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Preoperative Diagnosis of Carcinoma of the Thyroid in Surgery of the Thyroid
Preoperative Diagnosis of Carcinoma of the Thyroid in Surgery of the Thyroid FRANK H. LAHEY
is an attempt to extend further the discussion of thyroid malignancy, based on our own large experience with this problem. As may be indicated in the above statement, there is a great variety of problems which must be handled in patients who are sent to the clinic for the final decision as to whether or not an operation should be performed, whether or not the lesion is malignant and whether or not radical dissection followed by high voltage irradiation will be of value.
THIS PAPER
Discrete Adenomas of the Thyroid
Perhaps the most important problem to settle is whether or not the patient has a discrete adenoma, a particular tumor situation in which the incidence of malignancy is so high, as discussed by Dr. Swinton (page 749), whether there is a true discrete tumor or what appears to be such a tumor is merely a thickened lobe of the thyroid. When the suspicious enlargement is located in the upper pole this decision is not difficult to make since the upper pole can be pushed against the larynx, palpated through and through, and differences in consistency within the nodule or within the thyroid gland itself can be quite readily demonstrated. When, however, the nodule or suspected nodule is in the body of the thyroid, particularly in the lower pole, and when it is small, the decision can be difficult. We see such cases daily in the clinic and when this doubt arises we ask each other to examine the doubtful cases in order to have a variety of opinions as to whether or not this is a tumor and is sufficiently suspicious to advise an exploratory operation. Discrete adenomas of the thyroid usually stand out quite distinctly within the lobe of the thyroid, particularly when one finger can be put behind the lobe and the thumb in front and the lobe palpated through and through as the patient swallows. In such cases discrete adenomas can be diagnosed quite easily. It is of great advantage, however, in such 781
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cases to ask the patients to swallow a mouthful of water two or three times as they will thus elevate both lobes of the thyroid out of their position behind the calvicle and it will be possible to palpate low discrete adenomas which otherwise might well escape attention. When there is doubt concerning the certainty of a discrete adenoma we have considered it advisable to send the patients away for three or four months, then examine them again, and if there is still doubt, to send them away again for three or four months, examine them again, and if there is no change to assume that the condition is thyroiditis or a thickened lobe. There are very few cases in which removal of a lobe is advisable when the decision as to whether or not a discrete adenoma is present is so uncertain that exploration is necessary. In such cases we believe that it has proved wiser to determine by the lapse of time whether or not a definite adenoma exists. This difficulty in making a decision whether a discrete adenoma of the thyroid is or is not present arises usually when such suspicious areas exist in the body of the lower pole of the thyroid. Adenomas of the upper pole of the thyroid or that portion of the thyroid which is adherent to the larynx are much more easily demonstrated since it is possible, as stated, to push the upper pole against the firm structure of the pharynx, palpate it through and through and demonstrate a change in consistency which identifies it as a discrete adenoma. All of this difficulty would not occur if one would wait until discrete adenomas become of sufficient size so that they can be demonstrated without uncertainty. We believe, however, as stated by Dr. Swinton in his article on "The Problem of the Thyroid Adenoma" elsewhere in this issue, that since one in every ten discrete adenomas is malignant we would like to discover and remove them early in their development when they are still so small that their presence is debatable. Palpatory Findings in the Differential Diagnosis of Benign and Malignant Disease of the Thyroid
One of the most difficult problems with which we have had to deal has been the decision in the case of the firm thyroid gland suspected of thyroiditis as to whether the firmness is actually due to thyroiditis or to malignancy or whether both conditions exist simultaneously. I was confronted with this situation quite recently when a middle aged school teacher was sent to the clinic for this decision to be made because of moderate enlargement of the thyroid and the demonstration of increase in its consistency up to that of marble-like firmness. On palpation, the entire thyroid gland was of almost stony hardness. In the right upper pole, however, there was a suggestion of a single nodule. This could not be separated with certainty from the remaining portion of the
Preoperative Diagnosis of Carcinoma of Thyroid
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very firm thyroid gland. It was decided that such was the uncertainty and firmness in this case that only by exploration with a biopsy could this decision be safely made. The entire thyroid gland, therefore, was exposed, a biopsy specimen was taken from the area suspected of malignancy and proved to be a papillary adenocarcinoma arising in a discrete adenoma within a gland which was the site of thyroiditis. Biopsies of the remaining portion of the thyroid, in the right lobe and also in the left, revealed the presence only of thyroiditis. A total right hemithyroidectomy and radical dissection of the neck were done with removal of the sternomastoid, the entire right internal jugular and dissection of all of the gland from below the clavicle up to the angle of the jaw, followed by two million volt radiation ov-er a period of thirty-five days. Because this is, as a rule, a radiosensitive lesion and because of its fairly early discovery, this patient has an excellent chance of a five year survival. A similar case a few years ago presented the other aspect of the problem. One of my most respected surgical friends in this community who for many years has been ihterested in thyroid disease was asked to see a famous rabbi, a man of outstanding prominence and national eminence. He came to my surgical friend because of a firm thyroid, presumably thyroiditis. In the right lower pole, however, there was an enlarged area which suggested the possibility of local tumor formation which could be a coincident adenoma that had become malignant or a local enlargement of the right lobe from thyroiditis, since it is well known by everyone who has to deal with patients who have thyroiditis that there can be local enlargements even up to nodules when thyroiditis has progressed to the stage of Riedel's struma. He brought the patient to me for consultation and advice. The problem presented was as follows: If nothing were done, and it was assumed that this was only thyroiditis and the decision was wrong, this man could readily pass into the stage of inoperability. If the right lobe were removed, such is the fixation and tendency of thyroiditis to produce fibrosis and adhesions to other structures about the lobe that either damage or scar involvement could ruin his voice and deny him one of his most prized capacities, that is, to preach. It was decided, therefore, to expose his lobe and do a biopsy, which was done by my surgical friend. It proved to be thyroiditis and everyone is happy and secure. It seems to me from our experience that this procedure should be employed in any case of thyroiditis in which the decision for or against malignancy remains unsettled. Lest anyone assume that every case of thyroiditis requires a biopsy, I would like to say that we feel quite confident in making the diagnosis in most cases of thyroiditis. There are certain distinguishing points which can be depended upon. One is the fact that from the beginning in most cases of thyroiditis both lobes are involved simultaneously and that,
