- Email: [email protected]
Thyroid cancer in 1,330 cases of surgical goiter
Thyroid ASHBELC.
WILLIAMS,
Cancer in I ,3 30 Cases of Surgical Goiter M.D., JAMES M. DAVIS, M.D. ANDANDREW A. KIELY, M.D., Jacksonville, Florida
From tbe Jacksonville Hospital Educational Program and tbe Department of Surgery, St. Vincent’s Hospital, Jacksonville, Florida.
PATHOLOGY
The types of pathoIogic Iesions encountered are Iisted in TabIe I. Thyroiditis was present in 158 patients (I I .8 per cent) and in ninety-eight of these (7.4 per cent) it was of the Hashimoto type. Six additiona patients showed struma Iymphomatosa and cancer. These figures agree with those of recent reports indicating an increasing incidence of thyroiditis [I-31. One hundred forty-one, or 10.6 per cent of the entire group, were diagnosed as having diffuse hyperplasia. The reIativeIy high incidence of cancer, ninety-eight cases (7.4 per cent), is of particuIar interest. These cases wiI1 be discussed in some detail.
HE purpose of this paper is to present an anaIysis of thyroid Iesions in patients operated upon during the past ten years in one of the major cities of Southeastern United States. Of primary interest was the incidence of cancer, the types encountered and the surgical management of these Iesions incIuding foIIow-up studies. It has also been our intent to determine the morbidity and mortality of thyroid resection as performed in a typica American city.
T
CLINICAL
MATERIAL
The materia1 consists of 1,330 cases which includes a11 patients undergoing thyroid surgery in the four Iargest hospitals of JacksonviIIe, Florida, during the past ten years.* These procedures were performed by various members of the visiting and resident surgica1 staffs of these HospitaIs. The operative procedures ranged from biopsy of the thyroid gIand to tota thyroidectomy with bilateral neck dissection. Lobectomy and biIatera1 subtota1 Iobectomy were the operations performed most frequentIy. The postoperative hospita1 stay for the average patient with uncomplicated resection in recent years was three to five days. Over go per cent of the patients were female. The ages varied from five to eighty-one years with most patients from twenty to fifty years of age. Hyperthyroidism was the presenting problem in IO per cent of the patients.
TABLE I PATHOLOGICDIAGNOSIS
Journal
of Surgery,
Volume roq, November 1962
1,330
THYROID
-
OPERATIONS
IVo. of Operations
Diagnosis ._ Anenomatous goiter. ............ Adenoma ....................... Thyroiditis. ................... Diffuse hyperpIasia. ......... Cancer ......................... Thyroid cyst. ................... Thyroid tissue. ................. Terratoma (benign). ............ Abscess. .................. .... Carcinoma of esophagus invading thyroid. ...................... Parathyroid cyst, ............... Parathyroid adenoma. ........... Parathyroid tissue ............... Thymic cyst. ................... EpitheIiaI inclusion cyst
* St. Vincent’s, Baptist MemoriaI and St. Luke’s Hospitals and the DuvaI Medical Center. American
IN
672
Total ........................
623 279 158 141 98 I7 6 I
1 1 I
1,330
Thyroid
Cancer
MORTALITY
airway. Of the three patients experiencing unilateral nerve injury, tracheostomv was performed in one. This incidence of recurrent nerve injury is probably not realistic because of failure in diagnosis in some while others mav not have been recorded for various reasons. Cardiac arrest occurred in two instances with one survival. BilateraI closed thoracotomy drainage was necessary in one patient in whom bilateral pneumothorax developed, Tracheostomy was performed in a total of twenty-four patients. In four of these it as a prophylactic measure was performed while in the remainder it was necessitated b,v hemorrhage, laryngeal edema, paralysis of the vocal cords or by advanced cancer as rrIated previously.
