario fue diferente en ambos grupos, en el grupo A fue el cáncer de riñón y en el grupo B el cáncer de mama. La variabilidad de la prevalencia de metástasis en tiroides en los diferentes artículos de ambos grupos hace que este estudio tuviese una alta heterogeneidad (índice I2 y Q). Los funnel plot de ambos grupos indicaron alto sesgo de publicación. Discusión: La diferente prevalencia entre series clínicas y autopsias puede implicar que la detección de metástasis en tiroides en la clínica está infradiagnosticada. La razón de esto podría ser que las metástasis intratiroideas se presentan de forma asintomática siendo diagnosticadas como hallazgo casual en autopsias. En otras ocasiones se presentan como un nódulo tiroideo años después del tumor primario, lo que condiciona el diagnóstico. Conclusiones: La prevalencia de metástasis en tiroides es superior en las series de autopsias que en series clínicas (hasta 6.67 veces más frecuente en nuestro estudio). Las metástasis intratiroideas probablemente están infradiagnosticadas por cursar sin clínica siendo diagnosticadas como hallazgo casual en autopsias. Los tumores primarios más frecuentes fueron el riñón (series clínicas) y la mama (series de autopsias).

Clinical Examination and 131Cs Scanning in the Diagnosis of Cold Nodules of the Thyroid

The usefulness of 131Cs scanning in preoperative diagnosis of 131I cold nodules of the thyroid that present no clear clinical sign of malignancy is discussed. The results of clinical examination of 283 thyroid nodules, associated in 139 cases with 131Cs scanning, are correlated with the histologic nature. In nodules that were classified as cold, warm or hot in the 131Cs scan, the incidence of malignancy was 2.6, 12.3 and 25 %, respectively. In the nodules that, on the basis of clinical examination, were classified as probably benign, dubious or suspected for malignancy, the incidence of cancer was, respectively, 3.6, 26.3 and 72.7 %. Malignancy ocurred in 16 of 144 patients that were selected for surgical treatment only on the basis of clinical data and in 17 of 139 patients that were selected on the basis of clinical examination associated with 131Cs scanning. The accuracy of clinical preoperative diagnosis of thyroid cold nodules does not seem to be significantly improved by association of 131Cs scanning.

18F-PET/CT imaging of metastasis to the thyroid gland: Imaging findings and effect on patient management

Purpose

While metastasis to the thyroid from a primary cancer remote to the thyroid is uncommon, current imaging techniques have improved detection of these intrathyroid metastases. The purpose of this study was to evaluate the ¹⁸F-PET/CT appearance of intrathyroid metastases and assess the impact of detection on patient management.

Methods

The ¹⁸F-PET/CT appearance of intrathyroid metastasis, including standardized uptake value (SUV), disease extent, and the effect on patient management following diagnosis were retrospectively reviewed. Inclusion criteria included ¹⁸F-PET/CT imaging and diagnosis of the intrathyroid metastasis matching the remote primary tumor.

Results

Intrathyroid metastasis were detected in 24 patients. The intrathyroid metastases presented on ¹⁸F-PET/CT as focal nodular uptake (n = 21), multiple nodular uptake (n = 2), or diffuse uptake/infiltration of the thyroid gland (n = 1). The SUV ranged between 3.9 and 42 (median 12.5 ± 7.5); in 2 patients, the FDG-avidity was minimal. On ¹⁸F-PET/CT, distant metastases were present outside the neck (n = 18), or limited to the neck (n = 6). In 2 of these 6 patients, the thyroid was the only site of metastatic disease. Due to the metastatic disease, the therapy was changed in 23 of 24 patients; 1 patient was lost to follow-up.

Conclusion

In any patient with a previous or current history of an extrathyroid malignancy, an ¹⁸FDG-avid thyroid mass or diffuse infiltration of the thyroid on ¹⁸F-PET/CT should be considered a potential intrathyoid metastasis until proven otherwise. Knowledge of an intrathyroid metastasis may impact patient management, especially if the thyroid or neck are the only sites of metastatic disease.

Metastasis to the Thyroid Gland: A Critical Review

Background

Metastasis to the thyroid gland from nonthyroid sites is an uncommon clinical presentation in surgical practice. The aim of this review was to assess its incidence management and outcomes.

Methods

A literature review was performed to identify reports of metastases to the thyroid gland. Both clinical and autopsy series were included.