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while the thyroid gland may be enlarged throughout its entire extent, it still retains the anatomical outline which characterizes it when it is a normal structure-the sharp, peak-like apex, the triangular tongue of the upper portion of the thyroid as it is attached to the side of the larynx, the typical isthmus and the typical lateral lobes of the well known shape of a thyroid, not unlike a crescent breakfast roll. When can be added to that the history that following a recent throat infection there has occurred tenderness within the gland, when on palpation even moderate degrees of tenderness are present and when, in addition, there is fixation of the gland which so often characterizes thyroiditis, one can assume with reasonable certainty that the state is one of thyroiditis and not of malignancy. In the diagnosis of possible malignancy of the thyroid by palpation which, after all, is one of the very dependable features to make one suspicious of malignant degeneration in a previously existing benign adenoma, perhaps the most common cause of such firmness not of malignant origin is recent hemorrhage into the adenoma. In such cases recent hemorrhage, particularly after the hemorrhage has ceased and is becoming organized, can cause firmness within a discrete adenoma which is similar to the type of firmness which is seen in malignancy. With this hemorrhage into the adenoma goes fixation similar to that seen with malignancy. One of the most dependable evidences of malignant degeneration within a known previously existing adenoma is loss of spherical outline. Discrete adenomas are ball-like in character. When malignant degeneration has occurred within the adenoma and has eroded the capsule this complete, spherical, ball-like outline is lost and invasion of the parenchyma of the gland can be demonstrated. This also varies in degree. When part of the ball-like character of the gland is lost, it is not easy to demonstrate. When, however, a previously existing discrete adenoma can be shown to have lost part of its discrete outline by invasion of the parenchyma of the gland, that is almost certain evidence of malignant degeneration. Voice Changes
Much has been written previously about the value of voice change as an indication of involvement of the recurrent laryngeal nerve by a carcinoma of the thyroid. The more experience I have in cases of carcinoma of the thyroid, the more impressed I am with the ability of the recurrent laryngeal nerve to withstand invasion by malignancy. In patients with discrete adenomas of the thyroid who have vocal cord fixation and recurrent laryngeal nerve paralysis on the same side, a much greater number, In fact a predominating majority, have continued with the recurrent laryngeal paralysis on that side when the adenoma has been
Preoperative Diagnosis of Carcinoma of Thyroid
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removed and found to be benign than when the condition was due to carcinomatous degeneration within an adenoma. One should, I believe, still look with suspicion on any patient with an adenoma in one lobe of the thyroid and the rather sudden appearance of vocal cord paralysis on that side but, as my experience in observing these cases over the years has increased, I have a distinct conviction that this is of less and less value as a sign of beginning n;alignancy within the adeno:na. I have many times been impressed with the fact that carcinoma of the thyroid can become adherent to the larynx and to the trachea, but the recurrent laryngeal nerve can be demonstrated as passing; through the carcinoma uninvolved and without recurrent laryngeal paralysis on that side. The Decision between Radical Dissections and Complete Unilateral Total Thyroidectomy
We have tried to base our decisions for and against radical dissections of the neck and complete, unilateral total thyroidectomy on a few points. In those patients with papillary cystadenorr a.s entirely within the capsule of the thyroid, without invasion of the thyroid capsule and without lymphatic and blood vessel invasion, we believe that local removal without postoperative high voltage irradiation is safe and satisfactory. In those cases of papillary adenocarcinorra of the thyroid completely within the capsule in which there is no invasion of the capsule and no invasion of the lymphatics but there is blood vessel invasion, we believe that local removal is adequate since if blood vessel invasion has reached the stage of dissemination, it can be at such a distant point that radical dissection of the neck and total removal of the thyroid on that side may very well not include the region of dissemination. In cases in which there is invasion of the capsule or of the lymphatics, however, we believe that radical dissection of the neck, consisting of removal of the sternomastoid, all of the internal jugular, all of the lobe of the thyroid on that side with preservation of the recurrent laryngeal nerve and all of the nerve structures of the neck, followed by two million volt x-ray radiation, is indicated. This is the most favorable lesion of the neck in which radical dissection of the neck and two million volt x-ray radiation are to be advised. We have reported in a fairly recent article that 80 per cent of the patients with carcinoma of the thyroid of this papillary type who have had radical dissection of the neck together with removal of the entire thyroid lobe on that side, followed by supervoltage x-ray therapy, are alive and well five years after operation. In all the patients with adenocarcinoma of the thyroid and in all of the patients with small round cell and giant cell carcinoma of the thyroid, whether or not the capsule is invaded, whether or not the lymphatics or blood vessels are invaded, radical dissections of the neck are done, since this is the group
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of patients with a low five year survival rate, with a limited degree of radiosensitivity and the most unfavorable future from every viewpoint. Management of Multiple Adenomatous Goiter with Single Firm Nodule
One of the problems which concerns us in dealing with so many patients with thyroid disease is, what shall we do with the patient who has a multiple adenomatous goiter, not a discrete tumor, not of sufficient size to be unsightly, not causing pressure, not progressing into the mediastinum, not toxic, but possessing within the goiter one nodule that is more unduly firm than the others. In such cases we believe that exploration should be done, the hard nodule removed and submitted to the pathologist and, since the gland is already exposed, the other nodules which are really not true nodules, removed, preserving the largest possible amount of normal thyroid tissue. This attitude should be taken in tbe management of both lobes. It is only by approaching the problem from this point of view that we can be sure that the firm nodule is not beginning malignant degeneration in a sing'e discrete adenoma of the thyroid included in a thyroid showing multiple adenomatous degeneration. Management of Extensive Carcinoma of Both Lobes of Thyroid
One of the problems that we have to face not infrequently is the patient with an extensive carcinoma of both lobes of the thyroid. It is in this type of case that we would like to present our attitude and experience. Many patients with this type of carcinoma of the thyroid involving both lobes of the thyroid, sometimes quite firmly fixed, are sent to us for a decision on surgery as a last resort. Our decision for or against advising surgery in such cases is largely dependent upon movability of the involved thyroid gland. We have little faith in total thyroidectomy as a method of treating extensive carcinomatous involvement of both lobes of the thyroid. It is safe to assume that in such extensive cases total thyroidectomy will accomplish very little in .terms of five year survival and can bring about very undesirable complications during the period these patients survive. In cases of carcinoma involving both lobes of the thyroid, removal of all of the thyroid can rarely be done without a very high percentage of tetany and a very high percentage of bilateral abductor paralysis, both very undesirable complications to a patient whose life, in all probability, will not be prolonged particularly by such an operative procedure. When both lobes of the thyroid are involved we much prefe~ to take out tbe larger lobe and the istbmus if that is possible and at the ~ame time do a tracheotomy. By proceeding along this line the patient can be assured that he will not be voiceless and that be will
