J. Martin Miller

The cystic thyroid nodule. Recognition and management.

Sixty-eight cystic nodules of the thyroid, diagnosed by physical examination, radioiodine scan, and ultrasonogram, were treated by percutaneous aspiration and followed six months to eight years. In 30 cases the scans suggested benign disease; in 38 the patterns were equivocal and the ultrasonogram was important in providing diagnostic assurance of the cystic and probably benign nature of the nodules. Surgical excision or radioiodine therapy was carried out in 11 treatment failures. In 57 patients aspiration has been to date a satisfactory substitute for lobectomy. The possibility of serious mismanagement of thyroid cancer by inclusion in such a group is quite remote.

THE THYROID SCINTIGRAM. I. THE HOT NODULE

The Thyroid scintigram has not been found decisive for the identification of malignancy in thyroid nodules (1–12). Correct delineation of its sphere of usefulness has been delayed by three factors. First, proper attention has not been given to technical aspects of the scanning procedure. Second, many physicians have failed to interpret the scintigram in the light of the total information available from the patient. Third, there has been infrequent correlation of scintigram patterns and autoradiographs of the related tissue. In a previous publication we discussed the scintigram diagnosis of the hot autonomous nodule and offered arguments for its probable benign nature (13). Others have stressed the high incidence of thyroid cancer in cold nodules (1, 3, 5, 6, 14), a statistic heavily weighted by selection. They have called attention to the inverse correlation of function, as judged from the scintigram, and the probability of thyroid cancer. Nodules with little or no autonomous function have been subdivided...

The diagnosis of malignant follicular neoplasms of the thyroid by needle biopsy

To test the value of needle biopsy for a diagnosis of follicular thyroid malignancy, we compared needle biopsy and surgical diagnoses for 1005 patients. There were 67 follicular carcinomas, 34 Hurthle cell carcinomas, and 39 follicular variants of papillary carcinoma. Malignancy was diagnosed or suspected by biopsy for 114 of the cancers (82%), considered “possible” for 24 (17%), and misdiagnosed as “benign” in 2. Sensitivity of fine‐needle biopsy (FNB) for the diagnosis of 39 cancers approximated that of large‐needle biopsy (LNB) for 101 cancers 2 cm or larger. Diagnostic specificity for cancer varied with the degree of cytologic or histologic abnormality. Specificity of FNB was comparable to LNB on nodules large enough for both procedures. Specificity of FNB on nodules too small for LNB was substantially less. The sensitivity of needle biopsy allows selection of many follicular nodules for observation. Knowledge of the probability of cancer for each cytologic or histologic diagnosis is useful in determination of the need for thyroid surgery.

The needle biopsy diagnosis of PAPILLARY THYROID CARCINOMA

One hundred five cases of papillary thyroid carcinoma (PTC) were studied by needle biopsy and surgically confirmed in a 30‐month period. Eight years were required to diagnose the same number of cases without the use of needle biopsies. Identification of clinically unsuspected cancer and confirmation of clinical “possible” cancer diagnoses accounted for 30% of this change. Seventy percent was accounted for by the increase in nodules referred for evaluation. The accuracy of fine‐needle biopsy (FNB) improved with experience. Positive diagnoses of PTC were made in 19 of the first 35 PTCs and in 33 of the last 35. False‐negative and unsatisfactory FNBs decreased from seven in the first third of the study to zero in the last third. Large‐needle biopsy (LNB), initially used to check FNB, became less necessary as experience increased. Both FNB and LNB were more specific when papillary areas were included in the biopsy procedure, and approached the specificity of surgical biopsy. The increase in indentifying PTC may require modification of the therapeutic implications of this diagnosis.

Signet ring cell lymphoma of the thyroid: a case report.

The first case of extranodal signet ring cell lymphoma involving the thyroid gland is reported in a 53-year-old woman with Hashimotos thyroiditis. Since 1978, 24 cases of signet ring cell lymphoma, all involving primarily nodal tissue, have been documented in the literature. This rare neoplasm is believed to be a variant of non-Hodgkins follicular lymphoma, which may be mistaken for metastatic poorly differentiated adenocarcinoma.

Evaluation of thyroid nodules. Accent on needle biopsy.

The major problem posed by a thyroid nodule is the possibility of thyroid cancer. Fine-needle biopsy, occasionally supplemented by large-needle biopsy, provides the most cost-effective diagnostic evaluation.

Modified neck dissection for thyroid carcinoma

Abstract The presence of palpable cervical lymphadenopathy in patients with carcinoma of the thyroid nearly always indicates the presence of metastases to the nodes. A radical neck dissection is indicated in the surgical treatment of most of these patients who are otherwise operable (primary lesion can be removed). In our experience at least one-third of patients with carcinoma of the thyroid but without palpable cervical lymphadenopathy do have metastases to the cervical nodes. Whether or not cervical node dissections should be used for these patients is, therefore, not decisively established. However, a modified neck dissection is considered justified in the surgical treatment of many of this group of patients and better results are suggested if it is done. A modified neck dissection has been defined as a dissection which is identical to the classical radical neck dissection except for the preservation of the sternocleidomastoid muscle and the submaxillary gland area. This includes removal of the nodes adjacent to the thyroid and presupposes complete removal of the primary lesion.

Is Needle Aspiration of the Cystic Thyroid Nodule Effective and Safe Treatment

In 1955 one of us (JMM) first expressed dissatisfaction with the use of surgical lobectomy for diagnostic purposes in thyroid nodule patients.1 This attitude was in part related to the observation that some thyroid nodules are cysts, many of which can be eliminated by simple needle puncture.2–6 In a retrospective study, 88 of 425 surgically excised solitary or dominant nodules proved to be unilocular cysts, 2 cm or more in diameter. The development of techniques utilizing ultrasound to differentiate cystic from solid thyroid nodules has made it simpler to select nodules for aspiration. Nevertheless cyst aspiration is still not widely employed.

Is Lymphoma of the Thyroid a Disease Which Is Increasing in Frequency

It has been said that primary lymphoma of the thyroid gland is rare.1–9 The number of cases reported in the world literature has been cited at approximately 250.9 Although this is probably an underestimate, it is a general indication of the frequency of this disease. Most of the tumors are histiocytic or lymphocytic lymphomas. Primary involvement of the thyroid gland by Hodgkin’s disease is truly exceedingly rare.10 The diagnoses have almost always been made retrospectively after operations for different presumptive diagnoses.

The impact of needle biopsy on the diagnosis of the thyroid nodule

Management of the patient with a thyroid nodule has been the subject of debate for many years. The essential question for any given nodule is whether the risk of cancer is great enough to justify the risk of surgical treatment. Granted the risks are very small when operations are performed by expert thyroid surgeons in first rate hospitals. Nevertheless, even these small risks must be justified when one is dealing with a problem which is as common as thryoid nodules, especially since most thyroid nodules are benign, most of those which are malignant are not very agressive, and the few highly lethal are almost always incurable by surgical methods.