0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Thyroid Cancer With Concurrent Hyperthyroidism FREE

Tzu-Chieh Chao, MD, PhD; Jen-Der Lin, MD; Long-Bin Jeng, MD; Miin-Fu Chen, MD
[+] Author Affiliations

From the Division of General Surgery, Department of Surgery (Drs Chao, Jeng, and Chen), and the Division of Endocrinology and Metabolism, Department of Medicine (Dr Lin), Chang Gung University College of Medicine and Chang Gung Memorial Hospital, Taipei, Taiwan.


Arch Surg. 1999;134(2):130-134. doi:10.1001/archsurg.134.2.130.
Text Size: A A A
Published online

Objective  To study the clinical manifestation, outcome, and factors predicting metastases in patients with thyroid cancer and concurrent hyperthyroidism.

Design  Retrospective study of 37 thyrotoxic patients with differentiated carcinomas of the thyroid who were operated on between 1979 and 1995. The follow-up period ranged from 562 days to 14 years 9 months (mean ± SE, 2093 ± 201 days).

Setting  University hospital with an annual performance rate of about 700 thyroid operations.

Patients  Thyroidectomy was performed in 37 patients (31 women and 6 men), including 33 papillary carcinomas and 4 follicular carcinomas. The mean ± SE age of the patients was 38.6 ± 2.2 years.

Results  The mean ± SE diameter of tumors was 13.2 ± 0.9 mm (range, 2-67 mm). The tumor size in 25 patients (68%) was 10 mm or smaller. Subtotal thyroidectomy (21 patients), total thyroidectomy (8 patients), near-total thyroidectomy (4 patients), and completion thyroidectomy (4 patients) were performed. Twenty-eight patients underwent postoperative sodium iodide I 131 (131 I) ablation for thyroid remnant. There was 1 local recurrence, 3 metastases to regional neck lymph nodes, and 3 distant metastases. A patient with follicular carcinoma died of metastases at 3 years 4 months after thyroidectomy. Age, sex, duration of thyrotoxic symptoms, tumor size, histopathological findings, type of goiter, extent of surgery, 131 I ablation, and 6-week postoperative serum concentrations of thyroglobulin or thyrotropin were not significant factors in predicting metastases. Serum levels of triiodothyronine and thyroxine before antithyroid treatment in the patients with metastases were significantly higher than in those without metastases.

Conclusion  The majority of patients with thyroid cancer and concurrent hyperthyroidism have small carcinomas.

IT HAS been reported that thyroid cancer occurs in 0.76% to 8.7% of the glands removed for treatment of thyrotoxicosis.15 Although recent reports have found higher rates of thyroid cancer associated with hyperthyroidism, earlier reports emphasize the rarity of these 2 conditions occurring simultaneously. Controversy surrounds the disease course of thyroid cancer with concurrent hyperthyroidism. Belfiore et al6 and Ozaki et al2 have reported that thyroid cancer associated with Graves disease had an aggressive course. In contrast, other investigators did not highlight the aggressive characteristics.5,7,8 The discrepancies of the results are probably due to geographic, racial, or other unknown factors. To better understand the association of thyroid cancer with hyperthyroidism, we retrospectively reviewed the data of patients who had thyroid cancer with concurrent hyperthyroidism. In the present study, clinical manifestations, treatment, outcome, and factors predicting metastases are presented.

During a 17-year period from 1979 to 1995, 1013 patients with thyroid cancer were treated at the Division of General Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. There were 741 papillary carcinomas (73.1%), 168 follicular carcinomas (16.6%), 21 medullary carcinomas (2.1%), 48 anaplastic carcinomas (4.7%), and 35 carcinomas of other histological types (3.5%). During the same period, 3502 patients underwent thyroidectomy for thyrotoxicosis at our hospital. Hyperthyroidism was diagnosed on the basis of elevated triiodothyronine (T3), elevated thyroxine (T4), and low thyrotropin (TSH) levels in combination with hyperthyroid clinical symptoms. Of 3502 patients with hyperthyroidism, there were 2934 toxic diffuse goiters (Graves disease) (83.8%), 303 toxic multinodular goiters (8.7%), and 265 toxic adenoma (toxic autonomously functioning thyroid nodule) (7.6%). Patients were treated with carbimazole, methimazole, or propylthiouracil preoperatively. They also received Lugol iodine solution for 7 to 10 days before surgery. The indications for surgery were (1) recurrent thyrotoxicosis, (2) adverse effects of antithyroid medications, (3) patient unlikelihood or inability to take medications, (4) presence of cold nodules within toxic glands on thyroid scanning, (5) unusually large diffuse or multinodular goiters, (6) malignancy or fine-needle aspiration biopsy findings suggestive of thyroid cancer, and (7) autonomously functioning nodules.