‘fherc were seven operative deaths for an over-all mortality of 0. $ per cent. One patient had a fatal cardiac arrest on the operating table while another died of respiratory obstruction caused by hemorrhage which occurred severa hours after operation. A third patient died of myocardial infarction one week foIIowing an operation for substernal goiter which required a sternal splitting incision. Four deaths occurred in patients with advanced thyroid ca ricer,, surgery being limited to palliative resection and tracheostomy. COMPLICATIONS
AND
MORBIDITY
Complications are shown in Table II. Only those entailing additional morbidity and/or surgery are inchrded. Twenty-four patients in whom hypoparathyroidism developed recovered without requiring parathyroid hormone. Severe postoperative hemorrhage was experienced in seventeen patients. Tracheostomy was necessary in eight of these patients, and exploration of the wound in seven, while the remainder recovered with conservative therapy. AI1 but one survived. Eleven patients in whom wound infections developed responded successfully to antibiotics and local treatment. The two patients with bilateral recurrent nerve injury required emergency tracheostomy. One of these patients recovered cord function whiIe the other required a secondary procedure on the larynx to estabIish an adequate TABLE II COMPLlCATIONSIN 1,330 THYROID
Number
~.______
TABLE III
__-
INCIDENCE
24
OF
Bilateral. . Laryngeal edema requiring tracheostomy.. Cardiac arrest. . Myocardial infarction.. BiIateraI pneumothorax.. Esophageal fistula..
IN
SOLITARY
!
Total Number
Data
3 2
4
-___
I I 1
SoIitary noduIes. MuItinoduIar .
66
/
383 624
NOTE: The over-n11 incidence cases was 7.4 per cent.
673
AND
Malignant
j ~.
/
.~_~__
No.
’
5%
/ 56 / 27
(
14.6 4.3
in
1,330
,
2
.
NODIJLES
GOITERS
1
11 ..
CANCER
MULTINODULAR
r7
.
UniIateraI
Total................................
LESIONS
Among the 1,330 patients in this study to have thyroid ninety-eight were found cancer, an incidence of 7.4 per cent. Of these eighty-one were femaIe and seventeen were maIe patients. The age distribution in the ninety-eight patients with cancer ranged from five to eighty-one years. The peak incidence occurred in the fourth decade but there was remarkably little variation in the ages between twenty and seventy years. Of eight patients under twenty years of age, seven had papiIIary carcinoma and six of these had cervical metastases. One had a HiirthIe ceI1 carcinoma, an unusual lesion in chiIdren [4]. There were 383 solitary nodules found at operation or on pathoIogic examination. (Table III.) Fifty-six of these proved to be malignant, an incidence of 14.6 per cent. Of 624 patients found to have muItinoduIar goiters, cancer was present in twenty-seven or 4.3 per cent.
OPERATIONS
Comphcations
Hypoparathyroidism.. Hemorrhage............................ Wound infection. Recurrent Iaryngeal nerve injury
MALIGNANT
of cancer
WiIIiams,
Davis
TABLE IV PATHOLOGIC CLASSIFICATION OF NINETY-EIGHT PATIENTS WITH THYROID CANCER
and KieIy TABLE v RESULTS IN SEVENTY-SIX PATIENTS OBSERVED LESS THAN FIVE
-
YEARS
-
No. of Patients
Type
Pathologic
Type r
PapiIIary adenocarcinoma. ......... AIveoIar carcinoma (follicularj ...... Hiir-thIe ceI1 carcinoma. ............
Papillary Alveolar
9 7 s 4 2 I I I
Adenocarcinoma................... Lymphoma ....................... Anaplastic carcinoma. ............. MaIignant adenoma. ............... SmaII ceI1 carcinoma. .............. Epidermoid carcinoma ............. Fibrosarcoma ..................... Metastatic squamous ceI1 carcinoma from uterine cervix. ............. I-
-
TotaI ..........................
adenocarcinoma. carcinoma
(foIIicuIar) . . . .
29
.. .
.
.
5
Totals..
98
.... ..
2
2
5 3
f I
3 4 4
. .
I I
I I
...
I
UP Study
I
IO
Hiirthk cell carcinoma. Adenocarcinoma. Anaplastic carcinoma.. Lymphoma. Malinnant adenoma.. SmaII cell carcinoma.. Epidermoid carcinoma., Fibrosarcoma.. Squamous cell carcinoma, metaststic to thyroid..