Results

Metastases to the gland may be discovered at the time of diagnosis of the primary tumor, after preoperative investigation of a neck mass, or on histologic examination of a thyroidectomy specimen. The most common primary tumors in autopsy studies are from the lung. In clinical series, renal cell carcinoma is most common. For patients with widespread metastases in the setting of an aggressive malignancy, surgery is rarely indicated. However, when patients present with an isolated metastasis diagnosed during follow-up of indolent disease, surgery may achieve control of the central neck and even long-term cure. Other prognosticators include features of the primary tumor, time interval between initial diagnosis and metastasis, and extrathyroid extent of disease.

Conclusions

In patients with thyroid metastases, communication among clinicians treating the thyroid and the index primary tumor is essential. The setting is complex, and decisions must be made considering the features of the primary tumor, overall burden of metastases, and comorbidities. Careful balancing of these factors influences individualized approaches.

Prevalence of Differentiated Thyroid Cancer in Autopsy Studies Over Six Decades: A Meta-Analysis

Purpose

Differentiated thyroid cancer (DTC) incidence has been reported to have increased three- to 15-fold in the past few decades. It is unclear whether this represents overdiagnosis or a true increase in incidence. Therefore, the current study aimed to estimate the prevalence of incidental DTC in published autopsy series and determine whether this prevalence has been increasing over time.

Materials and Methods

PubMed, Embase, and Web of Science were searched from inception to December 2015 for relevant studies. Two authors searched for all autopsy studies that had included patients with no known history of thyroid pathology and reported the prevalence of incidental DTC (iDTC). Two authors independently extracted the data, and discrepancies were resolved by another author. The pooled prevalence of iDTC was assessed using a fixed-effects meta-analysis model with robust error variance. The time effect was studied using an inverse-variance weighted logit-linear regression model with robust error variance and a time variable.

Results

Thirty-five studies, conducted between 1949 and 2007, met the inclusion criteria and contributed 42 data sets and 12,834 autopsies. The prevalence of iDTC among the partial and whole examination subgroups was 4.1% (95% CI, 3.0% to 5.4%) and 11.2% (95% CI, 6.7% to 16.1%), respectively. Once the intensiveness of thyroid examination was accounted for in the regression model, the prevalence odds ratio stabilized from 1970 onward, and no time effect was observed.

Conclusion

The current study confirms that iDTC is common, but the observed increasing incidence is not mirrored by prevalence within autopsy studies and, therefore, is unlikely to reflect a true population-level increase in tumorigenesis. This strongly suggests that the current increasing incidence of iDTC most likely reflects diagnostic detection increasing over time.

A Rare Thyroid Metastasis from Uveal Melanoma and Response to Immunotherapy Agents

Thyroid metastasis is a rare occurrence with cutaneous melanoma and even more uncommon with uveal melanoma. The management of such metastasis is uncertain due to its infrequency and, in the era of immunotherapy, the effect of these novel drugs on uncommon metastasis, such as to the thyroid, is unknown. We report the rare case of a thyroid metastasis in a patient diagnosed with ocular melanoma initially managed with enucleation. Metastatic disease developed in the lung and thyroid gland. The case patient received the immunotherapy ipilimumab with stable disease in the thyroid and progressive disease elsewhere. The patient was then further treated with a second immunotherapy agent, pembrolizumab, and remains with stable disease one year later. We discuss the current literature on thyroid metastases from all causes and the optimal known management strategies. Furthermore, we provide an original report on the response of this disease to the novel immunomodulators, ipilimumab, and pembrolizumab with stable disease four years after initial diagnosis of ocular melanoma.

Iodine intake as a risk factor for thyroid cancer: a comprehensive review of animal and human studies