Of 3502 patients with hyperthyroidism, 41 (1.2%) were identified to have thyroid cancer. Thirty (1.0%) of 2934 patients with toxic diffuse goiter, 6 (2.0%) of 303 patients with toxic multinodular goiter, and 1 (0.4%) of 265 patients with toxic adenoma had malignant neoplasms of the thyroid. The histopathological type of the thyroid cancer associated with hyperthyroidism included 34 papillary thyroid carcinomas (83%), 4 follicular carcinomas (10%), 2 medullary carcinomas (5%), and 1 Hürthle cell carcinoma (2%). Tumor diameter was the maximum diameter measured on pathological examination or by ultrasonography. In carcinomas with multiple foci, the maximum diameter of tumor foci was used as the diameter of tumor. Small tumor was defined as a tumor measuring 10 mm or less and a large tumor, greater than 10 mm. The patients with medullary carcinoma and Hürthle cell carcinoma and a patient who died 30 days after surgery (papillary carcinoma) were excluded from the present study. Data from the remaining 37 patients were retrospectively reviewed. Results are presented as mean ± SE.

Goiter types of 37 patients with hyperthyroidism with thyroid cancer were toxic diffuse goiter (30 patients, 81%), toxic multinodular goiter (6 patients, 16%), and toxic adenoma (1 patient, 3%). Two of 30 patients with toxic diffuse goiter and 1 of 6 patients with toxic multinodular goiter were found to have papillary carcinoma by preoperative fine-needle aspiration cytology. The mean diameter of malignant tumors was 13.2 ± 0.9 mm (range, 2-67 mm). Twenty-five patients (68%) had a small tumor (≤10 mm) and 12 (32%) had a large tumor (>10 mm). The mean diameter of small tumors and large tumors was 6.4 ± 0.9 mm (range, 2-10 mm) and 30.0 ± 4.9 mm (range, 12-62 mm), respectively.

Thirty-one patients were women and 6 patients were men (ratio, 5.2:1). The age ranged from 20 to 82 years, with a mean ± SE age of 38.6 ± 2.2 years. The mean age of female patients was 37.5 ± 2.4 years (range, 20-82 years) and male patients was 44.5 ± 6.2 years (range, 24-69 years). Although women, on average, were 7 years younger than men, the difference was not statistically significant.

The duration of hyperthyroid clinical symptoms ranged from 30 days to 6 years (693 ± 122 days). Mean serum levels of T3 and T4 before administration of antithyroid medications were 5.78 ± 0.53 nmol/L (range, 2.73-12.01 nmol/L) and 232 ± 9 nmol/L (range, 172-320 nmol/L), respectively. Serum level of TSH was less than 200 µIU/L in each patient. Comparison of data between patients with small tumors and large tumors is shown in Table 1. There were no differences in age, sex, duration of thyrotoxic symptoms, serum levels of T3 and T4 before taking antithyroid medications, and 6-week postoperative serum thyroglobulin level between the 2 groups. However, 6-week postoperative serum TSH level in the group with small tumor was significantly (P<.05) lower than that in the group with large tumor. This difference could be attributed to the fact that most small tumors were treated with subtotal thyroidectomy (Table 2).