Lost To F&XV-
_-
I-l-
4:
Died of Tumor
I
47
z
16
II
-
i These incidences are simiIar to those appearing in the recent Iiterature [5,6] with the exception of Martin’s report from MemoriaI Hospital [7]. He found cancer in 15 per cent of muItinoduIar goiters and in 8 per cent of the soIitary nodules. He reports a 20 per cent incidence of cancer in a11 patients admitted to MemoriaI Hospital with thyroid Iesions. This incidence is approximately three times that of most other reporting centers. In 535 of our patients in whom data were available, it was noted that the clinical diagnosis of solitary nodule was made in 202 patients but was substantiated at surgery in only I 18 patients (58 per cent). This iIIustrates the [imitations of cIinica1 evaluation of thyroid lesions. CLINICOPATHOLOGIC
AND
FOLLOW-UP
DATA
The pathoIogic cIassification of the ninetyeight patients with thyroid cancer is shown in TabIe IV. PapiIIary adenocarcinoma was present in 50 per cent, or forty-nine patients, which is in accord with other reports [y-g]. There were nine instances of Htirthle ceI1 tumor and five of Iymphoma. Of the Iymphomas, one was a reticuIum ceI1 sarcoma, two were giant foIIicIe Iymphomas and two Hodgkin’s disease. Other unusual findings were one epidermoid carcinoma, one fibrosarcoma and one metastatic squamous carcinoma from the uterine cervix. 674
CervicaI node metastases were present in a11 patients with anapIastic carcinoma and Iymphoma. Of these nine patients, eight are dead and one is Iiving with disease. (TabIe v.) Of the forty-nine patients with papiIIary carcinoma, invoIved cervica1 nodes were found in eighteen. One patient, thirty-one years of age, died three years foIlowing tota thyroidectomy, bilateral neck dissection and mediastinal node dissection. An enlarged cervical node had been radiated fifteen years prior to surgery with onIy partial regression. This is the only patient known to have died of papiIIary carcinoma. Nodes were invoIved in seven of eighteen patients with folIicuIar carcinoma and two of these patients died of the disease in Iess than five years. In the seven patients with adenocarcinoma neck nodes were positive in four. Two of these patients died of disease in Iess than five years. In the nine patients with HiirthIe ceII carcinoma surgery was limited to thyroid resection. These patients are cIinicaIIy free of disease to date. (TabIe VI.) RadicaI neck dissections were performed in twenty-two patients (two biIatera1) and positive nodes were encountered in twenty of these. Of the twenty patients with positive nodes, the nodes were cIinicaIIy paIpabIe in fifteen. In view of the reports of FrazeII and Foote [S,g] there is IittIe doubt that more invoIved nodes wouId have been discovered if more neck dissections had been performed. The operations performed in the ninetyeight patients with cancer can be separated into several genera1 groups. TotaI Iobectomy,
Thyroid
Cancer
TABLE VI
infrequent and with few exceptions can be successfulIy resoIved. In view of this margin of safety and because the possibiIity of maIignancy is substantia1, it is our beIief that thyroid noduIes, both singIe and multipIe, should be removed unIess there is a definite contraindication.
RESULTS IN TWENTY-TWO PATIENTS OBSERVED FIVE TO TEP.
Pathologic
YEAKS
Type
PapiIlary adenocarcinoma. AIveolar carcinoma (follicular). Hiirthle ceil carcinoma .
1Living without
Tumor
’
.I
I I
/
22
Adenocarcinoma Malignant
adenomn.
Total..
