R. Lee Clark

Thyroid carcinoma—Biologic behavior and mortality: Postmortem findings in 42 cases, including 27 in which the disease was fatal

Thirty‐three autopsy cases of clinical thyroid carcinoma were studied as to types, precursor changes and biologic behavior of the tumors. Eleven carcinomas were of the solid type; 13 were spindle and giant cell and the remainder were papillary, follicular or both. The findings indicate that spindle and giant cell carcinomas arise from the papillary and follicular type. No precursor changes were found in the other tumors or in 9 occult carcinomas found at autopsy. The biologic behavior of all types, other than the spindle and giant cell, is unpredictable; survivals vary from a few months to 20 years or longer. The mortality rate is much higher than commonly is believed: Among the 554 patients treated, it was 19%. The treatment for all thyroid carcinomas is total thyroidectomy.

Solid carcinoma of the thyroid gland. Analysis of 53 cases

Of a series of thyroid carcinomas, approximately 10% have been of the solid type. The histologic pattern of solid thyroid carcinoma is distinctive: It is the only type that contains amyloid and it is unmixed with other types. The incidence in males and females is essentially equal. Solid carcinoma tends to metastasize to the cervical lymph nodes and the mediastinum. The diseases with which it is associated brings this type into special perspective among thyroid cancers. Its histologic pattern is not a guide to the prognosis. The treatment of choice is total thyroidectomy with resection of all regional metastases. Of 33 patients who were followed for five years or more after operation, 40% had no evidence of thyroid cancer at the time of this study; 15% were living with disease; 36% had died of the disease and 9% had died of other causes.

Significance of thyroid tissue in lymph nodes associated with carcinoma of the head, neck or lung

Thyroid carcinoma was found unexpectedly in the thyroid gland or lymph nodes, at autopsy or in the surgical material removed from 22 patients with carcinoma of the head or neck region, or of the lung. Of 120 patients who had wide‐field laryngectomy for squamous carcinoma of the head or neck, 6 (5%) had carcinoma in the portion of the thyroid gland removed at laryngectomy. Twenty of the 22 patients had mixed papillary and follicular or pure follicular thyroid carcinoma in the thyroid gland or lymph nodes and 2 had the solid type with amyloid stroma. Carcinoma was demonstrated in the thyroid glands of 15 of the 22 patients. Only a portion of the gland or none at all was removed from the other 7 patients and no primary carcinoma was demonstrated. Carcinoma was discovered, however, in every case in which the whole thyroid gland was available for study. Histologically, the metastases of mixed papillary and follicular carcinoma varied from predominantly papillary to predominantly follicular. The smaller the metastases, the more prominent were the follicles and the more normal was their appearance. From our observations, we believe that any thyroid tissue found in a lymph node represents metastatic thyroid cancer.