Table Graphic Jump LocationTable 1. Data of the Patients With Small and Large Thyroid Cancers*

Twenty-five patients underwent technetium Tc 99m pertechnetate thyroid scanning, including those with toxic diffuse goiter (19 patients), toxic multinodular goiter (5 patients), and toxic adenoma (1 patient). Four of 19 patients with toxic diffuse goiter and 2 of 5 with toxic multinodular goiters had coexistent cold nodules on thyroid scanning. Thyroid ultrasonography with fine-needle aspiration cytology was performed in 5 patients with cold nodule on thyroid scanning and 8 patients with clinically palpable nodule. Only 3 of these patients had evidence of papillary carcinoma. Fourteen patients underwent intraoperative frozen section biopsy, including 5 with toxic diffuse goiter, 3 with toxic diffuse goiter with cold nodules on thyroid scan, 2 with toxic diffuse goiter with a solid nodule on ultrasonogram, 2 with multinodular goiter, and 2 with multinodular goiter with a cold nodule on scan. Frozen sections disclosed malignant neoplasms in 12 patients (86%). Two false-negative case results included 1 toxic diffuse goiter and 1 multinodular goiter.

Operative methods are shown in Table 2. Subtotal thyroidectomy was performed in 21 patients (57%), including 19 patients with toxic diffuse goiter and 2 with toxic multinodular goiter. Total thyroidectomy (6 patients) and near-total thyroidectomy (6 patients) were performed after confirmation of thyroid cancer by frozen section biopsy. One patient with a huge multinodular goiter was primarily treated with total thyroidectomy and postoperative pathological evaluation revealed a small papillary carcinoma. Most patients (n=18; 49%) with small tumor underwent subtotal thyroidectomy. Three patients underwent completion total thyroidectomy after postoperative pathological confirmation of malignancy. Of these 3 patients, initial subtotal thyroidectomy was performed for toxic diffuse goiter (1 patient) and toxic multinodular goiter (2 patients). The overall postoperative complications were transient hypoparathyroidism (1 patient, 3%), permanent hypoparathyroidism (2 patients, 5%), and transient recurrent laryngeal nerve palsy (2 patients, 5%).

Whole-body scanning with 18 mBq sodium iodide I 131 (131 I) was performed on 29 patients 6 weeks after thyroidectomy. Of these 29 patients, 28 underwent subsequent 131 I ablation of thyroid remnant (13 subtotal thyroidectomies, 7 total thyroidectomies, 4 completion thyroidectomies, 4 near-total thyroidectomies) since thyroid tissue capable of 131 I uptake over a 24-hour period was greater than 1%. The overall mean dosage of 131 I radiation for ablation was 3182 ± 407 mBq (range, 1100-7400 mBq). The average ablation dosage of 131 I for the patients undergoing subtotal thyroidectomy was 3330 ± 407 mBq (range, 1110-3700 mBq). On the other hand, ablation dosage of 131 I for those with near-total or total thyroidectomy was 3219 ± 666 mBq (range, 1110-7400 mBq). These 28 patients also had thyroxine suppression treatment. Postoperative 131 I whole-body scanning and thyroid ablation were not performed on 8 patients with small tumors who underwent subtotal thyroidectomy. The mean tumor diameter of these 9 patients was 4.9 ± 0.7 mm (range, 2-8 mm).

The follow-up period ranged from 562 days to 14 years 9 months (2093 ± 201 days). Initial 6-week postoperative 131 I whole-body scan or chest x-ray films did not reveal tumor metastases. A recurrence of cancer at the thyroid bed occurred 2 years 6 months after a near-total thyroidectomy for a 3.5-cm follicular carcinoma. Distant metastases (2 papillary carcinomas and 1 follicular carcinoma) or metastases to regional neck lymph nodes (3 papillary carcinomas) occurred 20.5 ± 4.7 months (median, 17.5 months) after initial thyroidectomy (Table 3). The patient with follicular carcinoma died of metastases to the lungs, bone, and leptomeninges 3 years 4 months after thyroidectomy.