13 4 3
SUMMARY
The purpose of this survey was to ascertain the incidence of thyroid cancer (ninety-eight cases of thyroid cancer in 1,330 thyroidectomies) in a large Southeastern city, to determine the clinica and pathotogic characteristics of the malignant Iesions encountered in this area, to outIine the surgical procedures empIoyed and to present the foIIow-up resuIts to date (from severa months to ten years‘). WC hope thaat such a study, representing the tota experience with thyroid surgery in four hospitaIs in Jacksonville, FIorida, over a ten year period (1951 through 1961), should afford a true picture of the problem of thyroid cancer as encountered and handled at the community level. The cIinica1 impression as to whether or not the Iesions were singIe nodules or muItinodular goiters was compared with the surgical and pathologic findings. The incidence of cancer in singIe noduIes (11.6 per cent) is compared with that in muItinoduIar goiter (4.3 per cent). An analysis was made of the mortaIity, morbidity and incidence and types of postoperative complications, such as hemorrhage, recurrent, nerve injury, parathyroid tetany and respiratory obstruction in the over-all series of 1,330
either alone or in combination with additiona procedures such as subtota1 Iobectomy on the opposite side or noda dissection, was performed in $0 per cent of the patients. Next in frequency was total thyroidectomy (23 per cent) which in most patients was combined with radicaI neck dissection. SubtotaI Iobectomy, unilateral or biIatera1, was performed in 20 per cent of the patients. The remaining 7 per cent consisted of biopsy or paIIiative resection with tracheostomy. MuItipIe operations were performed in approximateIy one-third of the ninety-eight patients. Some patients have undergone as many as four procedures. Of the seventy-six patients foIIowed up Iess than five years forty-seven showed no evidence of disease, two are Iiving with cancer and eleven are lost to folIow-up study. (TabIe v.) Sixteen patients are known to be dead, having died of the disease. Twenty-two patients folIowed up five to ten years are clinicaIly weI1. (Table VI.) In aI1, sixty-nine patients (70 per cent) are Iiving without evidence of maIignancy to date.
operations. Findings
in
this
study
are
compared
with
similar
figures in published studies from other sections of the country. In view of the substantial incidence of cancer (7.1 per cent) in the entire series and of the inaccuracy in the cIinica1 detection of thyroid cancer, surgica1 remova is advised for single noduIes and multinodular goiters. This viewpoint is supported by a surprisingly Iow incidence of serious complications and by a surgica1 mortaIity of 0.5 per cent in the over-al1 series.
COMMENTS
It appears from this study and from the observations of others [6] that the surviva1 rate is determined to a greater degree by the pathologic type of thyroid malignancy than by the extent of the surgery performed. However, definite concIusions wil1 have to await the observation of Iarge numbers of patients for at least fifteen to twenty-five years. This study demonstrates the safety with which thyroid resection can be performed at the community level. The surgical mortality approaches zero whiIe the complications are
REFERENCES I. FOWLEH, E. F. The changing incidence and treatment of thyroid disease. Arch. Surg., 81: 733, 1960. 2. MACKSOOD, W., RAPPORT, R. L. and HODGES, F. The increasing incidence of Hashimoto’s disease. Arch. Surg., 83: 384, 1961.
675
WiIIiams,
Davis and KieIy
3. SHANDS, W. C. Carcinoma of the thyroid in association with struma Iymphomatosa. Ann. Surg., 151: 675, 1960. 4. ARIEL, I. M. and PACK, G. T. Cancer and Allied Diseases of Infancy and Childhood, p. 85. Boston, 1960. Little, Brown 81 Co. 5. SCHLICKE, C. P., HILL, J. E. and SCHULTZ, G. F. Carcinoma in chronic thyroiditis. Surg. Gynec. Ed Obst., I I I : 552, 1960.
676
6. WELCH, J. W., HELLWIG, C. A., CHESKY, V. E. and MCCUSKER, E. N. Thyroid cancer and its treatment. Surg. Gynec. @ Obst., 109: 27, 1959. 7. MARTIN, H. Surgery of thyroid tumors. Cancer, 7: 1063, 1954. 8. FRAZELL, E. L. and FOOTE, F. W., JR. PapiIIary thyroid carcinoma, pathological evidence of cervica1 node invoIvement. Cancer, 8: I 164, 1955. 9. FRAZELL, E. L. and FOOTE, F. W., JR. PapiIIary cancer of the thyroid. Cancer, I I : 895, 1958.