Preoperative Diagnosis of Carcinoma of Thyroid
787
have a good airway which will persist even in the presence of a great deal of x-ray reaction which not infrequently occurs, and he will be able to breathe normally during the period of his high voltage x-radiation on the removed and unremoved sides. We have had some extraordinary results with some of these patients who have had extensive bilateral involvement of the thyroid with carcinoma and with lesions, particularly adenocarcinoma, usually assumed to be of the unfavorable type when they have been submitted to two million volt x-ray therapy. One of the most important features of this approach to the management of inoperable carcinoma of the thyroid, that is, from the point of view of five-year survival rates, is the need to protect the patient against the possibility of having to have an emergency tracheotomy following or during his high voltage x-radiation with all of the malignant tissue still present within both lohes of the thyroid and in the thyroid isthmus. To attempt a tracheotomy in the presence of a bilaterally enlarged thyroid and thyroid isthmus invaded by malignancy which has reacted to x-radiation with induration and swelling is extremely difficult and far from satisfactory. We prefer, as stated above, to remove one lobe of the isthmus, bare the trachea and do a tracheotomy and then undertake rotational radiation on both sides of the neck, with the complete security that no emergency tracheotomy will be demanded, no matter how great the reaction.
.
Management of Advanced Malignant Thyroid Lesion Descending into Superior Mediastinum
In considering the patients who have advanced malignant disease of the thyroid, who are so frequently sent here in the hope that we can do something for them, I wish to discuss the dissection of these advanced malignancies which have descended into the superior mediastinum down behind the clavicle and the sternum. There is one type of malignancy already spoken of and to be noted in Drs. Warren and Meissner's classification (page 739), that is peculiarly noninvasive, papillary adenocarcinoma. As Drs. Warren and Meissner have stated, this includes the type of lesions which used to be called aberrant thyroids about which we wrote some years ago, only later to become aware that what we were discussing as lateral aberrant thyroid, movable, pigment stained nodules in the lateral regions of the neck, were actually metastases into the cervical lymph nodes with a small unrecognized primary tumor in the lobe on that side. These advanced types of malignancy which so frequently, particularly in young girls, invade both sides of the neck, lack invasiveness which characterizes the adenocarcinomas, small round cell and giant cell carcinomas. Dissection into the mediastinum in this type of malignancy is permissible since they are so movable, care being taken particularly on the left side to avoid injury to the thoracic duct. When
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the firm, fixed invasive type of malignancy characterizing adenocarcinoma, giant cell and small round cell carcinoma infiltrates behind the sternum, no attempt should be made to excise this tumor or to carry the dissection below into the mediastinum. There are no lines of cleavage in malignancies of this type and grade which have invaded the mediastinum. They cannot be separated. They cannot be adequately removed and attempts to enucleate them will result in venous hemorrhage, accumulation of hematomas, an extremely dangerous and undesirable complication in terms of pressure upon the trachea beneath the sternum, and infections, with no prospect of benefit. I particularly wish to warn against attempts to follow infiltrating types of carcinoma of the thyroid into the mediastinum. Indications for Tracheotomy
In connection with the above statement I might try to answer the question: When should a tracheotomy be done in carcinomas of the thyroid? Tracheotomy should be done when after the removal of the malignancy of the thyroid the trachea has collapsed, when the dissection has been extensive, when high-voltage x-radiation is to be given and when an injury to the recurrent laryngeal nerve is anticipated. It must be remembered that when the recurrent laryngeal nerve is roughly handled, is manipulated unduly as it is dissected out of the thyroid, and paralyzed, it will cut the glottic space in half since the cord will not adequately retract to increase the airway as demanded. In such cases a tracheotomy should 'always be done. There are very few cases of carcinoma of the thyroid which are extensive and infiltrating, particularly the type in which the operation in done as a last resort to be followed by high-voltage x-radiation, in which tracheotomy should not be done. It is important for me to distinguish clearly that in the patient with a discrete adenoma of the thyroid showing the complications spoken of earlier in this discussion (malignancy), who is to be given irradiation, tracheotomy is rarely necessary even though there may be a not inconsiderable degree of x-radiation reaction. Most patients with relatively early malignant degeneration in an adenoma who have had radical dissection of the neck, consisting of removal of the sternomastoid, the internal jugular and all of the thyroid gland with complete baring of the trachea and removal of the isthmus on the affected side, do not require tracheotomy. Should tracheotomy become necessary, however, it is easily done because the trachea has been so completely exposed by the removal of the isthmus and is so readily available for the introduction of the tube if it is even suspected that it is necessary. One of the problems with which we have had to deal also is the question already stated, in patients with extensive carcinoma of the thyroid in which but one lobe is removed and a tracheotomy done in order to
Preoperative Diagnosis of Carcinoma of Thyroid
789
make it possible to give palliative irradiation to the remaining malignancy in the thyroid, should this operation be done in the presence of distant metastases?\ From our experience we would say that it should, because local extension can often be checked by palliative irradiation, distant metastases are sometimes of such a type that they will take up radioactive iodine or even yield to palliative doses of x-rays at distant points and the patient is provided an adequate airway. Esophageal or Tracheal Involvement in Extensive Late Malignancy
One of the problems that not infrequently confronts us and we have to settle is, if there is a local area of esophagus caught by the extensive late malignancy in patients sent here for last resort procedures, what should be done? We have never thought it wise to excise portions of the esophagus since the wound will be complicated seriously by the discharge of food and the presence of saprophytic organisms. In such cases we have preferred to shave off sections of the malignant thyroid and leave them attached to the esophagus. A similar problem arises in those patients in whom the malignancy has invaded the trachea and removal of such adherent malignant sections would require the removal of a section of the trachea. It is surprising how resistant the trachea is to invasion from malignant thyroid tissue. In most instances, even when both lobes are involved the trachea can quite safely be separated, the isthmus cut off and one entire lobe preserved, but when the trachea has been invaded it has again been our custom to shave off sections of malignant thyroid tissue leaving such sections adherent to the trachea to be cared for by the later supervoltage radiation. Should the Recurrent Laryngeal Nerve Be Preserved in Dissections for Carcinoma of the Thyroid?