Table Graphic Jump LocationTable 3. Patient and Clinical Characteristics of Metastatic Thyroid Carcinoma

The patient age, tumor size, and 6-week postoperative serum levels of thyroglobulin and TSH in the patients with metastases were not different from those without metastases. However, mean serum levels of T3 and T4 in the patients with metastases were significantly greater than those in the patients without metastases (Table 4). To examine the factors capable of predicting metastases, various parameters were compared. Age, sex, duration of thyrotoxic symptoms, tumor size, histopathological tumor type, type of goiter, extent of surgery, 131 I ablation, 6-week postoperative serum levels of thyroglobulin or TSH were not significant factors in predicting metastases (Table 5). However, when patients were divided into 2 groups according to the median serum levels of T3 (6.93 nmol/L) and T4 (277 nmol/L) before initiation of antithyroid medications, T3 and T4 were significant factors in predicting metastases. Four (50%) of 8 patients with a T4 level higher than 277 nmol/L had metastases and 4 (44.4%) of 9 patients with a T3 level higher than 6.93 nmol/L had metastases.

Table Graphic Jump LocationTable 4. Parameters in Patients With Thyroid Cancer With Metastases or Without Metastases*
Table Graphic Jump LocationTable 5. Factors Predicting Metastases of Thyroid Cancer Associated With Hyperthyroidism*

In the present study, serum concentrations of T3 and T4 before antithyroid treatment were found to be significant prognostic factors in predicting metastases in patients with differentiated thyroid carcinoma with concurrent hyperthyroidism. To our knowledge, similar findings have never been reported. Serum concentrations of TSH are suppressed in patients with hyperthyroidism with elevated serum concentrations of T3 and T4. On the other hand, serum TSH concentrations become normal or elevated after surgery. It is not clear whether T3 or T4 influences the growth of normal thyroid or thyroid tumors. However, experimental data and clinical reports suggest that TSH not only stimulates normal thyroid cell growth and function9 but also the growth of thyroid tumors.10 Normal thyroid and benign and malignant thyroid tumors express TSH receptors on the plasma membrane.11 Thyrotropin interacts with TSH receptors and is primarily transducted via the TSH-receptor-adenylate cyclase pathway.9 Suppression of TSH by thyroid hormones has been used clinically to prevent the recurrence of thyroid cancer after surgery.1215 Therefore, elevated serum TSH concentrations in the postoperative period might stimulate the growth of residual thyroid cancer cells, eventually leading to local recurrence or metastases. However, as shown in the present study, postoperative TSH level is higher in patients with a tumor larger than 10 mm, but it is not a significant predictor of metastases in differentiated thyroid carcinoma with concurrent hyperthyroidism. This suggests that other factors may influence the prognosis of patients with thyroid cancer and concurrent hyperthyroidism. The presence of TSH receptor antibodies in the blood has been noted to be one of the causes of Graves disease.16,17 Like TSH, TSH receptor antibodies (thyroid-stimulating immunoglobulins) interact with TSH receptors and stimulate thyroid growth and function.18,19 Thyrotropin receptor–stimulating immunoglobulins have been found in the serum of patients with metastatic thyroid carcinomas and hyperthyroidism18 and of patients with thyroid carcinoma and concurrent hyperthyroidism.2,6 However, it has not yet been directly proven that TSH receptor–stimulating antibodies can stimulate the growth of thyroid carcinoma cells.

Although some authors have reported that some occult (≤1 cm) thyroid papillary carcinomas had an aggressive propensity,20,21 the concept that small thyroid carcinomas are associated with an excellent prognosis is widely accepted.2225 Hay et al25 have reported a 6% recurrence rate after 20 years in 535 patients with papillary carcinoma of 1.0 cm or less in diameter. Only 2 patients died of small papillary carcinoma in their series. As shown in the present study and the literature,2,7 most carcinomas associated with hyperthyroidism are small and found incidentally, during pathological examination of the thyroid and during surgery. One major question is what must be done when a small carcinoma is found postoperatively on pathological examination after subtotal thyroidectomy for hyperthyroidism. Although total or near-total thyroidectomy is generally recommended for differentiated thyroid carcinoma,2629 many investigators believe that patients with occult papillary carcinoma or follicular carcinoma with minimal capsular invasion can be treated with limited surgery, such as lobectomy and isthmectomy.2224,30,31 This is based on the findings that extent of surgery did not influence the outcome of patients with small differentiated thyroid carcinomas. In the present study, extent of thyroidectomy did not influence the incidence of metastases (Table 5). Grant et al30 have reported that there were no differences in local recurrence and survival rates of patients with thyroid cancer when subtotal thyroidectomy was compared with total thyroidectomy. Vickery et al31 have demonstrated that no patient with a small carcinoma experienced recurrence in the resected thyroid bed or contralateral lobe after subtotal thyroidectomy or lobectomy. In a retrospective study of 867 patients with thyroid carcinomas smaller than 10 mm by Schroeder et al,23 416 patients (48.0%) were operated on with a preoperative diagnosis of Graves disease. The majority of patients underwent subtotal thyroidectomy, lobectomy, or partial lobectomy. The type of thyroidectomy did not affect patient survival. Therefore, thyrotoxic patients with occult differentiated thyroid cancer may be treated with limited surgery without influencing the prognosis.