Thyroid cancer (TC) is the most common endocrine malignancy and in most countries, incidence rates are increasing. Although differences in population iodine intake are a determinant of benign thyroid disorders, the role of iodine intake in TC remains uncertain. We review the evidence linking iodine intake and TC from animal studies, ecological studies of iodine intake and differentiated and undifferentiated TC, iodine intake and mortality from TC and occult TC at autopsy, as well as the case–control and cohort studies of TC and intake of seafood and milk products. We perform a new meta-analysis of pooled measures of effect from case–control studies of total iodine intake and TC. Finally, we examine the post-Chernobyl studies linking iodine status and risk of TC after radiation exposure. The available evidence suggests iodine deficiency is a risk factor for TC, particularly for follicular TC and possibly, for anaplastic TC. This conclusion is based on: a) consistent data showing an increase in TC (mainly follicular) in iodine deficient animals; b) a plausible mechanism (chronic TSH stimulation induced by iodine deficiency); c) consistent data from before and after studies of iodine prophylaxis showing a decrease in follicular TC and anaplastic TC; d) the indirect association between changes in iodine intake and TC mortality in the decade from 2000 to 2010; e) the autopsy studies of occult TC showing higher microcarcinoma rates with lower iodine intakes; and f) the case control studies suggesting lower risk of TC with higher total iodine intakes.

Thyroid metastasectomy

Metastases to the thyroid gland are uncommon. Renal, lung, breast, and colon cancer and melanoma are the most common primary diseases implicated. Few retrospective series have been reported. Treatment decisions must be individualized, and will depend on the state of systemic disease. Selected patients could benefit from surgical treatment. Although most patients selected for surgery will not be cured, the aim of surgery is to avoid the complications of uncontrolled central neck disease.

Metastatic carcinoma to the thyroid gland: a single institution 20-year experience and review of the literature

The thyroid gland is an uncommon site for metastatic disease but cases have been well-documented in the literature, particularly in autopsy series. A retrospective review of surgical pathology and autopsy pathology database for patients with metastatic carcinoma to the thyroid was performed at the University of Massachusetts Medical Center between January 1993 to January 2013. We identified a total of 10 patients with metastatic carcinoma to the thyroid; 6 were in surgical pathology specimens out of a total of 1,295 thyroid carcinoma (0.46 %) and 4 were diagnosed at autopsy out of a total of 2,117 (0.19 %) autopsy cases during this period. Cases with direct extension of the tumor into the thyroid from local primary sites such as larynx, esophagus or soft tissues of the neck were excluded. The primary tumors in these cases comprised of four lung carcinomas, three colorectal carcinomas, a renal cell carcinoma, a pleural malignant mesothelioma, and an unknown primary. Therefore, it is important to keep intrathyroidal metastases in the differential diagnosis when evaluating a thyroid nodule, particularly in patients with a previous history of malignancy. Furthermore, a literature review reveals over 1,400 cases have been previously reported, with the most common malignancies from the kidney (34 %), lung (15 %), gastrointestinal tract (14 %), and breast (14 %).

Surgical management of metastases to the thyroid gland

BACKGROUND

Metastases to the thyroid gland are uncommon, with rates reported between 0.02% and 1.4% of surgically resected thyroid specimens. Our goal was to present our experience with surgical management of metastases to the thyroid gland.

METHODS

Twenty-one patients with metastatic disease to the thyroid were identified from a database of 1,992 patients with thyroid cancer who had surgery during 1986-2005. Patient, tumor, treatment, and outcome details were recorded by analysis of charts. The median age at time of surgery was 68 (range, 39-83) years; 12 were men and 9 were women.

RESULTS

All patients were managed by surgery, including lobectomy in ten patients, total thyroidectomy in six, completion thyroidectomy in two, and subtotal thyroidectomy in one. In two patients, the thyroid lesion was found to be unresectable at the time of surgery. Histopathology revealed renal cell carcinoma in ten, malignant melanoma in three, gastrointestinal adenocarcinoma in three, breast cancer in one, sarcoma in one, and adenocarcinoma from an unknown primary site in three patients. Seventeen patients have died. The cause of death in all 17 was widespread metastatic disease from their respective primary tumors. The median survival from surgery to death or last follow-up was 26.5 (range, 2-114) months.

CONCLUSIONS

In patients with metastases to the thyroid gland, local control of metastatic disease in the central compartment of the neck can be successfully achieved with minimal morbidity with surgical resection in selected patients.