WILLIAMS,
Cancer in I ,3 30 Cases of Surgical Goiter M.D., JAMES M. DAVIS, M.D. ANDANDREW A. KIELY, M.D., Jacksonville, Florida
From tbe Jacksonville Hospital Educational Program and tbe Department of Surgery, St. Vincent’s Hospital, Jacksonville, Florida.
PATHOLOGY
The types of pathoIogic Iesions encountered are Iisted in TabIe I. Thyroiditis was present in 158 patients (I I .8 per cent) and in ninety-eight of these (7.4 per cent) it was of the Hashimoto type. Six additiona patients showed struma Iymphomatosa and cancer. These figures agree with those of recent reports indicating an increasing incidence of thyroiditis [I-31. One hundred forty-one, or 10.6 per cent of the entire group, were diagnosed as having diffuse hyperplasia. The reIativeIy high incidence of cancer, ninety-eight cases (7.4 per cent), is of particuIar interest. These cases wiI1 be discussed in some detail.
HE purpose of this paper is to present an anaIysis of thyroid Iesions in patients operated upon during the past ten years in one of the major cities of Southeastern United States. Of primary interest was the incidence of cancer, the types encountered and the surgical management of these Iesions incIuding foIIow-up studies. It has also been our intent to determine the morbidity and mortality of thyroid resection as performed in a typica American city.
T
CLINICAL
MATERIAL
The materia1 consists of 1,330 cases which includes a11 patients undergoing thyroid surgery in the four Iargest hospitals of JacksonviIIe, Florida, during the past ten years.* These procedures were performed by various members of the visiting and resident surgica1 staffs of these HospitaIs. The operative procedures ranged from biopsy of the thyroid gIand to tota thyroidectomy with bilateral neck dissection. Lobectomy and biIatera1 subtota1 Iobectomy were the operations performed most frequentIy. The postoperative hospita1 stay for the average patient with uncomplicated resection in recent years was three to five days. Over go per cent of the patients were female. The ages varied from five to eighty-one years with most patients from twenty to fifty years of age. Hyperthyroidism was the presenting problem in IO per cent of the patients.
TABLE I PATHOLOGICDIAGNOSIS
Journal
of Surgery,
Volume roq, November 1962
1,330
THYROID
-
OPERATIONS
IVo. of Operations
Diagnosis ._ Anenomatous goiter. ............ Adenoma ....................... Thyroiditis. ................... Diffuse hyperpIasia. ......... Cancer ......................... Thyroid cyst. ................... Thyroid tissue. ................. Terratoma (benign). ............ Abscess. .................. .... Carcinoma of esophagus invading thyroid. ...................... Parathyroid cyst, ............... Parathyroid adenoma. ........... Parathyroid tissue ............... Thymic cyst. ................... EpitheIiaI inclusion cyst
* St. Vincent’s, Baptist MemoriaI and St. Luke’s Hospitals and the DuvaI Medical Center. American
IN
672
Total ........................
623 279 158 141 98 I7 6 I
1 1 I
1,330
Thyroid
Cancer
MORTALITY
airway. Of the three patients experiencing unilateral nerve injury, tracheostomv was performed in one. This incidence of recurrent nerve injury is probably not realistic because of failure in diagnosis in some while others mav not have been recorded for various reasons. Cardiac arrest occurred in two instances with one survival. BilateraI closed thoracotomy drainage was necessary in one patient in whom bilateral pneumothorax developed, Tracheostomy was performed in a total of twenty-four patients. In four of these it as a prophylactic measure was performed while in the remainder it was necessitated b,v hemorrhage, laryngeal edema, paralysis of the vocal cords or by advanced cancer as rrIated previously.