In the present study, 131 I ablation did not influence the incidence of metastases. Ablation of thyroid remnant with 131 I is generally performed after total or near-total thyroidectomy for well-differentiated thyroid carcinoma.32,33 Recent reports have shown a significant reduction in recurrence and cancer-related deaths for patients treated with 131 I ablative therapy.34,35 However, most investigators would not recommend the routine administration of 131 I to patients with small tumor confined to the thyroid bed.36 In the study by Schroder et al,23 postoperative 131 I ablation was not administered to the patients in the absence of metastases and the recurrence-free 20-year survival rate was high. Similar findings were reported by Hay et al25 Therefore, routine 131 I ablation is not indicated in the patients with small differentiated thyroid carcinoma.

In conclusion, the tumor size of the majority of patients with thyroid cancer and concurrent hyperthyroidism is 1 cm or smaller. Cold nodules on thyroid scanning might suggest the presence of thyroid carcinoma in thyrotoxic patients. Age, sex, tumor size, extent of surgery, or 131 I ablation do not influence the prognosis. Patients with thyroid cancer with higher serum concentrations of T3 or T4 before antithyroid treatment have an aggressive tumor course as compared with those with lower concentrations.

Reprints: Tzu-Chieh Chao, MD, PhD, Department of Surgery, Chang Gung Memorial Hospital, 199 Tung Hwa North Rd, Taipei, Taiwan (e-mail: ischen01@ms15.hinet.net).