To this question we would answer that the decision must be based upon factors shown to be present at the time of the surgical procedure. We can successfully preserve recurrent laryngeal nerves in practically all cases of early malignant degeneration within an adenoma of the thyroid even though the capsule has been invaded and parenchyma involved. In patients with extensive malignancies of the thyroid, however, sent here for either palliative surgery or the hopes of cure, the decision as to whether a nerve is or is not to be saved is based entirely upon how extensive is the degree of involvement of that structure by InvaSIOn. The Value of Frozen Sections in Determining Need for Immediate Radical Dissection for Discrete Adenomas
As Dr. Swinton has stated in his article on this subject, we have gradually been changing from the position that we will await the paraffin
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Frank H. Lahey
section microscopic diagnosis before determining the presence or absence of thyroid malignancy in discrete adenomas of the thyroid and the need for immediate radical dissection of the neck. To an~wer the question as to whether or not frozen sections can be depended upon for the decision to do or not to do a radical dissection of the neck we would say that when the frozen section unequivocally settles that the lesion is malignant we would be quite willing to undertake radical neck dissections and when in doubt we would prefer to wait for final reports on the paraffin sections. Since the decision for or against radical neck dissection in early discrete adenomas of the thyroid depends upon such delicate observations of invasion of the capsule or of the lymphatics there will be not infrequent occasions in which the first diagnosis by frozen section may be reported as benign as has recently happened to us, and later, on more accurate and better section, determined to be malignant. Therapeutic Indications in Presence of Distant Metastases
Are distant metastases to be treated with radioactive iodine or with local irradiation? This must be settled again on the basis of the individual case and the individual findings. We have not infrequently had patients sent to us who have a single metastasis in a long bone such as a humerus or a femur which has resulted in a spontaneous fracture. In several of these patients good union has resulted under traction and local irradiation, but when the lesions are in an unapproachable location they are best treated by radioactive iodine if it can be proved that there is a good uptake of radioactive iodine after a total thyroidectomy, but even in those lesions involving vertebral bodies much relief from pain has been accomplished by local x-radiation of the distant metastases. Bilateral Malignant Lesions of Thyroid in Young Persons
It is fortunate that most of the patients with malignant lesions of the thyroid coming to us for management have unilateral disease. There are occasional instances, particularly in young girls with the papillary adenocarcinoma type of malignancy, in which delay has taken place or spread has been rapid and involved both sides, in which the decision must be made as to whether or not bilateral radical dissection of the neck with removal of both sternomastoids and both internal jugulars is desirable. Our answer to this has been "no." We prefer in such cases to do radical dissections on the side with greater involvement and to do subradical resections, preserving the sternomastoid and the internal jugular on the opposite side followed by supervoltage radiation. The disfigurement associated with bilateral removal of both sternomastoids and the uncertainties associated with bilateral removal of both internal jugulars are such that we prefer the above stated course. It is amazing
Preoperative Diagnosis of Carcinoma of Thyroid
791
Fig. 208. In this illustration taken before operation, bilateral metastases in a patient with a large papillary adenocarcinoma may be seen. Because of the type of malignancy, even though this patient were not given radioactive iodine he would probably live a considerable number of years. Note the degree of tracheal deviation (marked by arrows) as a result of the size of the goiter.
Fig. 209. This patient was first operated on January 29, 1930, at which time radical dissection of the right side of the neck was performed. The pathologic report was papillary adenocystoma with blood vessel invasion. In 1936 and in 1939 nodules in the neck were removed; the diagnosis at that time was papillary adenocarcinoma with blood vessel invasion. a, Roentgenogram of the chest in 1942 showing pulmonary metastases; b, in 1948 no metastases are visible. At the present time the patient is in excellent health and the lungs are clear. (From Hare, Hugh F., and Newcomb, R. V. in Radiology 54: 401-407, March, 1950.)
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Frank H. Lahey
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I i
how littl~ disfigu~ement ~ccurs with t~e re.moval o~e sternoI?astoid and one mternal Jugular m a young gIrl WIth a bM;utlful neck If all of the nerve structures can be preserved. If there is no.l'Olt-shoulder or angel wing scapula which is associated with PllTalysls of the spinal accessory nerve these patients even when wearing low-necked dresses or bathing suits often show little or no difference when one compares the unoperated side with the operated side. The loss of both sternomastoids and the forward ridge pole-like effect upon the neck as the unfilled spacll beside the trachea projects that structure forward are extremely disfiguring and depressing to the average young person in whom this problem of bilateral dissection so often arises. Pulmonary Metastases
Are there instances of pulmonary metastases of such character that they can be demonstrated roentgenologically in which life can exist over a number of years? We have several such patients. Figure 208 shows a recent case with metastases in both lungs and an enormous goiter which on removal proved to be papillary adenocarcinoma. The patient will be given radioactive iodine now to promote his uptake after having a total thyroidectomy, but we have a number of young girls alive t!;nd well many years with such a type of pulmonary metastases, an exiJ,mple of which is shown in Figure 209, alive and well now twenty-tht.ee years after removal and x-radiation. ' CONCLUSIONS
;.