‘fherc were seven operative deaths for an over-all mortality of 0. $ per cent. One patient had a fatal cardiac arrest on the operating table while another died of respiratory obstruction caused by hemorrhage which occurred severa hours after operation. A third patient died of myocardial infarction one week foIIowing an operation for substernal goiter which required a sternal splitting incision. Four deaths occurred in patients with advanced thyroid ca ricer,, surgery being limited to palliative resection and tracheostomy. COMPLICATIONS
AND
MORBIDITY
Complications are shown in Table II. Only those entailing additional morbidity and/or surgery are inchrded. Twenty-four patients in whom hypoparathyroidism developed recovered without requiring parathyroid hormone. Severe postoperative hemorrhage was experienced in seventeen patients. Tracheostomy was necessary in eight of these patients, and exploration of the wound in seven, while the remainder recovered with conservative therapy. AI1 but one survived. Eleven patients in whom wound infections developed responded successfully to antibiotics and local treatment. The two patients with bilateral recurrent nerve injury required emergency tracheostomy. One of these patients recovered cord function whiIe the other required a secondary procedure on the larynx to estabIish an adequate TABLE II COMPLlCATIONSIN 1,330 THYROID
Number
~.______
TABLE III
__-
INCIDENCE
24
OF
Bilateral. . Laryngeal edema requiring tracheostomy.. Cardiac arrest. . Myocardial infarction.. BiIateraI pneumothorax.. Esophageal fistula..
IN
SOLITARY
!
Total Number
Data
3 2
4
-___
I I 1
SoIitary noduIes. MuItinoduIar .
66
/
383 624
NOTE: The over-n11 incidence cases was 7.4 per cent.
673
AND
Malignant
j ~.
/
.~_~__
No.
’
5%
/ 56 / 27
(
14.6 4.3
in
1,330
,
2
.
NODIJLES
GOITERS
1
11 ..
CANCER
MULTINODULAR
r7
.
UniIateraI
Total................................
LESIONS
Among the 1,330 patients in this study to have thyroid ninety-eight were found cancer, an incidence of 7.4 per cent. Of these eighty-one were femaIe and seventeen were maIe patients. The age distribution in the ninety-eight patients with cancer ranged from five to eighty-one years. The peak incidence occurred in the fourth decade but there was remarkably little variation in the ages between twenty and seventy years. Of eight patients under twenty years of age, seven had papiIIary carcinoma and six of these had cervical metastases. One had a HiirthIe ceI1 carcinoma, an unusual lesion in chiIdren [4]. There were 383 solitary nodules found at operation or on pathoIogic examination. (Table III.) Fifty-six of these proved to be malignant, an incidence of 14.6 per cent. Of 624 patients found to have muItinoduIar goiters, cancer was present in twenty-seven or 4.3 per cent.
OPERATIONS
Comphcations
Hypoparathyroidism.. Hemorrhage............................ Wound infection. Recurrent Iaryngeal nerve injury
MALIGNANT
of cancer
WiIIiams,
Davis
TABLE IV PATHOLOGIC CLASSIFICATION OF NINETY-EIGHT PATIENTS WITH THYROID CANCER
and KieIy TABLE v RESULTS IN SEVENTY-SIX PATIENTS OBSERVED LESS THAN FIVE
-
YEARS
-
No. of Patients
Type
Pathologic
Type r
PapiIIary adenocarcinoma. ......... AIveoIar carcinoma (follicularj ...... Hiir-thIe ceI1 carcinoma. ............
Papillary Alveolar
9 7 s 4 2 I I I
Adenocarcinoma................... Lymphoma ....................... Anaplastic carcinoma. ............. MaIignant adenoma. ............... SmaII ceI1 carcinoma. .............. Epidermoid carcinoma ............. Fibrosarcoma ..................... Metastatic squamous ceI1 carcinoma from uterine cervix. ............. I-
-
TotaI ..........................
adenocarcinoma. carcinoma
(foIIicuIar) . . . .
29
.. .
.
.
5
Totals..
98
.... ..
2
2
5 3
f I
3 4 4
. .
I I
I I
...
I
UP Study
I
IO
Hiirthk cell carcinoma. Adenocarcinoma. Anaplastic carcinoma.. Lymphoma. Malinnant adenoma.. SmaII cell carcinoma.. Epidermoid carcinoma., Fibrosarcoma.. Squamous cell carcinoma, metaststic to thyroid..