Shapiro  STFriedmann  NBPerzik  SLCatz  B Incidence of thyroid carcinoma in Graves' disease. Cancer. 1970;261261- 1270
Link to Article
Ozaki  OIto  KKobayashi  KToshima  KIwasaki  HYashiro  T Thyroid carcinoma in Graves' disease. World J Surg. 1990;14437- 441
Link to Article
Wahl  RAGoretzki  PMeybier  HNitschke  JLinder  MRoher  H-D Coexistence of hyperthyroidism and thyroid cancer. World J Surg. 1982;6385- 390
Link to Article
Rieger  RPimpl  WMoney  SRettenbacher  LGalvan  G Hyperthyroidism and concurrent thyroid cancer. Surgery. 1989;1066- 10
Behar  RArganini  MWu  T-C  et al.  Graves' disease and thyroid cancer. Surgery. 1986;1001121- 1127
Belfiore  AGarofalo  MRGiuffrida  D  et al.  Increased aggressiveness of thyroid cancer in patients with Graves' disease. J Clin Endocrinol Metab. 1990;70830- 835
Link to Article
Hales  IBMcElduff  ACrummer  P  et al.  Does Graves' disease or thyrotoxicosis affect the prognosis of thyroid cancer. J Clin Endocrinol Metab. 1992;75886- 889
Edmonds  CJTellez  M Hyperthyroidism and thyroid cancer. Clin Endocrinol. 1988;28253- 259
Link to Article
Dumont  JELamy  FRoger  PMaenhaut  C Physiological and pathological regulation of thyroid cell proliferation and differentiation by thyrotropin and other factors. Physiol Rev. 1992;72667- 697
Doniach  I The effect of radioactive iodine alone and in combination with methylthiouracil upon tumor production in the rat's thyroid gland. Br J Cancer. 1953;7181- 202
Link to Article
Ichikawa  YSaito  EAbe  YHomma  MMuraki  TIto  K Presence of TSH receptor in thyroid neoplasms. J Clin Endocrinol Metab. 1976;42395- 398
Link to Article
Pujol  PDaures  J-PNsakala  NBaldet  LBringer  JJaffiol  C Degree of thyrotropin suppression as a prognostic determination in differentiated thyroid cancer. J Clin Endocrinol Metab. 1996;814318- 4323
Rossi  RLCady  BSilverman  ML  et al.  Surgically incurable well-differentiated thyroid carcinoma: prognostic factors and results of therapy. Arch Surg. 1988;123569- 574
Link to Article
Simpson  WJPanzarella  TCarruthers  JSGospodarowicz  MKSutcliffe  SB Papillary and follicular thyroid cancer: impact of treatment of 1578 patients. Int J Radiat Oncol Biol Phys. 1988;141063- 1075
Link to Article
Cunningham  MPDuda  RBRecant  WChmiel  JSSylvester  JFremgen  A Survival discriminants for differentiated cancer. Am J Surg. 1990;160344- 347
Link to Article
Rees Smith  BMcLachlan  SMFurmaniak  J Autoantibodies to the thyrotropin receptor. Endocr Rev. 1988;9106- 121
Link to Article
Sugino  KMimura  TOzaki  O  et al.  Early recurrence of hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy. World J Surg. 1995;19648- 652
Link to Article
Filetti  SBelfiore  AAmir  SM  et al.  The role of thyroid-stimulating antibodies of Graves' disease in differentiated thyroid cancer. N Engl J Med. 1988;318753- 759
Link to Article
Di Paola  RMenzaghi  CDe Filippis  VCorda  DDi Cerbo  A Cyclooxygenase-dependent thyroid cell proliferation induced by immunoglobulins from patients with Graves' disease. J Clin Endocrinol Metab. 1997;82670- 673
Miki  HOshimo  KInoue  H  et al.  Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland. J Surg Oncol. 1993;5478- 81
Link to Article
Allo  MDChristianson  WKoivunen  D Not all "occult" papillary carcinomas are "minimal." Surgery. 1988;104971- 976
Wanebo  HJAndrews  WKaiser  DL Thyroid cancer: some basic considerations. Am J Surg. 1981;142474- 479
Link to Article
Schroder  DMChambors  AFrance  CJ Operative strategy for thyroid cancer: is total thyroidectomy worth the price? Cancer. 1986;582320- 2328
Link to Article
Farrar  WBCooperman  MJames  AG Surgical management of papillary and follicular carcinoma of the thyroid. Ann Surg. 1980;192701- 704
Link to Article
Hay  IDGrant  CSvan Heerden  JA  et al.  Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery. 1992;1121139- 1147
Clark  OHLevin  KZeng  Q-HGreenspan  FSSiperstein  A Thyroid cancer: the case for total thyroidectomy. Eur J Cancer Clin Oncol. 1988;24305- 313
Link to Article
Levin  KEClark  AHDuh  Q-YDemeure  MSiperstein  AEClark  OH Reoperative thyroid surgery. Surgery. 1992;111604- 609
Ley  PBRoberts  JWSymmonds  RE  Jr  et al.  Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review. Am Surg. 1993;59110- 114
Hamming  JFVan de Velde  CJGoslings  BM  et al.  Prognosis and morbidity after total thyroidectomy for papillary, follicular and medullary thyroid cancer. Eur J Cancer Clin Oncol. 1989;251317- 1323
Link to Article
Grant  CSHay  IDGough  IRBergstralh  EJGoellner  JRMcConahey  WM Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important? Surgery. 1988;104954- 962
Vickery  ALJWang  C-AWalker  AM Treatment of intrathyroid papillary carcinoma of the thyroid. Cancer. 1987;602587- 2595
Link to Article
Van De Velde  CJHHamming  JFGoslings  BM  et al.  Report of the consensus development conference on the management of differentiated thyroid cancer in the Netherlands. Eur J Cancer Clin Oncol. 1988;24287- 292
Link to Article
Baldet  LManderscheid  JCGlinoer  D  et al.  The management of differentiated thyroid cancer in Europe in 1988: results of an international survey. Acta Endocrinol. 1989;120547- 558
Mazzaferri  ELJhiang  SM Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994;97418- 428
Link to Article
Attie  JNBock  GMoskowitz  GWMargouleff  DDubner  S Postoperative radioactive iodine evaluation of total thyroidectomy for thyroid carcinoma: reappraisal and therapeutic implications. Head Neck. 1992;14297- 302
Link to Article
Schlumberger  MParmentier  Cde Vathaire  FTubiana  M Iodine-131 and external radiation in the treatment of local and metastatic thyroid cancer. Falk  SAed.Thyroid Disease Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy. 2nd ed. Philadelphia, Pa Lippincott-Raven1997;601- 617