Increased incidence of papillary thyroid microcarcinoma with decreased tumor size of thyroid cancer

The prevalence of papillary thyroid microcarcinoma (PTMC) in thyroid cancer varies from 20.0% to 42.8% with a mean of 30.0%. Most of these patients have benign clinical courses and receive less aggressive therapeutic procedures in most medical centers. This study retrospectively reviewed 30 years data in one institute and compared it with recent publications to illustrate change in trends and influence of PTMC. Incidental PTMC is usually diagnosed as a postoperative microcarcinoma following thyroidectomy for presumably benign thyroid lesions. Subtotal thyroidectomy or lobectomy without radioactive iodide treatment is sufficient to treat incidental PTMC. In contrast, aggressive surgical treatment with (131)I therapy is indicated for non-incidental PTMC. Those with PTMC in the absence of extra-thyroid invasion diagnosed by postoperative permanent section received follow-up if they had initially received subtotal thyroidectomy. In long-term follow-up studies, cancer-specific mortality for PTMC ranged from 0% to 4%. Most of the mortality cases had distant metastasis at the time of surgery. The clinical course and therapeutic strategies for the non-incidental PTMC patients depend on the TNM stage at the time of diagnosis. One-third of PTMC with clinically aggressive behavior cannot be treated as indolent disease. Invasive tumor markers or larger tumor size are useful to predict tumor recurrence or distant metastasis for PTMC.

Thyroid metastases from colorectal cancer: the Institut Gustave Roussy experience

The prevalence of thyroid metastases in colorectal cancer (CRC) patients is unknown. We retrieved the records of all patients with CRC and pathologically proved thyroid metastasis for the period 1993-2004. Among 5,862 consecutive patients with CRC, 6 (0.1%) were diagnosed with thyroid metastases, a median of 61 months after the diagnosis of primary tumour, and a median of 19 months after the last surgical resection or radiofrequency ablation of other metastases (which were present in all cases). Signs and symptoms, when present (n=3), consisted of cervical pain, cervical adenopathy, goitre, dysphagia, and/or dysphonia. In other cases, the diagnosis was made by positron emission tomography scanning. Thyroidectomy was performed in the 5 patients with isolated thyroid metastases, with cervical lymph node dissection being required in all cases. The only patient treated conservatively because of concomitant liver and lung metastases developed life-threatening dyspnoea, which required emergent tracheal stenting. Median overall survival was 77 months, 58 months, and 12 months after the diagnosis of primary CRC, initial metastases, and thyroid metastasis, respectively. It is concluded that thyroid metastases are rare and occur late in the course of CRC. Thyroidectomy (with cervical lymph node dissection) may result in prevention or improvement of life-threatening symptoms and prolonged survival.

Severe hypothyroidism induced by thyroid metastasis of colon adenocarcinoma: a case report and review of the literature

An 85-year-old man who had undergone a right hemicolectomy for colon cancer presented with severe hypothyroidism and hoarseness 21 months after the operation. The serum thyrotropin (TSH) was markedly elevated to 118.14 microIU/mL and serum free thyroxine (fT4) level was markedly suppressed to 0.34 ng/dL. Symptoms of hoarseness and neck swelling were already evident 4 months prior at which time tests for normal thyroid function were performed. The patient was referred due to aggravated pain on his diffusely enlarged hard goiter. An enlarged thyroid with some calcification was noticed in the neck ultrasonography with multiple cervical lymphadenopathies. Core biopsy of the thyroid gland showed invasion of poorly differentiated adenocarcinoma cells. Immunohistochemical studies showed positive staining only for carcinoembryonic antigen (CEA). There were multiple lung parenchymal nodules and adrenal masses at the time of evaluation. The patient was started on palliative chemotherapy with thyroid hormone replacement and gradually became euthyroid. From these findings and the clinical observations, thyroid metastasis with hypothyroidism developing acutely from metastatic colon adenocarcinoma was diagnosed.

Metastatic breast carcinoma involving the thyroid gland diagnosed by fine-needle aspiration: a case report

Secondary involvement of the thyroid gland from a remote primary malignancy is uncommon. The distinction of metastatic carcinoma (MC) or sarcoma from a primary thyroid malignancy is important because the treatment is different. We discuss a case of a 64-yr-old female with a history of breast carcinoma, who presented with pain and swelling in her neck 5 yrs after being diagnosed with breast cancer. She had undergone mastectomy with subsequent chemotherapy and radiation for infiltrating mammary carcinoma. During the 5-yr interval, she had been free of clinically evident metastatic disease. Subsequent work-up revealed two distinct nodules in the left lobe of her thyroid gland as well as a subcutaneous mass in her right shoulder. A fine-needle aspiration (FNA) of the larger thyroid nodule showed malignant epithelial cells with features consistent with breast carcinoma in a background of benign thyroid epithelial cells and colloid. The case was signed out as metastatic breast carcinoma. Subsequent FNA and biopsy of her right shoulder lesion also revealed metastatic breast carcinoma with similar morphology to the material in the thyroid FNA.

