The effect of thyroid hormone administration upon survival in patients with differentiated thyroid carcinoma.

Seven hundred sixty-one patients with operable differentiated thyroid carcinoma were treated between 1931 and 1970. Median follow-up time was 18 years and ranged from 5 to 40 years. Sixty-three percent of the patients were followed more than 15 years, and 46% were followed more than 20 years. Because resections usually spared sufficient thyroid tissue for homeostasis, thyroid hormone was not routinely prescribed after operations performed before 1960. Altogether 244 patients with papillary carcinoma and 76 patients with follicular carcinoma received thyroid hormone, while 296 patients with papillary carcinoma and 45 patients with follicular carcinoma did not receive thyroid hormone after operation. With papillary carcinoma, 14% of men greater than 40 and women greater than 50 years of age (high risk) but only 2% of men less than or equal to 40 years of age and women less than or equal to 50 years of age (low risk) died of disease (P 0.0001). Twenty-six percent of high-risk but only 4% of patients with low-risk follicular cancer died (P 0.0001). However, there was no statistically significant improvement in survival times with use of thyroid hormone when patients were categorized by risk group and pathology. These data support the importance of age and sex in previously described risk groups; these factors supersede the effects of adjuvant treatment. This absence of effect on survival times calls into question current recommendations for routine use of thyroid hormone after surgical therapy. Conceptually, such absence of adjunctive hormone effect on survival time after operation is similar to hormonal effects in other endocrine cancers, which may nevertheless provide good palliation in some cases.

Control of massively bleeding arterioportal fistula using a balloon catheter.

The commercial availability of double-lumen balloon catheters has added a new tool for the angiographer in controlling gastrointestinal bleeding. Our report describes a situation in which the unique properties of this catheter were quite effective in controlling life-threatening hemorrhage.

Parietal cell vagotomy for intractable and obstructing duodenal ulcer.

Parietal cell vagotomy can be accomplished with minimal morbidity and mortality. Symptoms and signs of delayed gastric emptying early after operation are common and occur more frequently in patients with preoperative gastric outlet obstruction than in those without, a difference that is statistically significant. These symptoms are generally mild and transient. Dumping and diarrhea were not problems in our series. In patients with preoperative gastric outlet obstruction, parietal cell vagotomy with pyloroduodenal dilatation achieved good or excellent results in 79 percent of patients; however, the possibility of a higher recurrence rate requires further evaluation and suggests caution and selectivity in the use of this procedure. The recurrence rate of 3 percent of these patients without gastric outlet obstruction and a very good or excellent clinical result in 91 percent of these patients appear acceptable and encourage us to continue to use parietal cell vagotomy as the procedure of choice in patients with intractable duodenal ulcer. Most patients with recurrent ulcer have been treated medically with success. Close long-term clinical follow-up studies will be required to assess better the success of this procedure.

Angiography vs. pancreatography in diagnosis of carcinoma of the pancreas.

Relative efficacy of angiography and pancreatography in the diagnosis of pancreatic carcinoma was assessed in 13 patients. Pancreatography provided a correct preoperative diagnosis in 10 patients. In 3 patients the duct could not be cannulated. Twelve patients underwent angiography and a correct diagnosis was made in 10. Preoperative diagnosis was not made by either technique in 1 patient. Pancreatography did not detect carcinoma of the pancreas at an earlier stage than did angiography. These procedures should be considered complementary to each other. Angiography defines the size, extension and resectability of the tumor. Pancreatography outlines the internal architecture of the gland and duct system.

Risk factor analysis in differentiated thyroid cancer.

Six hundred patients with primary differentiated thyroid carcinoma had follow-up studies for a minimum of 15 years and a maximum of 45 years. Recurrence rate and death rate were significantly different in defined high-risk and low-risk groups of patients. These basic risk groups were defined by age and sex alone; low risk consisted of men 40 years of age and younger and women 50 years of age and younger whereas the high-risk group were older patients. Recurrence and death rates in patients at high risk were 33% and 27% while respective figures for patients at low risk were 11% and 4%. In more recent years these results have shown significant improvement. Basic risk group definition outweighed the effect of pathologic type, local disease extension, type of treatment, and site of recurrence or metastasis. For instance, radioactive iodine cured 70% of patients at low risk with metastatic disease but only 10% of patients at high risk. Less aggressive biologic behavior of thyroid cancer before the age of menopause implies that an estrogen-rich milieu may alter the effects of initiating and promoting factors in carcinogenesis. It also suggests that therapeutic trials of estrogen be undertaken in progressive metastatic differentiated thyroid cancer.