I am very aware of the narrative character of this article but; after all, such problems as are presented here confront the practical surg~on every day. It is my hope that this recital ,of our own experiences a:f1d of our own viewpoints, based upon a large and practical experience, with the problem of thyroid malignancy, will be of some aid in the sblution of these problems. ~ ,
is an attempt to extend further the discussion of thyroid malignancy, based on our own large experience with this problem. As may be indicated in the above statement, there is a great variety of problems which must be handled in patients who are sent to the clinic for the final decision as to whether or not an operation should be performed, whether or not the lesion is malignant and whether or not radical dissection followed by high voltage irradiation will be of value.
THIS PAPER
Discrete Adenomas of the Thyroid
Perhaps the most important problem to settle is whether or not the patient has a discrete adenoma, a particular tumor situation in which the incidence of malignancy is so high, as discussed by Dr. Swinton (page 749), whether there is a true discrete tumor or what appears to be such a tumor is merely a thickened lobe of the thyroid. When the suspicious enlargement is located in the upper pole this decision is not difficult to make since the upper pole can be pushed against the larynx, palpated through and through, and differences in consistency within the nodule or within the thyroid gland itself can be quite readily demonstrated. When, however, the nodule or suspected nodule is in the body of the thyroid, particularly in the lower pole, and when it is small, the decision can be difficult. We see such cases daily in the clinic and when this doubt arises we ask each other to examine the doubtful cases in order to have a variety of opinions as to whether or not this is a tumor and is sufficiently suspicious to advise an exploratory operation. Discrete adenomas of the thyroid usually stand out quite distinctly within the lobe of the thyroid, particularly when one finger can be put behind the lobe and the thumb in front and the lobe palpated through and through as the patient swallows. In such cases discrete adenomas can be diagnosed quite easily. It is of great advantage, however, in such 781
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Frank H. Lahey
cases to ask the patients to swallow a mouthful of water two or three times as they will thus elevate both lobes of the thyroid out of their position behind the calvicle and it will be possible to palpate low discrete adenomas which otherwise might well escape attention. When there is doubt concerning the certainty of a discrete adenoma we have considered it advisable to send the patients away for three or four months, then examine them again, and if there is still doubt, to send them away again for three or four months, examine them again, and if there is no change to assume that the condition is thyroiditis or a thickened lobe. There are very few cases in which removal of a lobe is advisable when the decision as to whether or not a discrete adenoma is present is so uncertain that exploration is necessary. In such cases we believe that it has proved wiser to determine by the lapse of time whether or not a definite adenoma exists. This difficulty in making a decision whether a discrete adenoma of the thyroid is or is not present arises usually when such suspicious areas exist in the body of the lower pole of the thyroid. Adenomas of the upper pole of the thyroid or that portion of the thyroid which is adherent to the larynx are much more easily demonstrated since it is possible, as stated, to push the upper pole against the firm structure of the pharynx, palpate it through and through and demonstrate a change in consistency which identifies it as a discrete adenoma. All of this difficulty would not occur if one would wait until discrete adenomas become of sufficient size so that they can be demonstrated without uncertainty. We believe, however, as stated by Dr. Swinton in his article on "The Problem of the Thyroid Adenoma" elsewhere in this issue, that since one in every ten discrete adenomas is malignant we would like to discover and remove them early in their development when they are still so small that their presence is debatable. Palpatory Findings in the Differential Diagnosis of Benign and Malignant Disease of the Thyroid
One of the most difficult problems with which we have had to deal has been the decision in the case of the firm thyroid gland suspected of thyroiditis as to whether the firmness is actually due to thyroiditis or to malignancy or whether both conditions exist simultaneously. I was confronted with this situation quite recently when a middle aged school teacher was sent to the clinic for this decision to be made because of moderate enlargement of the thyroid and the demonstration of increase in its consistency up to that of marble-like firmness. On palpation, the entire thyroid gland was of almost stony hardness. In the right upper pole, however, there was a suggestion of a single nodule. This could not be separated with certainty from the remaining portion of the
Preoperative Diagnosis of Carcinoma of Thyroid
783
very firm thyroid gland. It was decided that such was the uncertainty and firmness in this case that only by exploration with a biopsy could this decision be safely made. The entire thyroid gland, therefore, was exposed, a biopsy specimen was taken from the area suspected of malignancy and proved to be a papillary adenocarcinoma arising in a discrete adenoma within a gland which was the site of thyroiditis. Biopsies of the remaining portion of the thyroid, in the right lobe and also in the left, revealed the presence only of thyroiditis. A total right hemithyroidectomy and radical dissection of the neck were done with removal of the sternomastoid, the entire right internal jugular and dissection of all of the gland from below the clavicle up to the angle of the jaw, followed by two million volt radiation ov-er a period of thirty-five days. Because this is, as a rule, a radiosensitive lesion and because of its fairly early discovery, this patient has an excellent chance of a five year survival. A similar case a few years ago presented the other aspect of the problem. One of my most respected surgical friends in this community who for many years has been ihterested in thyroid disease was asked to see a famous rabbi, a man of outstanding prominence and national eminence. He came to my surgical friend because of a firm thyroid, presumably thyroiditis. In the right lower pole, however, there was an enlarged area which suggested the possibility of local tumor formation which could be a coincident adenoma that had become malignant or a local enlargement of the right lobe from thyroiditis, since it is well known by everyone who has to deal with patients who have thyroiditis that there can be local enlargements even up to nodules when thyroiditis has progressed to the stage of Riedel's struma. He brought the patient to me for consultation and advice. The problem presented was as follows: If nothing were done, and it was assumed that this was only thyroiditis and the decision was wrong, this man could readily pass into the stage of inoperability. If the right lobe were removed, such is the fixation and tendency of thyroiditis to produce fibrosis and adhesions to other structures about the lobe that either damage or scar involvement could ruin his voice and deny him one of his most prized capacities, that is, to preach. It was decided, therefore, to expose his lobe and do a biopsy, which was done by my surgical friend. It proved to be thyroiditis and everyone is happy and secure. It seems to me from our experience that this procedure should be employed in any case of thyroiditis in which the decision for or against malignancy remains unsettled. Lest anyone assume that every case of thyroiditis requires a biopsy, I would like to say that we feel quite confident in making the diagnosis in most cases of thyroiditis. There are certain distinguishing points which can be depended upon. One is the fact that from the beginning in most cases of thyroiditis both lobes are involved simultaneously and that,