Nonpalpable thyroid carcinoma: clinical controversies on preoperative selection

This article emphasizes some controversies concerning the preoperative selection of nonpalpable thyroid tumors. The prevalence of occult thyroid carcinoma in surgical series (1.8-10%) is not higher than in autopsy thyroid series (2.7-24%). The prevalence of occult thyroid carcinoma in thyroid glands examined in the same institution by ultrasound, for a clinical thyroid abnormality or for investigation of other neck structures without clinically evident or suspected thyroid disease, varies from 3% to 8% and is very similar independent of the fact that a thyroid abnormality is or is not the indication for ultrasonography. These data suggest that the presence of a thyroid disease is not a risk factor for harboring an occult thyroid carcinoma (except for C-cell hyperplasia in the rare case of MEN 2 syndromes). As it is not cost effective to examine all the nonpalpable lesions with fine-needle aspiration (FNA) guided by ultrasounds, it is necessary to define to which extent ultrasound is useful in selecting those lesions to be examined cytologically by FNA. The use of ultrasound to select these lesions is very controversial. Ultrasound-guided cytologic diagnosis of nonpalpable nodules is not as accurate as in the case of palpable nodules. Sampling of material adequate for cytologic analysis depends on the lesion size; it is 64% for a 0.7-cm lesion and it increases to 86.7% for a mean size of 1.1 cm. For the diagnosis of occult thyroid carcinomas (< or =1 cm), sensitivity is 35.8% and false-negative results are 49.3%. Nonpalpable nodules with a size of 1.5 cm represent an absolute indication to perform an ultrasound-guided FNA because this is the size limit for dividing thyroid nodules in probably innocuous or potentially dangerous categories and because the cytologic diagnosis of nodules of this size is sufficiently reliable. For the smaller incidentally discovered thyroid nodules following ultrasound, physicians should discuss with the patient whether and when to perform an ultrasound-guided FNA considering the patient's data (risk factors, age, health state, etc.), the natural history of a small thyroid carcinoma, as well as the accuracy of ultrasound and ultrasound-guided FNA in the specific institution.

Thyroid incidentalomas. Prevalence, diagnosis, significance, and management

Thyroid incidentalomas are common, always impalpable, often less than 1.5 cm in size, and frequently benign. The authors recommend that low-risk patients with incidentalomas be followed up with clinical palpation in 6 to 12 months and not be subjected to routine testing with US-FNA. In the authors' strategy, fine-needle aspiration is reserved for an impalpable nodule and is performed under ultrasonographic guidance in the high-risk group of patients in whom either the imaging features or the clinical history is worrisome for malignancy. It does not seem necessary, practical, or cost-effective to perform biopsy or to excise surgically all impalpable nodules. Because of the high prevalence of thyroid incidentalomas, most of which are benign, a nonsurgical approach is logical.

Automated therapeutic drug monitoring in an ambulatory care endocrine clinic

OBJECTIVE

To develop and implement an automated therapeutic drug monitoring system for accessing data from endocrine clinic patients who had been prescribed insulin, oral hypoglycemic agents (OHA), or levothyroxine.

DATA SOURCES

We designed a computer system to retrieve clinical data from the Medical Information System (MIS), a centralized hospital computer system, and import this information directly into a Macintosh personal computer. Physician entry of prescriptions for insulin, OHA, or levothyroxine into MIS formed the basis for a computer program to retrieve daily diagnostic and prescription information, demographics, and laboratory analyses, including blood glucose and glycosylated hemoglobin for insulin and OHA orders and free and total thyroxine, total triiodothyronine, and thyroid stimulating hormone for levothyroxine orders. The information was imported into a database program (4th Dimension).

RESULTS

The system identifies laboratory values outside of predetermined therapeutic ranges, maintains an up-to-date patient profile, and edits and generates reports. Preliminary experience suggests that automation eliminates 75-90 percent of the time required to manually collect the same information, and improves the accuracy, comprehensiveness, and utility of reports.

CONCLUSIONS

Automated therapeutic drug monitoring minimizes the time required to collect clinical data, alerts clinicians to potential problems, and provides a means to assess overall therapeutic management. Our methodology can be used to evaluate other medications in a variety of general or specialty clinics.

