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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
A Clinical Study EARL BELLE SMITH, M.D.,
St. Francis General Hospital, Pittsburgh, Pennsylvania
THERE are few diseases more controversial as to dassification and management than thyroid carcinoma.'-1' The possible explanations for this dilemma are:
A. Thyroid malignancy is different in various parts of the world and this fact is probably related to the iodine content of the human diet of the different environments. B. There are differences of opinions among pathologists concerning the classifications of various forms of thyroid cancer. C. There are different concepts of the management of thyroid cancer particularly papillary and follicular carcinomas of the thyroid gland.
behavior pattern similar to a follicular carcinoma. It is also well known that malignancies arising in other organs metastasize to the thyroid gland. The most common primary sites are the breasts and kidneys. Metastatic hypernephroma may be confused with solid adenoma or the hurthle cell cancer of the thyroid not frequently, primary cancers of the lung, colon and rectum metastasize to the thyroid gland.
This clinical study consist of our evaluations of 31 cases admitted to the St. Francis General Hospital during the 10 year period June, 1960 to June 1970. We have attempted to make a comparative analysis of our opinions and results with those of others.
Histologically, thyroid carcinoma may be divided into two main divisions; namely, differentiated and undifferentiated. The differentiated carcinoma of the thyroid has two subdivisions, i.e., papillary and follicular. Microscopically, the fofner is characterized by areas of normal thyroid architecture, with many papillary infoldings and proliferations and the latter is illustrative of typical thyroid follicles. Follicular thyroid cancer may be further sub-divided into invasive and localized, depending upon the tumor's biological behavior to invade surrounding tissues. On the basis of microscopic characteristics and undifferentiated cancer of the thyroid has been sub-divided into two groups, namely: the small cell type and the giant cell type. However, biologically, these divisions are almost identical. In the third primary group, we shall include the unusually malignant tumors of the thyroid namely; epidermoid, hurthle cell, fibrosarcoma and lymphoma. Hurthle cell cancer has a
With the exception of the papillary variety, carcinoma of the thyroid is a disease of the middle and the later spans of life. The papillary type is the most common type of thyroid malignancy and constitutes 50 to 60 per cent of the latter. The female to male ratio is 3:1 and is quite common in the first and second decades of life. Follicular cell cancer of the thyroid comprises 25 per cent of thyroid cancers in middle-aged individuals. In the older age group undifferentiated can comprises 25 per cent of thyroid malignancy. Thirty cases with an established diagnosis of thyroid cancer which had been treated at St. Francis General Hospital from 1960-1970. (Table 1): The female to male ratio for papillary carcinoma was 7:1 and 3:2 for follicular carcinoma. There were 13 patients with papillary carcinoma in the second decade and seven patients with fallicular carcinoma in the fourth decade.
TABLE 1.-THYROID CANCER AT ST. FRANCIS GENERAL HOSPITAL 1960-1970
Type of Cancer
Papillary Ca. Follicular Ca. Anaplastic Ca. Hurthle Cell Ca. Others (Fibrosarcoma 2, Undiff. 1, Metastatic 1 )
13 7 5
41.9 22.6 16.1 6.4
9 per cent) and others (dysphagia. If positive cervical nodes are present on the ipsilateral side a radical or limited neck dissection should be performed in continuity. radiotherapy for adolescent acne vulgaris. If true vocal cord paralysis is present there is strong evidence that the lesion is malignant.. (Table 2) T. a total thyroidectomy with post-operative administration of radio-active iodine is recommended. Hoarseness Increase in Size Asymptomatic Cough Dysphagia Feeling of Pressure Choking Sensation Dull Ache 56 33 33 29 48 35 12 38 42 30 24 34 44 36 12 TREATMENT A comparative analysis of symptoms and signs in non-toxic nodular goiter and thyroid cancer in the Illinois Research Hospital (Table 3). Fifty-four per cent of thyroid cancer in Clark's series'3 (120 cases) treated by total thyroidectomy showed intraglandular dissemination of the carcinoma. In the early stages. i.-SYMPTOMS AND SIGNS IN NON-TOXIC NODULAR GOITER AND THYROID CANCER (Illinois Research Hospital) In 100 Consecutive Cases of Benign In 50 Consecutive Nodular Goiter Non-Toxic Cases of Thyroid (Per Cent) Cancer (Per Cent) 21 Clinical Features It is extremely difficult to establish a pre-operative diagnosis of early carcinoma particularly in the presence of certain types of non-toxic nodular goiter.-THYROID CARCINOMA OCCURRING IN GOITER (MAJARAKIS)12 Type Toxic Diffuse Goiter Toxic Nodular Goiter Non-Toxic Nodular Goiter Solitary Non-Toxic Nodule Non-Toxic Multi-Nodular Goiter Percentage 0. per cent).0 15. DIAGNOSIS AND CLINICAL FEATURES TABLE 2.here are a few case reports of thyroid cancer developing in persons who were exposed to radiation.) 7 (22. cold thyroid nodule by scan.5 per cent and 30 per cent. generalized malaise. neck pain 5 (16. Difficulty in breathing 4 (12. Test doses have shown that where there is little or no up-take of the radioactive iodine (so-called "cold nodule"). 2 ETIOLOGY Thyroid Carcinoma 105 There does exist a clinical correlation between nodular goiter and thyroid cancer.6 20. Papillary adenocarcinoma of the thyroid should be treated by total or subtotal thyroidectomy depending upon the gross findings of the lesion at surgery. Occasionally many thyroid cancers (particularly papillary) show no apparent increase in size over a period of four to five years.VOL.7 TABLE 3. Majarakis et al12 reported the incidence of thyroid carcinoma in goiter from 1930 to 1952. Scintigram (thyroid scan) aids considerably in the correct diagnosis of the thyroid nodule as noted in Fig. It is extremely importaat that a skeletal survey or metastic bone survey be obtained in all cases of follicular adenocarcinoma of the thyroid. The symptoms in thyroid cancer at St. enlarged thymus and exposure to the atom bomb. Francis General Hospital are as follows. neck mass 30 (96. 1. The changes of cancer being present are greater than when the reverse is true.1 per cent). However. It is our opinion that papillary adenocarcinoma .9 8. Therefore.e. The surgeon should be acquainted with the gross pathology of thyroid cancer and qualified pathologist should be available for consultation.7 per cent). The final diagnosis is usually made by tissue biopsy.6 per cent). The risk of the latter in patients with the former ranges between 0. No.1. any nodule in the thyroid which appears to be solitary should be removed. headache. It could be concluded that subtotal thyroidectomy does not remove all of the cancer in many cases. 63. Sometimes the first clinical manifestation is a palpable metastatic focus in one of the cervical lymph nodes. For most patients with follicular adenocarcinoma. Late symptoms include pains in the neck. The incidence may decrease in parts of the world where nodular goiter is common. etc. dysphagia and/or dysphonia.1 1. total thyroidectomy should remove all the intragrandular tumor cells and decrease the incidence of distant speeding and metastases. there are no subjective symptoms. hoarseness 3 (9.