Figures

Tables

Table Graphic Jump LocationTable 1. Data of the Patients With Small and Large Thyroid Cancers*
Table Graphic Jump LocationTable 3. Patient and Clinical Characteristics of Metastatic Thyroid Carcinoma
Table Graphic Jump LocationTable 4. Parameters in Patients With Thyroid Cancer With Metastases or Without Metastases*
Table Graphic Jump LocationTable 5. Factors Predicting Metastases of Thyroid Cancer Associated With Hyperthyroidism*

References

Shapiro  STFriedmann  NBPerzik  SLCatz  B Incidence of thyroid carcinoma in Graves' disease. Cancer. 1970;261261- 1270
Link to Article
Ozaki  OIto  KKobayashi  KToshima  KIwasaki  HYashiro  T Thyroid carcinoma in Graves' disease. World J Surg. 1990;14437- 441
Link to Article
Wahl  RAGoretzki  PMeybier  HNitschke  JLinder  MRoher  H-D Coexistence of hyperthyroidism and thyroid cancer. World J Surg. 1982;6385- 390
Link to Article
Rieger  RPimpl  WMoney  SRettenbacher  LGalvan  G Hyperthyroidism and concurrent thyroid cancer. Surgery. 1989;1066- 10
Behar  RArganini  MWu  T-C  et al.  Graves' disease and thyroid cancer. Surgery. 1986;1001121- 1127
Belfiore  AGarofalo  MRGiuffrida  D  et al.  Increased aggressiveness of thyroid cancer in patients with Graves' disease. J Clin Endocrinol Metab. 1990;70830- 835
Link to Article
Hales  IBMcElduff  ACrummer  P  et al.  Does Graves' disease or thyrotoxicosis affect the prognosis of thyroid cancer. J Clin Endocrinol Metab. 1992;75886- 889
Edmonds  CJTellez  M Hyperthyroidism and thyroid cancer. Clin Endocrinol. 1988;28253- 259
Link to Article
Dumont  JELamy  FRoger  PMaenhaut  C Physiological and pathological regulation of thyroid cell proliferation and differentiation by thyrotropin and other factors. Physiol Rev. 1992;72667- 697
Doniach  I The effect of radioactive iodine alone and in combination with methylthiouracil upon tumor production in the rat's thyroid gland. Br J Cancer. 1953;7181- 202
Link to Article
Ichikawa  YSaito  EAbe  YHomma  MMuraki  TIto  K Presence of TSH receptor in thyroid neoplasms. J Clin Endocrinol Metab. 1976;42395- 398
Link to Article
Pujol  PDaures  J-PNsakala  NBaldet  LBringer  JJaffiol  C Degree of thyrotropin suppression as a prognostic determination in differentiated thyroid cancer. J Clin Endocrinol Metab. 1996;814318- 4323
Rossi  RLCady  BSilverman  ML  et al.  Surgically incurable well-differentiated thyroid carcinoma: prognostic factors and results of therapy. Arch Surg. 1988;123569- 574
Link to Article
Simpson  WJPanzarella  TCarruthers  JSGospodarowicz  MKSutcliffe  SB Papillary and follicular thyroid cancer: impact of treatment of 1578 patients. Int J Radiat Oncol Biol Phys. 1988;141063- 1075
Link to Article
Cunningham  MPDuda  RBRecant  WChmiel  JSSylvester  JFremgen  A Survival discriminants for differentiated cancer. Am J Surg. 1990;160344- 347
Link to Article
Rees Smith  BMcLachlan  SMFurmaniak  J Autoantibodies to the thyrotropin receptor. Endocr Rev. 1988;9106- 121
Link to Article
Sugino  KMimura  TOzaki  O  et al.  Early recurrence of hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy. World J Surg. 1995;19648- 652
Link to Article