The prevalence of unsuspected thyroid pathology in 300 sequential autopsies, with special reference to the incidental carcinoma

Three-hundred whole thyroid glands were collected at autopsy from patients who had no known clinical history of thyroid disease, and who varied from 13 to 82 years of age; 200 were male and 100 female. Thyroid glands were weighed, measured, and examined after previous formalin fixation. Histologic examination was done in 16 areas from both lobes and isthmus, and divided into three levels, anterior, medial, and posterior. All areas suspected of neoplasia macroscopically were identified and studied microscopically; other areas were collected randomly for microscopic examination in the proportion of one fragment per 5 grams of tissue. In all cases both benign and malignant neoplasias were an incidental finding, seen in 6.6% of the cases and with no relation to the patient's main disease. Overall, there were malignant neoplasias in 2.33% but occult carcinoma comprised 1% of the cases. The incidence of other thyroid pathologies, all of them unrelated to the main disease of the patient, are also reported.

Management of thyroid nodules

This review describes the frequency of solitary thyroid nodules and their relationship to thyroid cancer. The importance of selecting patients appropriately for surgical excision is stressed. The factors predisposing to nodule formation and to a nodule being malignant are reviewed with emphasis that prior radiation exposure does not appear to increase the likelihood that a given nodule harbors a malignancy. In considering the laboratory evaluation of thyroid nodules, the limitations of isotope scans and ultrasonography are noted. Fine needle aspiration biopsy is described as revolutionizing the management of thyroid nodules and decreasing unnecessary operations. In the context of the natural history of differentiated thyroid cancer, the application of a decision analysis model to management options is described in some detail, and a cost-effective management regimen is recommended with fine needle aspiration biopsy as the initial procedure.

Familial papillary carcinoma of the thyroid

Of 226 consecutive papillary carcinoma patients, 14 indicated that at least one other relative was similarly affected. Pathology confirmation was obtained in 8 of the 14 families. Of the eight families with documented familial papillary carcinoma, one had five members, another had four members, and yet another had three members affected. The remaining families had two members affected. In those families with two or more persons with confirmed papillary carcinomas of the thyroid, 20 first- and second-degree relatives were examined. Of those, one had a previously unidentified papillary carcinoma and 6 had a benign thyroid disease (4 primary hypothyroidism and 2 simple goiters). High-resolution chromosome studies of four patients from four different families were normal, and there was no increase in chromosome breakage in a fifth patient from yet another family. Autosomal dominant inheritance is possible. Although there was no family history of lipomas, osteomas, or intestinal polyposis to suggest Gardner syndrome, four parents of our familial papillary carcinoma patients had colon cancer. In addition, three other relatives died of unidentified intra-abdominal cancer. The apparently high frequency of colon cancer and other abdominal cancer in relatives was an additional concern. Based on our observations, three clinical recommendations can be made: obtain a family history of all patients with papillary carcinoma of the thyroid, since between 3.5 to 6.2% will have another affected relative; when two or more persons in a family have papillary carcinoma of the thyroid, all first- and second-degree relatives should have a neck palpation by an experienced examiner; and families with two or more persons with papillary carcinoma should be observed for possible colon cancer.

Thyroid carcinoma in benign thyroid diseases. An analysis from minute carcinoma

The relative frequency of thyroid carcinoma in benign thyroid diseases such as toxic diffuse goiter (toxic goiter), adenomatous goiter (goiter), adenoma, and chronic thyroiditis (thyroiditis) was studied using 3,219 surgically removed thyroid glands. Coexistence of carcinoma and benign diseases was found in 257 glands. Among them, 157 glands had minute carcinoma (diameter of cancer nodule is smaller than 10 mm) and 100 glands had advanced carcinoma (larger than 10.1 mm in diameter). The incidence of carcinoma including minute carcinoma was 29.4% in goiter (98/333), 21.0% in thyroiditis (11/53), 8.6% in adenoma (55/638), and 5.3% in toxic goiter (98/1852). Chi-square test also revealed that the rate of carcinoma not only advanced carcinoma but also minute carcinoma was higher in goiter than in the other diseases (P less than 0.01, respectively). Among the patients aged under 39, the incidence of advanced carcinoma and minute carcinoma in thyroiditis were the highest, respectively (83% and 100% in thyroiditis, 9.0% and 11.4% in goiter, 2. 6% and 1.9% in adenoma, and 0.7% and 3.4% in toxic goiter), however, among the patients aged over 40, they were secondary lower and the lowest, respectively (19% and 16.8% in goiter, 5.2% and 7.5% in adenoma, 4.2% and 6.7% in thyroiditis, and 1.4% and 7.5% in toxic goiter). We concluded that adenomatous goiter accompanies carcinoma more frequently than other benign thyroid diseases and the high incidence of carcinoma in chronic thyroiditis is probably due to a preoperative selection of the patients.