8. M. 1. WOOLNER. Francis General Hospital dur- 13. Cancer of Thyroid. The next step is to free the bacterial ATP by adding perchloric acid. 4. World News. Surg. C. such as a gastrostomy or a pharyngostomy. of Surg. 9. 199: No. et al Thyroid Carcinoma in Man After Exposure to Ionizing Radiation.A. 7. The treatment of thyroid cancer should be individualized and usually. 332. 8th Edition.. MAJARAKIS. 102:354. Am. SOGOLow. R. the blood cells found in the urine are ruptured with a chemical called Triton X-100 and the free ATP is destroyed with apyrase. 1966. E.. Thyroid scan showing a radiolucent defect in the right lobe (right side is to the left). 1960-1970. 5. MORFIT. may be the only indicated palliative procedures. Surg.. is an SUMMARY 1. A trac-heostomy or some type of feeding mechanism. J.. L. Endocrinol. R. with bacterial ATP. RICKEY. V. Post-operative supervoltage radiation may be administered depending upon the tolerance of the patient. the acidity of the specimen is reduced. A. 10. 406.. because of the contiguous spread of this tumor to surrounding tissues it is not technically feasible to remove all of the tumor. Classification and Prognosis of Thyroid Carcinoma.106 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH. 17:30. 1962. Thyroid. Undifferentiated carcinoma of the thyroid should be treated by total thyroidectomy. W. Dr. L. the firefly agents added. J. 4. 1966. From there. The Ratimale for Management of Thyroid Carcinoma. Surg. Grace Lee Picciolo of Goddard reports the test involves lighting up luciferase and luciferin. 2. 3. Clinical Symposia. 1970 . Long Term Result in the Treatment of Carcinoma of Thyroid Am... CHRISTOPHER'S Textbook of Surgery: Thyroid Carcinoma. 17: No. Thyroid Gland. PP. N. Anaplastic carcinoma of the thyroid is usually inoperable. CLARK. E. 3. which are obtained from firefly tails. 6. 149: No. 115:545. 1966. 2. D. H. First. B. 6. A. Clin. J. R. Meta. M. Significance of Intraglandular Dissemination. 63. 112:637. 11. Carcinoma of the H. J. PP. J. 1971 ing the 10 year period. E. ALBRIGHT. endocrine-dependent tumor and thyroid replacement therapy is indicated especially in patients who are subjected to a subtotal thyroidectomy. M. et al. Surg. 12. McDERMOTT. The biological behavior of thyroid cancer depends upon the histopathology of the tumor and the resistance of the host. Cancer of the Thyroid. J. 1968. 1954. an enzyme found in potatoes. JR. Dec. RAWSON. Cancer. J. The most frequent early sign of thyroid cancer is a painless palpable solitary mass in the neck. 1963. A. PP. L. et al. and the amount of light produced is measured by means of a sensitive photoelectric device. FAST URINARY BACTERIA COUNT A screening test to measure the quantity of bacteria in urine in 15 minutes rather than the usual 24 to 48 hours it takes to grow cultures has been developed by scientists at Goddard Space Flight Center and Johns Hopkins Hospital. 4. 13:1530-1541. B. Med. JR. 1961. J. Carcinoma of the Thyroid Gland. 1953. A pre-operative thyroid scan is a worthwhile adjunct in the overall management of the nodular thyroid gland. 14:1336-1354. Meta. however. Surg. LITERATURE CITED Fig.A. Thirty-one proved cases of thyroid cancer were managed at the St. 1959. thereby. P. COLCOCK.. 1967. 42: No. Endocrinol.M. CLIN. surgical experiences and an unbiased follow-up analysis of unselected cases determine a logical approach to definitive management. et al: Thyroid Carcinoma After Radiation Treatment for Adolescent Acne Vulgaris. Eng. et al Carcinoma of the Thyroid. 1967. Total Thyroidectomy for Carcinoma of the Thyroid. MORFIT. H. 59:894-902.. Med. precluding subtotal or total thyroidectomy.
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