Follow-up study of thyroid cancer treated by unilateral lobectomy

c oNsr~~n4nLE uncertainty persists concerning what constitutes adequate surgical resection for differentiated carcinoma of the thyroid gland. The present discussion will be limited to the problem of surgery of the thyroid gland itself, when cancer is found grossly involving only one lobe. In recent years, the trend has been toward more extensive resection of the thyroid gland. With rare exceptions [l-3] genera1 agreement has come that anything less than total lobectomy is inadequate and not curative in this situation, because of the high incidence of residual cancer (20 per cent) found on completing the Iobectomy [4] or of stump recurrence [s;]. Beyond this point, authoritative opinion is divided among those who advocate only total lobectomy with or without resection of the isthmus [6,7], those who advocate total Iobectomy plus resection of some portion of the opposite lobe [4,8], and those who advocate total thyroidectomy [9-201. Support for use of the more extensive procedures has come from the observation of intragIandular spread or “muIticentric involvement” by cancer, reported after routine surgical pathologic examination as I I to 30 per cent involvement of the opposite lobe [8,9,12-r4,18,19,21,22]. Crile [7], however, takes the position that “the mere presence of isoIated microfoci of cancer in a lobe of the thyroid does not necessariIy mean that cancer will develop cIinicaIIy.” For the past twelve years at The University of Texas M. D. Anderson Hospital and Tumor Institute, we have been engaged in evaIuating the adequacy of these primary surgical procedures for carcinoma of the thyroid gIand. Prior to rgfo, at this institution, total lobectomy on the involved side, with or without neck dissection, was considered adequate therapy whenever there was no gross involvement of the opposite lobe. Later, when total thyroid gland resections were performed to facilitate radioiodine therapy of metastatic thyroid cancer, a significant incidence of cancer in the contraIatera1 Iobe was observed. This cast doubt on the adequacy of tota unilateral lobectomy as a curative procedure. As a result, a program for evaluating the problem was initiated whereby patients who had undergone previous “curative” lobectomy would either be submitted to prophyIactic resection of the remaining lobe or would be observed clinically on a long-term basis. A third group of patients would be treated by tota thyroidectomy as the initial surgical procedure or following previous thyroid biopsy or partial lobectomy. A corolIary project was undertaken to study the resected gland, whenever possible, by subseria1 whoIe organ sections in order to determine the mode of intraglandular dissemination and the true incidence of contralateral lobe involvement. Previous communications from this institution [g,23] have reported this dissemination to the opposite lobe in 30 per cent of glands examined by routine pathologic technics and in 84 per cent of glands submitted to subseria1 whole organ study. The present report concerns that group of patients with thyroid cancer whose initial surgical management was total lobectomy with or without neck dissection. This was then folIowed either by immediate prophylactic

REPRODUCIBILITY OF THE TECHNIC OF MAMMOGRAPHY (EGAN) FOR CANCER OF THE BREAST.

Summary The findings of the reproducibility study indicate that the technic of mammography developed by Egan can be learned by other radiologists, that films of acceptable quality can be produced, and that the interpretations provide information which is useful in the clinical management of breast disease.

Other malignant neoplasms associated with carcinoma of the thyroid: Thyroid carcinoma multiplex

All patients with thyroid carcinoma seen at The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston between March 1944 and June 1968 were studied to determine the incidence of a second malignant tumor either before or after the diagnosis of thyroid cancer. Additionally, those patients having thyroid cancer as the initial cancer were studied to determine their risk of developing a second malignant tumor. Analysis of the latter was by the patient‐year method. Results showed that thyroid cancer patients have an increased number of second primary malignant tumors, and that they have a higher risk of developing a second primary after the diagnosis of thyroid cancer than the general population of the state of Connecticut. Possible explanations for these findings are discussed.

Hepatic tissue tolerance to thio-TEPA administered by the isolation-perfusion technique.

Summary An isolation technique is described which allows for perfusion of the intact canine liver with the minimum of leakage from the perfusion circuit into the general circulation. With this low leakage the maximum dosage of Thio-TEPA tolerated by the normal hepatic cells in dogs was 0.3 mg./kg.

Rehabilitation of the cancer patient

Reversal in the attitude of the public and the physician alike toward the potential for rehabilitation of cancer patients is the a priori requisite without which certain improvements in cancer care cannot be fully realized. Continued use of five‐year survival rates to assess treatment results is becoming an outmoded static dimension; within this limited concept we have achieved a “cure” rate of approximately only 33%. To date, negative attitudes—plus space, monetary and personnel limitations—have precluded extensive investigation into the full potential for cancer patient rehabilitation. With the proposed government‐sponsored expansion of rehabilitation parameters a decrease in morbidity incidence and an increase in the “salvage for living” potential of the cancer patient become realistic possibilities. We should now look toward doubling the “cure” rate. Through the use of routine physiatric therapy subjective and objective benefits to medically treated cancer patients have been demonstrated over the past eight years at the M. D. Anderson Hospital and Tumor Institute. The physiatrist is recognized as a prime contributor in reducing morbidity incidence in cancer patients.