The hemangioendothelioma of the thyroid

65 cases of hemangioendothelioma (HE) of the thyroid were accepted as such after control of slides of surgical or autopsy specimen or both. In a few of the more recent cases material could be examined by electron microscope and in some the search for factor VIII-related antigen (FVIIIRAG) was carried out. The demonstration of Weibel-Palade bodies in tumour cells in two cases and the evidence of FVIIIRAG in tumour cells of at least two cases, including primary tumour and distant metastasis, finally show, that the hemangioendothelioma of the thyroid is not simply an anaplastic carcinoma with some peculiar features; at least some of these tumours are true endotheliomas. The proposal that the term hemangioendothelioma be eliminated from the classification of thyroid tumours is therefore unfounded.

Surgical intervention in chronic (Hashimoto's) thyroiditis

The incidence of chronic (Hashimoto's) thyroiditis in surgical specimens is relatively high, i.e., 13% in collected studies, for a disease with clinical and laboratory characteristics that are sufficiently specific, that thyroidectomy should rarely be required for diagnosis or treatment. This incidence is presumably related to the difficulty in distinguishing between thyroiditis and a thyroid neoplasm. Experience with 260 thyroidectomies at the North Carolina Memorial Hospital performed between 1875 and 1980 for a dominant thyroid mass was reviewed to determine the reliability of criteria for diagnosis and the indications for surgical treatment. Using the criteria of clinical findings, complemented by laboratory studies, e.g., free thyroxine index, thyroid autoantibodies, TSH level, thyroid scan, in addition to the judicious use of the cutting (core) needle biopsy procedure, the incidence of Hashimoto's thyroiditis in this series was 3% and cancer-27%. Four patients had Hashimoto's thyroiditis coincidental to another disease for which thyroidectomy was performed. In seven patients Hashimoto's thyroiditis alone constituted the indications for operation. The indications for operation in these patients were: autonomous function with mild hyperthyroidism (2 patients); associated cold nodule (2 patients); thyromegaly unresponsive to suppressive therapy (2 patients); and rapidly enlarging mass simulating a neoplasm (1 patient). Only one of 71 patients with well differentiated carcinoma had Hashimoto's thyroiditis. One patient with Hashimoto's thyroiditis had associated lymphoma. In most patients, Hashimoto's thyroiditis can be identified using appropriate clinical and laboratory criteria without resorting to thyroidectomy to differentiate between thyroiditis and a neoplasm. Operations are indicated in patients with suspected or established chronic thyroiditis for: 1) the presence of a dominant mass with incomplete regression on suppressive therapy. 2) Progression of thyromegaly despite suppressive therapy. 3) Historic or physical findings suggest a malignancy, e.g., irradiation, multiple endocrine adenomatosis (MEA) syndrome, nerve paralysis, pain, tracheal compression, stipple calcification and cervical lymph node enlargement. 4) Indeterminant findings on cutting needle biopsy, e.g., lymphoma versus thyroiditis. Rarely, an operation is required for an oppressive goiter or associated hyperthyroidism.

Thyroid carcinoma: a clinical and pathologic study of 125 cases

Retrospective clinicopathological study of 125 thyroid carcinoma cases followed for 9 to 19 years was performed. Case selection for unfavorable histologic type and advanced disease was observed for referred cases. All medullary and anaplastic tumors were in patients over age 40; younger patients all had papillary and follicular carcinoma. Actuarial survival rates showed favorable outcome from papillary carcinoma followed by follicular and medullary or anaplastic tumors. Within the papillary carcinoma group, older age and male sex adversely affected survival; the former appeared related to clinical stage at presentation. Clinically palpable papillary carcinomas that were poorly circumscribed or showed vascular invasion were associated with poorer survival than tumors without these features. For papillary carcinomas under 1.5 cm, soft tissue invasion, vascular invasion, and occult lymph node metastases did not effect disease free survival. Two deaths from thyroid cancer were observed in this group, however, in patients who presented initially and with distant metastases. The biology of these small lesions is briefly discussed.

