The case records of 235 patients who were treated for differentiated thyroid cancer between 1949 and 1981 were reviewed. Forty-two (18%) had distant metastatic spread outside the neck and received radioiodine (131I) therapy. In cases where the distant spread was confined to the lungs, 54% of patients were alive, free of disease, 10 years after 131I treatment was started. By contrast, no patient with skeletal involvement has survived for 10 years and only one for five years after treatment. A variety of cytotoxic drugs has been tried on an ad hoc basis with no notable success. One patient developed preleukaemia three months after completion of 131I treatment, but no other serious side effects were observed. Factors that influence the behaviour of metastatic thyroid carcinoma are discussed and a possible revised approach to 131I therapy is suggested in the light of these findings.

SUMMARYThree cases of carcinoma of aberrant breast tissue are described and the literature is briefly reviewed. It is suggested that subcutaneous nodules of uncertain origin around the periphery of the breast should be viewed with suspicion and treated by early excision.

THE concentration of attention on the navicular has caused the other bones of the wrist to be neglected. We would like to rectify this in the case of the triquetrum, and emphasize the fact that fracture of this bone is commonly misdiagnosed as fracture of the posterior pole of the lunate. Bohler, quoting Schnek's statistics, first brought this latter diagnosis into prominence. In our opinion he exaggerated its frequency, isolated fracture of the posterior pole of the lunate being very rare, and only seen by us twice in a series of over a thousand wrist injuries. ANATOMYThe triquetrum is exceptional in having no part in the radiocarpal joint, but in taking part in the midcarpal joint, and moving freely with the lunate. This degree of mobility of the FIG. z4z.-Wrist in ulnar deviation, showing the possibilities of compression of the triquetrum.triquetrum is accomplished by leaving a space between the proximal pole of the triquetrum and the triangular fibrocartilage passing from the base of the styloid process of the ulna to the radius, and this space is filled with loose areolar tissue. Though there is thus no joint or bursa on the distal side of the fibrocartilage, the effect is the same. The triquetrum, roughly pyramidal in shape, inserts its sharpest angle between the lunate and the hamate; this wedge insertion would produce a tendency to extrusion of the bone in falls on the extended hand, if this weakness were not counteracted by the fact that in falls on the extended hand the wrist moves into ulnar deviation, and the triquetrum swings more deeply AND W. I?. GREENING into the wrist under cover of the lower end of the ulna (Fig. 242).Inspection of the volar surface of the bone shows the facet for the pisiform to lie at the apex of this surface, and thus a quadrangular surface is left between it and the edge of the articular surface for the lunate for the attachment of the volar intercarpal ligaments. Of the three remaining surfaces two are completely articular, for the lunate and hamate, and the third, which looks dorsomedially, corresponds to the double curved surface of the proximal row of carpal bones. It is marked by a groove, visible in most anteroposterior views of the wrist though not infrequently overlain by the shadow of the pisiform. Of the two areas thus delineated the smaller lateral area is for the attachment of the ulnar collateral ligament of the wrist, and forms a marked colliculus corresponding to the tuberosity of the navicular on the other side of the wrist. The larger and more medial area is again subdivided by a fainter line, the proximal facet being smooth and in contact with the areolar tissue previously mentioned. Owing to the curve of this surface of the bone, the distal facet comes to lie more on the dorsum of the wrist, and forms the posterior tubercle serving for the attachment of the dorsal intercarpal ligaments, which radiate from it in four directions, two ligaments branching FIG. z43.-Fracture of the radial corner of the triquetrum, from impact against the radius.proximally to th...

No abstract

Two hundred and ninety-three patients with thyroid cancer were treated at The Royal Marsden Hospital, London, between 1931 and 1963. Thirty-six per cent of the tumours were papillary, 21 per cent follicular, 1 per cent medullary and 42 per cent anaplastic. Surgery combined with radiotherapy formed the commonest treatment regime. Thirty-six per cent of the patients with papillary carcinoma survived for 20 years, 20 per cent with follicular tumour and 4 per cent with anaplastic carcinoma. The present series indicates that treatment influences the survival time, confirms the prognostic value of histology and age and shows that papillary node metastases do not prejudice survival.