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Frank H. Lahey
while the thyroid gland may be enlarged throughout its entire extent, it still retains the anatomical outline which characterizes it when it is a normal structure-the sharp, peak-like apex, the triangular tongue of the upper portion of the thyroid as it is attached to the side of the larynx, the typical isthmus and the typical lateral lobes of the well known shape of a thyroid, not unlike a crescent breakfast roll. When can be added to that the history that following a recent throat infection there has occurred tenderness within the gland, when on palpation even moderate degrees of tenderness are present and when, in addition, there is fixation of the gland which so often characterizes thyroiditis, one can assume with reasonable certainty that the state is one of thyroiditis and not of malignancy. In the diagnosis of possible malignancy of the thyroid by palpation which, after all, is one of the very dependable features to make one suspicious of malignant degeneration in a previously existing benign adenoma, perhaps the most common cause of such firmness not of malignant origin is recent hemorrhage into the adenoma. In such cases recent hemorrhage, particularly after the hemorrhage has ceased and is becoming organized, can cause firmness within a discrete adenoma which is similar to the type of firmness which is seen in malignancy. With this hemorrhage into the adenoma goes fixation similar to that seen with malignancy. One of the most dependable evidences of malignant degeneration within a known previously existing adenoma is loss of spherical outline. Discrete adenomas are ball-like in character. When malignant degeneration has occurred within the adenoma and has eroded the capsule this complete, spherical, ball-like outline is lost and invasion of the parenchyma of the gland can be demonstrated. This also varies in degree. When part of the ball-like character of the gland is lost, it is not easy to demonstrate. When, however, a previously existing discrete adenoma can be shown to have lost part of its discrete outline by invasion of the parenchyma of the gland, that is almost certain evidence of malignant degeneration. Voice Changes
Much has been written previously about the value of voice change as an indication of involvement of the recurrent laryngeal nerve by a carcinoma of the thyroid. The more experience I have in cases of carcinoma of the thyroid, the more impressed I am with the ability of the recurrent laryngeal nerve to withstand invasion by malignancy. In patients with discrete adenomas of the thyroid who have vocal cord fixation and recurrent laryngeal nerve paralysis on the same side, a much greater number, In fact a predominating majority, have continued with the recurrent laryngeal paralysis on that side when the adenoma has been
Preoperative Diagnosis of Carcinoma of Thyroid
785
removed and found to be benign than when the condition was due to carcinomatous degeneration within an adenoma. One should, I believe, still look with suspicion on any patient with an adenoma in one lobe of the thyroid and the rather sudden appearance of vocal cord paralysis on that side but, as my experience in observing these cases over the years has increased, I have a distinct conviction that this is of less and less value as a sign of beginning n;alignancy within the adeno:na. I have many times been impressed with the fact that carcinoma of the thyroid can become adherent to the larynx and to the trachea, but the recurrent laryngeal nerve can be demonstrated as passing; through the carcinoma uninvolved and without recurrent laryngeal paralysis on that side. The Decision between Radical Dissections and Complete Unilateral Total Thyroidectomy
We have tried to base our decisions for and against radical dissections of the neck and complete, unilateral total thyroidectomy on a few points. In those patients with papillary cystadenorr a.s entirely within the capsule of the thyroid, without invasion of the thyroid capsule and without lymphatic and blood vessel invasion, we believe that local removal without postoperative high voltage irradiation is safe and satisfactory. In those cases of papillary adenocarcinorra of the thyroid completely within the capsule in which there is no invasion of the capsule and no invasion of the lymphatics but there is blood vessel invasion, we believe that local removal is adequate since if blood vessel invasion has reached the stage of dissemination, it can be at such a distant point that radical dissection of the neck and total removal of the thyroid on that side may very well not include the region of dissemination. In cases in which there is invasion of the capsule or of the lymphatics, however, we believe that radical dissection of the neck, consisting of removal of the sternomastoid, all of the internal jugular, all of the lobe of the thyroid on that side with preservation of the recurrent laryngeal nerve and all of the nerve structures of the neck, followed by two million volt x-ray radiation, is indicated. This is the most favorable lesion of the neck in which radical dissection of the neck and two million volt x-ray radiation are to be advised. We have reported in a fairly recent article that 80 per cent of the patients with carcinoma of the thyroid of this papillary type who have had radical dissection of the neck together with removal of the entire thyroid lobe on that side, followed by supervoltage x-ray therapy, are alive and well five years after operation. In all the patients with adenocarcinoma of the thyroid and in all of the patients with small round cell and giant cell carcinoma of the thyroid, whether or not the capsule is invaded, whether or not the lymphatics or blood vessels are invaded, radical dissections of the neck are done, since this is the group
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Frank H. Lahey
of patients with a low five year survival rate, with a limited degree of radiosensitivity and the most unfavorable future from every viewpoint. Management of Multiple Adenomatous Goiter with Single Firm Nodule
One of the problems which concerns us in dealing with so many patients with thyroid disease is, what shall we do with the patient who has a multiple adenomatous goiter, not a discrete tumor, not of sufficient size to be unsightly, not causing pressure, not progressing into the mediastinum, not toxic, but possessing within the goiter one nodule that is more unduly firm than the others. In such cases we believe that exploration should be done, the hard nodule removed and submitted to the pathologist and, since the gland is already exposed, the other nodules which are really not true nodules, removed, preserving the largest possible amount of normal thyroid tissue. This attitude should be taken in tbe management of both lobes. It is only by approaching the problem from this point of view that we can be sure that the firm nodule is not beginning malignant degeneration in a sing'e discrete adenoma of the thyroid included in a thyroid showing multiple adenomatous degeneration. Management of Extensive Carcinoma of Both Lobes of Thyroid
One of the problems that we have to face not infrequently is the patient with an extensive carcinoma of both lobes of the thyroid. It is in this type of case that we would like to present our attitude and experience. Many patients with this type of carcinoma of the thyroid involving both lobes of the thyroid, sometimes quite firmly fixed, are sent to us for a decision on surgery as a last resort. Our decision for or against advising surgery in such cases is largely dependent upon movability of the involved thyroid gland. We have little faith in total thyroidectomy as a method of treating extensive carcinomatous involvement of both lobes of the thyroid. It is safe to assume that in such extensive cases total thyroidectomy will accomplish very little in .terms of five year survival and can bring about very undesirable complications during the period these patients survive. In cases of carcinoma involving both lobes of the thyroid, removal of all of the thyroid can rarely be done without a very high percentage of tetany and a very high percentage of bilateral abductor paralysis, both very undesirable complications to a patient whose life, in all probability, will not be prolonged particularly by such an operative procedure. When both lobes of the thyroid are involved we much prefe~ to take out tbe larger lobe and the istbmus if that is possible and at the ~ame time do a tracheotomy. By proceeding along this line the patient can be assured that he will not be voiceless and that be will
