Total versus subtotal thyroidectomy. Arguments, approaches, and recommendations.

Arguments for routine total thyroidectomy or routine, less than total resection have been espoused for treatment of well-differentiated intrathyroidal carcinoma. Numerous reports in the literature support either approach. No prospective randomized studies have been performed, partly because of the indolent nature of the disease. Many reports are also complicated by the failure of the authors to divide patients into high-risk and low-risk groups and to categorize and evaluate fully the histologic types of the resected tumors. Good evidence exists to show that in the majority of cases of intrathyroidal, well-differentiated lesions, bilateral subtotal resection yields results that compare favorably with total thyroidectomy. Logically, at least, a total thyroidectomy would seem to be preferable, because subtotal resection can be imprecise. Therefore, subtotal thyroidectomy can be recommended over total thyroidectomy, if only on the basis of comparison of complications. The type and rate of complications vary among surgeons. Each thyroid surgeon, therefore, must establish an individual complication rate. Total thyroidectomy in inexperienced hands is not recommended. We recommend, therefore, that total thyroidectomy be used selectively by surgeons who have the skill and experience necessary to make the decision intraoperatively. If, for example, during resection of the lobe that contains the primary tumor, the laryngeal nerves and parathyroid glands can be clearly identified and if there is minimal bleeding and trauma, the surgeon may proceed to side two to perform a total thyroidectomy. If the lesion is large, however, with distortion of anatomy, dissection may be difficult even for an experienced surgeon. Intracapsular parathyroids or undiscovered parathyroids on the side of initial resection should prompt the surgeon to perform a subtotal resection on side two. Under these circumstances, the surgeon should not feel that a total thyroidectomy justifies the increased risk. A unilateral resection, such as lobectomy plus isthmusectomy, can be performed with satisfactory long-term results in low-risk patients, that is, in those with small (less than 1.5 cm) unilateral intrathyroidal exposure and in those with no evidence of metastatic disease. Alternately, the AGES criteria of Hay et al can be used to identify patients in low- or high-risk groups. If the decision to perform a bilateral resection is based on the previous criteria, we recommend that a total thyroidectomy be performed only by an experienced surgeon. During surgery, if there is any suggestion that the laryngeal nerves or parathyroid glands would be at increased risk if a total resection were performed, it may be necessary to revert to a subtotal procedure.(ABSTRACT TRUNCATED AT 400 WORDS)

Rationale for elective neck dissection in 1990.

Elective neck dissection has long been a subject of debate among surgeons. The proponents of elective neck dissection base their rationale on studies that show a 30% incidence of occult disease in those situations for which elective neck dissection is recommended. One hundred eighty-two patients with advanced stages of squamous cell carcinoma of the head and neck were studied. All patients had preoperative computed tomography or magnetic resonance imaging, and all patients had some form of radical neck dissection. The sensitivity of clinical exam was compared with the sensitivity of computed tomography or magnetic resonance imaging in ability to detect nodal disease. The sensitivity of clinical exam alone was 71.7%, while the sensitivity of computed tomography or magnetic resonance imaging was 91.1%. Based on physical exam alone, there would be a 39% rate of occult disease; if computed tomography or magnetic resonance imaging data is combined with physical exam, the occult disease rate would drop to 12%. All centers performing elective neck dissection must reassess their rationale or restudy their occult disease rate with computed tomography or magnetic resonance imaging.

Induction of fibrin-specific antibodies by immunization with synthetic peptides that correspond to amino termini of thrombin cleavage sites.

Fibrin-specific antibodies have been produced in rabbits which were immunized with synthetic peptides. Specificity against human fibrin monomer was achieved because the synthetic peptide haptens were derived from sites unique to fibrin as compared with fibrinogen. Two undecapeptides were chemically synthesized according to the amino acid sequence of the amino termini of human fibrin alpha- and beta-chains which are revealed by thrombin cleavage. Rabbits immunized with either an alpha- or beta-chain peptide conjugate produced anti-peptide sera which reacted with fibrin monomer. Following immunoadsorption of the rabbit sera with human fibrinogen-Sepharose, fibrin-specific antibodies were detectable by solid-phase radioimmunoassay that did not react with fibrinogen. Antisera elicited by clotted human fibrin contained antibodies that reacted with fibrin and fibrinogen when treated in a similar manner.