Lost To F&XV-
_-
I-l-
4:
Died of Tumor
I
47
z
16
II
-
i These incidences are simiIar to those appearing in the recent Iiterature [5,6] with the exception of Martin’s report from MemoriaI Hospital [7]. He found cancer in 15 per cent of muItinoduIar goiters and in 8 per cent of the soIitary nodules. He reports a 20 per cent incidence of cancer in a11 patients admitted to MemoriaI Hospital with thyroid Iesions. This incidence is approximately three times that of most other reporting centers. In 535 of our patients in whom data were available, it was noted that the clinical diagnosis of solitary nodule was made in 202 patients but was substantiated at surgery in only I 18 patients (58 per cent). This iIIustrates the [imitations of cIinica1 evaluation of thyroid lesions. CLINICOPATHOLOGIC
AND
FOLLOW-UP
DATA
The pathoIogic cIassification of the ninetyeight patients with thyroid cancer is shown in TabIe IV. PapiIIary adenocarcinoma was present in 50 per cent, or forty-nine patients, which is in accord with other reports [y-g]. There were nine instances of Htirthle ceI1 tumor and five of Iymphoma. Of the Iymphomas, one was a reticuIum ceI1 sarcoma, two were giant foIIicIe Iymphomas and two Hodgkin’s disease. Other unusual findings were one epidermoid carcinoma, one fibrosarcoma and one metastatic squamous carcinoma from the uterine cervix. 674
CervicaI node metastases were present in a11 patients with anapIastic carcinoma and Iymphoma. Of these nine patients, eight are dead and one is Iiving with disease. (TabIe v.) Of the forty-nine patients with papiIIary carcinoma, invoIved cervica1 nodes were found in eighteen. One patient, thirty-one years of age, died three years foIlowing tota thyroidectomy, bilateral neck dissection and mediastinal node dissection. An enlarged cervical node had been radiated fifteen years prior to surgery with onIy partial regression. This is the only patient known to have died of papiIIary carcinoma. Nodes were invoIved in seven of eighteen patients with folIicuIar carcinoma and two of these patients died of the disease in Iess than five years. In the seven patients with adenocarcinoma neck nodes were positive in four. Two of these patients died of disease in Iess than five years. In the nine patients with HiirthIe ceII carcinoma surgery was limited to thyroid resection. These patients are cIinicaIIy free of disease to date. (TabIe VI.) RadicaI neck dissections were performed in twenty-two patients (two biIatera1) and positive nodes were encountered in twenty of these. Of the twenty patients with positive nodes, the nodes were cIinicaIIy paIpabIe in fifteen. In view of the reports of FrazeII and Foote [S,g] there is IittIe doubt that more invoIved nodes wouId have been discovered if more neck dissections had been performed. The operations performed in the ninetyeight patients with cancer can be separated into several genera1 groups. TotaI Iobectomy,
Thyroid
Cancer
TABLE VI
infrequent and with few exceptions can be successfulIy resoIved. In view of this margin of safety and because the possibiIity of maIignancy is substantia1, it is our beIief that thyroid noduIes, both singIe and multipIe, should be removed unIess there is a definite contraindication.
RESULTS IN TWENTY-TWO PATIENTS OBSERVED FIVE TO TEP.
Pathologic
YEAKS
Type
PapiIlary adenocarcinoma. AIveolar carcinoma (follicular). Hiirthle ceil carcinoma .
1Living without
Tumor
’
.I
I I
/
22
Adenocarcinoma Malignant
adenomn.
Total..
