The pathogenesis of thyroid carcinoma in Graves' goiter is still obscure and the methods for preoperative diagnosis of such carcinomas is not well established. We studied the incidence, clinical features, and pathological findings of thyroid carcinoma in Graves' goiter. From October, 1983 to September, 1985, a total of 739 patients with Graves' disease underwent subtotal thyroidectomy at Ito Hospital, Tokyo. All of these patients underwent roentgenography of the neck before surgery. Thyroid carcinoma was revealed in the resected specimen in 15 (2.0%) of 739 patients. During the same period, another 4 patients underwent surgery for thyroid carcinoma who had had Graves' disease previously and these 4 cases were included in the present study. The incidence of thyroid carcinoma associated with Graves' disease was 2.6% (19 of 743 cases). Histological examination revealed 15 papillary and 4 follicular carcinomas. The size of the carcinoma foci was 13.8 +/- 15.6 mm in diameter (range: 1-60 mm), 10 (52.6%) foci being 10 mm or greater. Invasive growth into the surrounding thyroid tissue was predominant and regional lymph node metastasis was noted in all 6 patients who underwent cervical dissection. Preoperative roentgenography revealed calcification in 5 (26.3%) of 19 cases. Our present study indicates that thyroid carcinoma in Graves' goiter may show markedly invasive growth with lymph node metastasis even though the primary tumor is small in size, and it is suggested that the detection of calcification may serve as a part of the diagnostic measures when the carcinoma focus is difficult to palpate in the diffusely-enlarged Graves' goiter.

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We analyzed the results of ethanol sclerotherapy in 61 patients with cystic thyroid lesions which recurred after aspiration. Cytologic study showed all of the lesions to be benign. The patients were followed clinically and ultrasonically 1 month and 6 or more months after treatment. If the cystic lesions recurred, repeated treatment was offered. During the follow-up, 36 (59.0%) patients experienced no recurrence after the initial treatment and 5 (8.2%) patients received treatments 2 or more additional times. In 44 (72.1%) of the 61 patients, the cystic lesion almost disappeared or decreased in size, but in 17 (27.9%) patients it did not decrease. Four patients underwent surgery after the ethanol sclerotherapy. Although no severe complications were observed, there were complaints of slight pain in 12 patients, severe pain in 1 patient, and a drunken feeling in 1 patient. We consider instillation of ethanol into recurrent cystic lesions of the thyroid to be a simple, safe, economical, and effective treatment.

Familial occurrence of differentiated, nonmedullary thyroid carcinoma in 23 patients from 11 families is reported. Five patients were male and 18 were female. The familial relationship of patients was “parent and child” in 12 cases from 6 families, and “siblings” in 11 cases from 5 families. Carcinoma of other organs was noted in other members in 8 families. Histological examination revealed 18 papillary, 2 follicular, and 2 anaplastic carcinomas (the 2 anaplastic carcinomas were considered to be transformed from preexisting differentiated carcinoma). In 1 case, the histological type was unknown. The average diameter of the primary lesion was 29.9 mm. Cervical lymph node metastasis was found in 77.8% and local recurrence in 28.6% of the patients. Solid and invasive growth was dominant. On HLA typing, phenotypes of B7 and DR1 were significantly redominant in familial patients compared with nonfamilial patients and normal Japanese. Moreover, the haplotype of B7‐Cw7‐DR1 was observed in 5 of 13 patients tested. It is suggested from these observations that some types of differentiated, nonmedullary thyroid carcinoma may show familial occurrence and that they may have common factors with regard to the genetic and immunologic basis of the disease.

Most patients with thyroid carcinoma have a good prognosis. Due to the small number of fatal cases, it has not been clarified what conditions result in death for patients with thyroid carcinoma. To provide appropriate management for advanced thyroid carcinoma patients, we analyzed causes of death in 161 fatal cases. Clinical characteristics and immediate (final) causes of death based on pathological conditions were analyzed in 62 anaplastic carcinomas and 99 fatal differentiated carcinomas. Single fatal conditions could not be specified in 55 patients. In the remaining 106 patients, respiratory insufficiency (43%) was the most common specific fatal condition, followed by circulatory failure (15%), hemorrhage (15%), and airway obstruction (13%). Respiratory insufficiency due to remarkable pulmonary metastasis replacing lung tissue, massive hemorrhage and airway obstruction due to uncontrolled local tumors, and circulatory failure resulting from compression of the vena cava by extensive mediastinal or sternal metastases were found to be the most important immediate causes of death. Based on this knowledge, several palliative procedures may be worth considering to improve survival and quality of life in patients with advanced thyroid carcinoma. (J Clin Endocrinol Metab 84: [4043][4044][4045][4046][4047][4048][4049] 1999)

To investigate the biological characteristics of papillary thyroid carcinoma from the perspectives of lymph node metastasis, lymph node recurrence, and distant metastasis, 746 patients with nonadvanced papillary thyroid carcinoma were retrospectively studied. There were 76 men and 670 women with a mean age of 42.7 years. The rate of lymph node metastasis was significantly higher in young patients (aged less than 30 years). Lymph node recurrence was observed in 80 patients and distant metastasis in 13, being seen with significant frequency in the young and elderly (aged over 50 years) patients and in the men. The frequency of distant metastasis was significantly greater in the elderly patients and in those with lymph node recurrence. These findings indicate that the role of regional lymph nodes and the clinical meaning of lymph node recurrence differ between young and elderly patients.

Papillary microcarcinoma of the thyroid has been often detected by aspiration biopsy cytology performed with ultrasonographic guidance. Autopsy studies also have often revealed small thyroid carcinomas, and it was concluded that most small thyroid carcinomas should not be regarded as a clinical matter. In this study, 112 patients with papillary microcarcinoma 10 mm or less in size treated between 1992 and 1995 were analyzed. There were 104 females and 8 males, with a mean age of 46.0 years. Diagnosis of papillary carcinoma was made preoperatively in 100 of these patients (89.3%), and 77 patients underwent aspiration biopsy cytology under ultrasound guidance. Seventy of these patients underwent modified neck dissection, and 63.8% of these patients had lymph node metastases. The number of lymph node metastasis increased as primary tumor size increased. There was no clear border or clinical differences between primary tumors 10 mm or less and tumors more than 10 mm. One patient had lymph node recurrence after surgery and another patient had recurrent nerve palsy at the first visit. Based on these findings, papillary microcarcinoma should be treated surgically.

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