Filetti  SBelfiore  AAmir  SM  et al.  The role of thyroid-stimulating antibodies of Graves' disease in differentiated thyroid cancer. N Engl J Med. 1988;318753- 759
Link to Article
Di Paola  RMenzaghi  CDe Filippis  VCorda  DDi Cerbo  A Cyclooxygenase-dependent thyroid cell proliferation induced by immunoglobulins from patients with Graves' disease. J Clin Endocrinol Metab. 1997;82670- 673
Miki  HOshimo  KInoue  H  et al.  Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland. J Surg Oncol. 1993;5478- 81
Link to Article
Allo  MDChristianson  WKoivunen  D Not all "occult" papillary carcinomas are "minimal." Surgery. 1988;104971- 976
Wanebo  HJAndrews  WKaiser  DL Thyroid cancer: some basic considerations. Am J Surg. 1981;142474- 479
Link to Article
Schroder  DMChambors  AFrance  CJ Operative strategy for thyroid cancer: is total thyroidectomy worth the price? Cancer. 1986;582320- 2328
Link to Article
Farrar  WBCooperman  MJames  AG Surgical management of papillary and follicular carcinoma of the thyroid. Ann Surg. 1980;192701- 704
Link to Article
Hay  IDGrant  CSvan Heerden  JA  et al.  Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery. 1992;1121139- 1147
Clark  OHLevin  KZeng  Q-HGreenspan  FSSiperstein  A Thyroid cancer: the case for total thyroidectomy. Eur J Cancer Clin Oncol. 1988;24305- 313
Link to Article
Levin  KEClark  AHDuh  Q-YDemeure  MSiperstein  AEClark  OH Reoperative thyroid surgery. Surgery. 1992;111604- 609
Ley  PBRoberts  JWSymmonds  RE  Jr  et al.  Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review. Am Surg. 1993;59110- 114
Hamming  JFVan de Velde  CJGoslings  BM  et al.  Prognosis and morbidity after total thyroidectomy for papillary, follicular and medullary thyroid cancer. Eur J Cancer Clin Oncol. 1989;251317- 1323
Link to Article
Grant  CSHay  IDGough  IRBergstralh  EJGoellner  JRMcConahey  WM Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important? Surgery. 1988;104954- 962
Vickery  ALJWang  C-AWalker  AM Treatment of intrathyroid papillary carcinoma of the thyroid. Cancer. 1987;602587- 2595
Link to Article
Van De Velde  CJHHamming  JFGoslings  BM  et al.  Report of the consensus development conference on the management of differentiated thyroid cancer in the Netherlands. Eur J Cancer Clin Oncol. 1988;24287- 292
Link to Article
Baldet  LManderscheid  JCGlinoer  D  et al.  The management of differentiated thyroid cancer in Europe in 1988: results of an international survey. Acta Endocrinol. 1989;120547- 558
Mazzaferri  ELJhiang  SM Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994;97418- 428
Link to Article
Attie  JNBock  GMoskowitz  GWMargouleff  DDubner  S Postoperative radioactive iodine evaluation of total thyroidectomy for thyroid carcinoma: reappraisal and therapeutic implications. Head Neck. 1992;14297- 302
Link to Article
Schlumberger  MParmentier  Cde Vathaire  FTubiana  M Iodine-131 and external radiation in the treatment of local and metastatic thyroid cancer. Falk  SAed.Thyroid Disease Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy. 2nd ed. Philadelphia, Pa Lippincott-Raven1997;601- 617

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 19

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Population for Whom a Goiter Disease Should Be Considered