The advantages of subtotal thyroidectomy and suppression of TSH in the primary treatment of papillary carcinoma of the thyroid.

Patients between the ages of 6 and 45 years with distant metastases from papillary carcinoma of the thyroid can be treated as effectively by subtotal thyroidectomy and suppressive doses of thyroid hormone as by total thyroidectomy followed by treatment with iodine 131 (131I). Moreover, distant metastases can be treated by either 131I or suppression as effectively after they are apparent on x-ray as they can be when treated in a subclinical stage. Therefore, in patients younger than 45 years old it is rarely necessary to perform a total thyroidectomy or to do frequent postoperative scans. In patients older than 44 or younger than 7 who have distant metastases or extensive involvement of both lobes, total or almost total thyroidectomy is justified if it can be done with minimal morbidity. In patients of this age group whose tumors fail to respond to suppressive doses of thyroid, 131I should be used. In view of the importance of diagnostic related groups (DRG) to the economy of hospitals, we note that the cost of total thyroidectomy, ablation by 131I, and intermittent body scans is at least three times that of less radical procedures which, in conjunction with suppression by thyroid feeding, give the same survival with less morbidity.

Immunologic studies in two patients with persistent lymphocytic thyroiditis, thyrotoxicosis, and low radioactive iodine uptake.

Two patients with persistent lymphocytic thyroiditis and thyrotoxicosis were studied. Both patients presented with severe hyperthyroidism of nine months' duration and had nontender, small thyroid glands. Uptake of radioactive iodine (131I) was consistently low. Serum thyroxine and triiodothyronine levels remained elevated without remission until thyroidectomy. The serum thyroglobulin level was normal, but testing for microsomal antibody gave weakly positive results in one case. Thyroglobulin and thyroid stimulatory antibodies were not found. The ratio of helper to suppressor T cells was elevated in one case. Neither patient showed response to propranolol, prednisone, or iodine. Light microscopic and immunohistologic studies showed severe lymphocytic thyroiditis with formation of secondary lymphoid follicles. Lymphocytes were predominately T cells (OKT11-positive), primarily helper/inducer T cells (OKT4-positive). Hyperplastic nodules contained high immunoreactive thyroglobulin and thyroxine levels. Aberrant thymus was seen within the thyroid. These studies suggest the possibility of intrathyroidal stimulation and hydrolysis of thyroglobulin within thyroid cells and also support the hypothesis that T and B cell immunoregulatory defects are important in the pathogenesis of this disease.

A simple semiquantitative radiometric measurement of antithyroglobulin antibodies in human serum. Comparison with hemagglutination method.

A simple solid-phase radiometric assay for the measurement of thyroglobulin autoantibodies (TgRA) was developed and evaluated. The assay is semiquantitative, and the results were expressed as a ratio between sample versus negative control (normal human serum). In 59 normal subjects, the mean ratio was 0.93 +/- (SD) 0.34. Thyroglobulin antibodies by radiometric assay, by hemagglutination (TgHA), as well as microsomal antibodies by hemagglutination (MCHA) were measured in 41 patients with a histopathologic diagnosis of Hashimoto's thyroiditis (n = 22), adenomatous goiter (n = 10), carcinoma (n = 5), adenoma (n = 4), and in 59 patients without histopathologic diagnosis of thyroid disease. In patients with Hashimoto's thyroiditis, TgRA, TgHA, and MCHA were positive in 54, 31, and 81% of patients, respectively. 1 patient had positive TgRA with negative MCHA levels, and 2 had negative antibody titers by all methods. Thyrotropin-stimulating hormone levels were elevated (greater than 10 microU/ml) in 17 of these patients. Our results suggest that although the TgRA method is more sensitive than TgHA for detecting thyroglobulin antibodies, its diagnostic sensitivity is not equal to that of MCHA.

A planned system of patient education.

A planned system of patient education is now used in more than 70 group clinics, hospitals, and other health care institutions. Essential features of this system are (1) a patient education center, (2) a patient educator, and (3) patient education programs. Structured programs are especially useful in the management of chronically ill patients. Patients have responded enthusiastically to this planned system. The response of physicians has ranged from enthusiastic to resistant.

Treatment of hyperthyroidism with a large initial dose of sodium iodide I 131.

A retrospective study was undertaken of 229 patients with hyperthyroidism due to Graves disease treated at the Cleveland Clinic with a large initial dose of sodium iodide I 131 (mean dose, 12.7 +/- 7.5 millicuries). The results indicate that a large initial dose is the most effective therapy for this disorder. Ninety percent of this group of patients required only one dose and recovered from hyperthyroidism within 12 weeks. Because we are convinced that there is no way to prevent the development of hypothyroidism in these patients, we have prescribed permanent thyroid hormone replacement after the hyperthyroidism has been controlled. In a mean five-year follow-up of 190 patients, 174 (91.5%) were still taking thyroid hormone.