Preoperative Diagnosis of Carcinoma of Thyroid
787
have a good airway which will persist even in the presence of a great deal of x-ray reaction which not infrequently occurs, and he will be able to breathe normally during the period of his high voltage x-radiation on the removed and unremoved sides. We have had some extraordinary results with some of these patients who have had extensive bilateral involvement of the thyroid with carcinoma and with lesions, particularly adenocarcinoma, usually assumed to be of the unfavorable type when they have been submitted to two million volt x-ray therapy. One of the most important features of this approach to the management of inoperable carcinoma of the thyroid, that is, from the point of view of five-year survival rates, is the need to protect the patient against the possibility of having to have an emergency tracheotomy following or during his high voltage x-radiation with all of the malignant tissue still present within both lohes of the thyroid and in the thyroid isthmus. To attempt a tracheotomy in the presence of a bilaterally enlarged thyroid and thyroid isthmus invaded by malignancy which has reacted to x-radiation with induration and swelling is extremely difficult and far from satisfactory. We prefer, as stated above, to remove one lobe of the isthmus, bare the trachea and do a tracheotomy and then undertake rotational radiation on both sides of the neck, with the complete security that no emergency tracheotomy will be demanded, no matter how great the reaction.
.
Management of Advanced Malignant Thyroid Lesion Descending into Superior Mediastinum
In considering the patients who have advanced malignant disease of the thyroid, who are so frequently sent here in the hope that we can do something for them, I wish to discuss the dissection of these advanced malignancies which have descended into the superior mediastinum down behind the clavicle and the sternum. There is one type of malignancy already spoken of and to be noted in Drs. Warren and Meissner's classification (page 739), that is peculiarly noninvasive, papillary adenocarcinoma. As Drs. Warren and Meissner have stated, this includes the type of lesions which used to be called aberrant thyroids about which we wrote some years ago, only later to become aware that what we were discussing as lateral aberrant thyroid, movable, pigment stained nodules in the lateral regions of the neck, were actually metastases into the cervical lymph nodes with a small unrecognized primary tumor in the lobe on that side. These advanced types of malignancy which so frequently, particularly in young girls, invade both sides of the neck, lack invasiveness which characterizes the adenocarcinomas, small round cell and giant cell carcinomas. Dissection into the mediastinum in this type of malignancy is permissible since they are so movable, care being taken particularly on the left side to avoid injury to the thoracic duct. When
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Frank H. Lahey
the firm, fixed invasive type of malignancy characterizing adenocarcinoma, giant cell and small round cell carcinoma infiltrates behind the sternum, no attempt should be made to excise this tumor or to carry the dissection below into the mediastinum. There are no lines of cleavage in malignancies of this type and grade which have invaded the mediastinum. They cannot be separated. They cannot be adequately removed and attempts to enucleate them will result in venous hemorrhage, accumulation of hematomas, an extremely dangerous and undesirable complication in terms of pressure upon the trachea beneath the sternum, and infections, with no prospect of benefit. I particularly wish to warn against attempts to follow infiltrating types of carcinoma of the thyroid into the mediastinum. Indications for Tracheotomy
In connection with the above statement I might try to answer the question: When should a tracheotomy be done in carcinomas of the thyroid? Tracheotomy should be done when after the removal of the malignancy of the thyroid the trachea has collapsed, when the dissection has been extensive, when high-voltage x-radiation is to be given and when an injury to the recurrent laryngeal nerve is anticipated. It must be remembered that when the recurrent laryngeal nerve is roughly handled, is manipulated unduly as it is dissected out of the thyroid, and paralyzed, it will cut the glottic space in half since the cord will not adequately retract to increase the airway as demanded. In such cases a tracheotomy should 'always be done. There are very few cases of carcinoma of the thyroid which are extensive and infiltrating, particularly the type in which the operation in done as a last resort to be followed by high-voltage x-radiation, in which tracheotomy should not be done. It is important for me to distinguish clearly that in the patient with a discrete adenoma of the thyroid showing the complications spoken of earlier in this discussion (malignancy), who is to be given irradiation, tracheotomy is rarely necessary even though there may be a not inconsiderable degree of x-radiation reaction. Most patients with relatively early malignant degeneration in an adenoma who have had radical dissection of the neck, consisting of removal of the sternomastoid, the internal jugular and all of the thyroid gland with complete baring of the trachea and removal of the isthmus on the affected side, do not require tracheotomy. Should tracheotomy become necessary, however, it is easily done because the trachea has been so completely exposed by the removal of the isthmus and is so readily available for the introduction of the tube if it is even suspected that it is necessary. One of the problems with which we have had to deal also is the question already stated, in patients with extensive carcinoma of the thyroid in which but one lobe is removed and a tracheotomy done in order to
Preoperative Diagnosis of Carcinoma of Thyroid
789
make it possible to give palliative irradiation to the remaining malignancy in the thyroid, should this operation be done in the presence of distant metastases?\ From our experience we would say that it should, because local extension can often be checked by palliative irradiation, distant metastases are sometimes of such a type that they will take up radioactive iodine or even yield to palliative doses of x-rays at distant points and the patient is provided an adequate airway. Esophageal or Tracheal Involvement in Extensive Late Malignancy
One of the problems that not infrequently confronts us and we have to settle is, if there is a local area of esophagus caught by the extensive late malignancy in patients sent here for last resort procedures, what should be done? We have never thought it wise to excise portions of the esophagus since the wound will be complicated seriously by the discharge of food and the presence of saprophytic organisms. In such cases we have preferred to shave off sections of the malignant thyroid and leave them attached to the esophagus. A similar problem arises in those patients in whom the malignancy has invaded the trachea and removal of such adherent malignant sections would require the removal of a section of the trachea. It is surprising how resistant the trachea is to invasion from malignant thyroid tissue. In most instances, even when both lobes are involved the trachea can quite safely be separated, the isthmus cut off and one entire lobe preserved, but when the trachea has been invaded it has again been our custom to shave off sections of malignant thyroid tissue leaving such sections adherent to the trachea to be cared for by the later supervoltage radiation. Should the Recurrent Laryngeal Nerve Be Preserved in Dissections for Carcinoma of the Thyroid?
