[Prospective therapy study in differentiated thyroid carcinoma]

Controversy still exists regarding the appropriate treatment for differentiated thyroid carcinoma, i.e. the extent of surgery and the usefulness of prophylactic 131I thyroid ablation. However, the debate is nowadays confined to those patients who may be categorized as having a favorable prognosis with respect to tumor-related death or serious recurrence, and the point of discussion is essentially the optimal treatment to prevent curable recurrences. From the literature it may be deduced that patients with a node negative papillary tumor of stage I and II in the age-related TNM classification system, and patients with a minimally invasive follicular carcinoma, have an excellent prognosis with respect to survival and recurrence. In a prospective study during a 20-year period from one surgical and one pathological institution 136 consecutive patients were treated. Patients with an incidental pT1 N0 tumor, or with a stage I or II node negative papillary carcinoma, or with a minimally invasive follicular carcinoma respectively, had a reduced extent of treatment. This consisted in resection for the concomitant benign goiter (7%), hemithyroidectomy (32%), or total thyroidectomy without 131I ablation (18%). All other patients, including those with a node positive tumor in stage I or II, had total thyroidectomy and 131I ablation (43%). Patients with a multifocal tumor had total thyroidectomy with or without 131I ablation. Hemi- or total thyroidectomy was technically carried out by capsular dissection with identification of the parathyroids, as introduced by Kocher and Halsted. Peritracheal and -laryngeal nodes were regularly searched for, and functional neck dissection was done in node positive tumors. Total thyroidectomy was carried out by completion thyroidectomy in 29 (35%) of the 83 patients. 5 patients (7%) with papillary carcinoma, all in stage III or IV, and 5 patients (8%) with follicular carcinoma, all with a high degree of capsular angio-invasion, died from the tumor 6 months to 16 years after diagnosis. A further patient with a high degree follicular carcinoma is alive with residual disease. All these patients with an unfavorable course underwent total thyroidectomy and 131I ablation as initial therapy. Two patients with papillary carcinoma had a presumptively curable recurrence, namely, a node recurrence in a pT1 N1 tumor (following total thyroidectomy and radio-iodine ablation), and a contralateral recurrence after hemithyroidectomy in a pT2 N0 tumor in a young patient. In sum, in no case with an unfavorable course was a radical therapy omitted initially, and less than total thyroidectomy with 131I ablation (n = 77 [57%]) led to a (curable) recurrence in only one instance (1.3%).(ABSTRACT TRUNCATED AT 400 WORDS)