DOES THE METHOD OF MANAGEMENT OF PAPILLARY THYROID-CARCINOMA MAKE A DIFFERENCE IN OUTCOME

We have analyzed data on a group of 269 patients with papillary thyroid carcinoma followed on average for 12 years to determine (1) if a prognostic classification scheme can be used to predict an appropriate surgical approach; (2) the effect of treatment on prognosis; and (3) if patients with a ''excellent'' prognosis benefit from more extensive surgical resection and I-131 ablation. Prognostic classification schemes developed by the American Joint Commission, Cady et al., Hay et al., the European Thyroid Association, and our own clinical class scheme each appropriately divided patients into risk category groups. With each system, some patients classified in the low risk group eventually died of the tumor. Considering the excellent but not perfect precision of the prognostic schemes, the need for detailed pathologic analysis, and ideally postoperative thyroid scanning, we conclude that the prognostic classification schemes do not allow the decision at the operating table regarding the appropriate extent of surgery. Patients followed at our institution, operated on by one of three experienced surgeons, and usually given I-131 ablation were compared to other patients in the follow-up group operated on by other surgeons and not routinely ablated. There were significantly fewer deaths and recurrences among the patients managed by our method. However, when the groups were restricted to those considering only patients who had more extensive surgery, postoperative I-131 ablation, or both, the differences between the groups became insignificant. This finding indicates that the difference in prognosis, comparing patients treated at our institution and those initially treated elsewhere, was primarily due to the routine use of more extensive surgery and postoperative radioactive iodide ablation. Patients under age 45 with intrathyroidal disease or positive neck nodes and tumors less than 2.5 cm in diameter had an excellent prognosis, as shown by the absence of deaths due to tumor during the follow-up period. However, extensive surgery and I-131 ablation was associated with a significant reduction in recurrences. These data support the use of lobectomy plus contralateral subtotal lobectomy or near-total thyroidectomy as the primary operative procedures for thyroid cancers larger than 1 cm in size and in patients beyond age 45; they also support the use of I-131 ablation postoperatively to provide the best prognosis with reduction in deaths and recurrences.