To this question we would answer that the decision must be based upon factors shown to be present at the time of the surgical procedure. We can successfully preserve recurrent laryngeal nerves in practically all cases of early malignant degeneration within an adenoma of the thyroid even though the capsule has been invaded and parenchyma involved. In patients with extensive malignancies of the thyroid, however, sent here for either palliative surgery or the hopes of cure, the decision as to whether a nerve is or is not to be saved is based entirely upon how extensive is the degree of involvement of that structure by InvaSIOn. The Value of Frozen Sections in Determining Need for Immediate Radical Dissection for Discrete Adenomas
As Dr. Swinton has stated in his article on this subject, we have gradually been changing from the position that we will await the paraffin
790
Frank H. Lahey
section microscopic diagnosis before determining the presence or absence of thyroid malignancy in discrete adenomas of the thyroid and the need for immediate radical dissection of the neck. To an~wer the question as to whether or not frozen sections can be depended upon for the decision to do or not to do a radical dissection of the neck we would say that when the frozen section unequivocally settles that the lesion is malignant we would be quite willing to undertake radical neck dissections and when in doubt we would prefer to wait for final reports on the paraffin sections. Since the decision for or against radical neck dissection in early discrete adenomas of the thyroid depends upon such delicate observations of invasion of the capsule or of the lymphatics there will be not infrequent occasions in which the first diagnosis by frozen section may be reported as benign as has recently happened to us, and later, on more accurate and better section, determined to be malignant. Therapeutic Indications in Presence of Distant Metastases
Are distant metastases to be treated with radioactive iodine or with local irradiation? This must be settled again on the basis of the individual case and the individual findings. We have not infrequently had patients sent to us who have a single metastasis in a long bone such as a humerus or a femur which has resulted in a spontaneous fracture. In several of these patients good union has resulted under traction and local irradiation, but when the lesions are in an unapproachable location they are best treated by radioactive iodine if it can be proved that there is a good uptake of radioactive iodine after a total thyroidectomy, but even in those lesions involving vertebral bodies much relief from pain has been accomplished by local x-radiation of the distant metastases. Bilateral Malignant Lesions of Thyroid in Young Persons
It is fortunate that most of the patients with malignant lesions of the thyroid coming to us for management have unilateral disease. There are occasional instances, particularly in young girls with the papillary adenocarcinoma type of malignancy, in which delay has taken place or spread has been rapid and involved both sides, in which the decision must be made as to whether or not bilateral radical dissection of the neck with removal of both sternomastoids and both internal jugulars is desirable. Our answer to this has been "no." We prefer in such cases to do radical dissections on the side with greater involvement and to do subradical resections, preserving the sternomastoid and the internal jugular on the opposite side followed by supervoltage radiation. The disfigurement associated with bilateral removal of both sternomastoids and the uncertainties associated with bilateral removal of both internal jugulars are such that we prefer the above stated course. It is amazing
Preoperative Diagnosis of Carcinoma of Thyroid
791
Fig. 208. In this illustration taken before operation, bilateral metastases in a patient with a large papillary adenocarcinoma may be seen. Because of the type of malignancy, even though this patient were not given radioactive iodine he would probably live a considerable number of years. Note the degree of tracheal deviation (marked by arrows) as a result of the size of the goiter.
Fig. 209. This patient was first operated on January 29, 1930, at which time radical dissection of the right side of the neck was performed. The pathologic report was papillary adenocystoma with blood vessel invasion. In 1936 and in 1939 nodules in the neck were removed; the diagnosis at that time was papillary adenocarcinoma with blood vessel invasion. a, Roentgenogram of the chest in 1942 showing pulmonary metastases; b, in 1948 no metastases are visible. At the present time the patient is in excellent health and the lungs are clear. (From Hare, Hugh F., and Newcomb, R. V. in Radiology 54: 401-407, March, 1950.)
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Frank H. Lahey
792
I i
how littl~ disfigu~ement ~ccurs with t~e re.moval o~e sternoI?astoid and one mternal Jugular m a young gIrl WIth a bM;utlful neck If all of the nerve structures can be preserved. If there is no.l'Olt-shoulder or angel wing scapula which is associated with PllTalysls of the spinal accessory nerve these patients even when wearing low-necked dresses or bathing suits often show little or no difference when one compares the unoperated side with the operated side. The loss of both sternomastoids and the forward ridge pole-like effect upon the neck as the unfilled spacll beside the trachea projects that structure forward are extremely disfiguring and depressing to the average young person in whom this problem of bilateral dissection so often arises. Pulmonary Metastases
Are there instances of pulmonary metastases of such character that they can be demonstrated roentgenologically in which life can exist over a number of years? We have several such patients. Figure 208 shows a recent case with metastases in both lungs and an enormous goiter which on removal proved to be papillary adenocarcinoma. The patient will be given radioactive iodine now to promote his uptake after having a total thyroidectomy, but we have a number of young girls alive t!;nd well many years with such a type of pulmonary metastases, an exiJ,mple of which is shown in Figure 209, alive and well now twenty-tht.ee years after removal and x-radiation. ' CONCLUSIONS
;.
I am very aware of the narrative character of this article but; after all, such problems as are presented here confront the practical surg~on every day. It is my hope that this recital ,of our own experiences a:f1d of our own viewpoints, based upon a large and practical experience, with the problem of thyroid malignancy, will be of some aid in the sblution of these problems. ~ ,