13 4 3
SUMMARY
The purpose of this survey was to ascertain the incidence of thyroid cancer (ninety-eight cases of thyroid cancer in 1,330 thyroidectomies) in a large Southeastern city, to determine the clinica and pathotogic characteristics of the malignant Iesions encountered in this area, to outIine the surgical procedures empIoyed and to present the foIIow-up resuIts to date (from severa months to ten years‘). WC hope thaat such a study, representing the tota experience with thyroid surgery in four hospitaIs in Jacksonville, FIorida, over a ten year period (1951 through 1961), should afford a true picture of the problem of thyroid cancer as encountered and handled at the community level. The cIinica1 impression as to whether or not the Iesions were singIe nodules or muItinodular goiters was compared with the surgical and pathologic findings. The incidence of cancer in singIe noduIes (11.6 per cent) is compared with that in muItinoduIar goiter (4.3 per cent). An analysis was made of the mortaIity, morbidity and incidence and types of postoperative complications, such as hemorrhage, recurrent, nerve injury, parathyroid tetany and respiratory obstruction in the over-all series of 1,330
either alone or in combination with additiona procedures such as subtota1 Iobectomy on the opposite side or noda dissection, was performed in $0 per cent of the patients. Next in frequency was total thyroidectomy (23 per cent) which in most patients was combined with radicaI neck dissection. SubtotaI Iobectomy, unilateral or biIatera1, was performed in 20 per cent of the patients. The remaining 7 per cent consisted of biopsy or paIIiative resection with tracheostomy. MuItipIe operations were performed in approximateIy one-third of the ninety-eight patients. Some patients have undergone as many as four procedures. Of the seventy-six patients foIIowed up Iess than five years forty-seven showed no evidence of disease, two are Iiving with cancer and eleven are lost to folIow-up study. (TabIe v.) Sixteen patients are known to be dead, having died of the disease. Twenty-two patients folIowed up five to ten years are clinicaIly weI1. (Table VI.) In aI1, sixty-nine patients (70 per cent) are Iiving without evidence of maIignancy to date.
operations. Findings
in
this
study
are
compared
with
similar
figures in published studies from other sections of the country. In view of the substantial incidence of cancer (7.1 per cent) in the entire series and of the inaccuracy in the cIinica1 detection of thyroid cancer, surgica1 remova is advised for single noduIes and multinodular goiters. This viewpoint is supported by a surprisingly Iow incidence of serious complications and by a surgica1 mortaIity of 0.5 per cent in the over-al1 series.
COMMENTS
It appears from this study and from the observations of others [6] that the surviva1 rate is determined to a greater degree by the pathologic type of thyroid malignancy than by the extent of the surgery performed. However, definite concIusions wil1 have to await the observation of Iarge numbers of patients for at least fifteen to twenty-five years. This study demonstrates the safety with which thyroid resection can be performed at the community level. The surgical mortality approaches zero whiIe the complications are
REFERENCES I. FOWLEH, E. F. The changing incidence and treatment of thyroid disease. Arch. Surg., 81: 733, 1960. 2. MACKSOOD, W., RAPPORT, R. L. and HODGES, F. The increasing incidence of Hashimoto’s disease. Arch. Surg., 83: 384, 1961.
675
WiIIiams,
Davis and KieIy
3. SHANDS, W. C. Carcinoma of the thyroid in association with struma Iymphomatosa. Ann. Surg., 151: 675, 1960. 4. ARIEL, I. M. and PACK, G. T. Cancer and Allied Diseases of Infancy and Childhood, p. 85. Boston, 1960. Little, Brown 81 Co. 5. SCHLICKE, C. P., HILL, J. E. and SCHULTZ, G. F. Carcinoma in chronic thyroiditis. Surg. Gynec. Ed Obst., I I I : 552, 1960.
676
6. WELCH, J. W., HELLWIG, C. A., CHESKY, V. E. and MCCUSKER, E. N. Thyroid cancer and its treatment. Surg. Gynec. @ Obst., 109: 27, 1959. 7. MARTIN, H. Surgery of thyroid tumors. Cancer, 7: 1063, 1954. 8. FRAZELL, E. L. and FOOTE, F. W., JR. PapiIIary thyroid carcinoma, pathological evidence of cervica1 node invoIvement. Cancer, 8: I 164, 1955. 9. FRAZELL, E. L. and FOOTE, F. W., JR. PapiIIary cancer of the thyroid. Cancer, I I : 895, 1958.