The incidence of carcinoma in solitary "cold" thyroid nodules

Two hundred and three patients with single thyroid nodules were referred for radioactive scan of the thyroid. Solitary "cold" nodules were identified in 130 patients and 68 of these patients came to surgery. Of this group, 12 patients were found to have carcinoma. There was no obvious selection process which distinguished the 68 patients who underwent surgery from the 62 who did not. There is a significant risk of thyroid neoplasms occurring in patients with solitary "cold" nodules, and this is particularly true in patients under forty.

Thyroid diseases in black patients

During the 26-year period, January 1, 1950 to December 31, 1975, inclusively, there were 680 thyroidectomies for clinical evidence of primary thyroid disease performed at the Howard University Hospital (0.6 percent of routine surgicals). There were 595 female and 85 male patients (ratio 7:1). All of the patients were black. In the 680 cases, the incidence of carcinoma was 4.6 percent, adenoma 11.3 percent, nodular goiter 51.9 percent, diffuse hyperplasia 21.3 percent, various thyroiditis 7.1 percent, and miscellaneous conditions 3.8 percent. A statistical analysis, together with a brief review of the literature on each entity, will be presented.

Thyroid nodules--benign or malignant? 1. Diagnosis

Radioisotope scanning is an invaluable aid in determining whether a palpable thyroid nodule is benign or malignant. In many cases, however, precise diagnosis is impossible without needle biopsy or surgical exploration.

Management of carcinoma of the thyroid

Greater precision has developed in recent decades in the selection of patients for operation for thyroid nodules suspicious for malignancy and in adapting operative procedures to the extent and pathologic variety of the individual thyroid carcinoma, when present. A thyroid lobectomy is considered to be the minimal operative procedure usually indicated for a suspicious thyroid nodule or carcinoma involving one lobe of the thyroid gland. Factors determining the extent of operation for thyroid carcinoma include the pathologic variety, gross distribution of the malignancy, and health status of the individual patient. Total or near total thyroidectomy should be considered for all patients with thyroid carcinoma except for single occult carcinomas and unilateral low grade angio-invasive carcinomas. Removal of lymph nodes in regions adjacent to the thyroid carcinoma is advisable, lateral neck dissections being reserved for patients with palpable lymphadenopathy, demonstrated metastases to lateral cervical lymph nodes, or a poorly differentiated carcinoma likely to metastasize to these lymph nodes. A modified radical lymph node dissection is satisfactory except for those carcinomas invading muscles in the neck. Anatomic neck dissections provide a better prognosis than incomplete lymph node procedures for patients with regional lymph node metastases. Following operation, patients should receive thyroid hormone therapy, be evaluated for possible treatment with radioactive iodine or other therapeutic measures, and be followed for evidence of recurrent disease as well as thyroid and parathyroid function. Adequate early operation is preferred to late ultraradical procedures, from standpoints of morbidity and prognosis. Unfavorable prognostic factors include extensive gross disease, poorly differentiated carcinoma present as the entire lesion or as foci in a differentiated carcinoma, and age over 40. With adequate surgical treatment, the prognosis for operable thyroid carcinoma is good.

Mucoepidermoid carcinoma of the thyroid gland

A 20-year-old euthyroid white woman presented with two palpable thyroid nodules. The scintiscan showed an area of increased uptake in the isthmus corresponding with one of the palpable nodules. The uptake in the rest of the gland was diminished including the area of the second palpable nodule which was in the superior portion of the left lobe. Microscopic examination revealed diffuse lymphocytic thyroiditis, follicular adenoma and the isthmus and mucoepidermoid carcinoma of the upper left lobe. No primary site for the muceopidermoid carcinoma outside the thyroid has been identified. Mucoepidermoid carcinoma of the thyroid gland has not previously been reported; the literature is briefly reviewed and etiologic considerations are discussed.

The solitary thyroid nodule. A review of 771 thyroidectomy specimens

A review of 771 thyroidectomy specimens showed an incidence of carcinomas of 4.2 per cent. Despite opinion that the incidence of carcinomas in thyroid nodules is overmphasized, it is felt necessary still to encourage the careful examination of solitary nodules in young patients.