Pancreatic neoplasms are common and a leading cause of death from malignant disease. Their aggressiveness as well as the poor results of treatment has led to a somewhat nihilistic attitude in their surgical management with an emphasis on palliation rather than cure. Papillary cystic neoplasm of the pancreas, although rare, is frequently confused with more malignant tumors which are less successfully treated by pancreatic resection. This neoplasm arises from ductular epithelium, usually occurs in young women, and often remains asymptomatic until it becomes manifest as an abdominal mass or by a complication, e.g., rupture, hemorrhage, or secondary infection. Because of lack of familiarity with the tumor as well as its unusual presentation, the diagnosis is infrequently made at the initial operation. Our experience with 3 young females with papillary cystic neoplasms of the pancreas is reported. Included is a review of the literature indicating the unique characteristics of the tumor. Although locally invasive, these tumors appear to have limited malignant potential and rarely metastasize. An aggressive surgical approach seems fully justified.

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This is a review of 68 patients 20 years of age and younger with well‐differentiated carcinoma of the thyroid seen at the University of North Carolina Memorial Hospital and University of Iowa Hospital since 1935. These patients are included in the Thyroid Carcinoma Registry that provides continuing follow‐up of all patients with carcinoma of the thyroid at these 2 hospitals. The historical, clinical, laboratory, and surgical pathological findings in these 68 patients, their treatment, and survival are reported. Comparisons are made with findings in the 486 patients 21 years of age or older with well‐differentiated carcinoma of the thyroid seen during the same time. The most striking finding of this clinical investigation is that only 1 of the 68 patients, followed up for as long as 30 years, has died as a result of the well‐differentiated thyroid carcinoma. There was a history of irradiation to the head or neck, 28% of patients younger than 15 years of age, 15% of those 15 to 20 years of age, and 6% of patients older than 21 years. The results of this study reaffirm the conclusion that the treatment of well‐differentiated carcinoma of the thyroid in young patients as in older patients is empirical. Our experience suggests that the surgical approach should be determined by the biologic aggressiveness of the disease. Lobectomy, including isthmusectomy, is performed for well‐circumscribed lesions less than 2 cm in diameter in the absence of lymph node metastases. Near total thyroidectomy is advised in the presence of unilateral disease and ipsilateral lymph node metastases. Total thyroidectomy is performed for multifocal disease, when required to remove gross neoplasm, with bilateral lymph node metastases, and with follicular carcinoma in the presence of metastatic disease. Thyroid hormone therapy is used prophylactically. Radioiodine is advised for inoperable, residual, or recurrent disease.

The incidence of chronic (Hashimoto's) thyroiditis in surgical specimens is relatively high, i.e., 13% in collected studies, for a disease with clinical and laboratory characteristics that are sufficiently specific, that thyroidectomy should rarely be required for diagnosis or treatment. This incidence is presumably related to the difficulty in distinguishing between thyroiditis and a thyroid neoplasm. Experience with 260 thyroidectomies at the North Carolina Memorial Hospital performed between 1875 and 1980 for a dominant thyroid mass was reviewed to determine the reliability of criteria for diagnosis and the indications for surgical treatment. Using the criteria of clinical findings, complemented by laboratory studies, e.g., free thyroxine index, thyroid autoantibodies, TSH level, thyroid scan, in addition to the judicious use of the cutting (core) needle biopsy procedure, the incidence of Hashimoto's thyroiditis in this series was 3% and cancer-27%. Four patients had Hashimoto's thyroiditis coincidental to another disease for which thyroidectomy was performed. In seven patients Hashimoto's thyroiditis alone constituted the indications for operation. The indications for operation in these patients were: autonomous function with mild hyperthyroidism (2 patients); associated cold nodule (2 patients); thyromegaly unresponsive to suppressive therapy (2 patients); and rapidly enlarging mass simulating a neoplasm (1 patient). Only one of 71 patients with well differentiated carcinoma had Hashimoto's thyroiditis. One patient with Hashimoto's thyroiditis had associated lymphoma. In most patients, Hashimoto's thyroiditis can be identified using appropriate clinical and laboratory criteria without resorting to thyroidectomy to differentiate between thyroiditis and a neoplasm. Operations are indicated in patients with suspected or established chronic thyroiditis for: 1) the presence of a dominant mass with incomplete regression on suppressive therapy. 2) Progression of thyromegaly despite suppressive therapy. 3) Historic or physical findings suggest a malignancy, e.g., irradiation, multiple endocrine adenomatosis (MEA) syndrome, nerve paralysis, pain, tracheal compression, stipple calcification and cervical lymph node enlargement. 4) Indeterminant findings on cutting needle biopsy, e.g., lymphoma versus thyroiditis. Rarely, an operation is required for an oppressive goiter or associated hyperthyroidism.