No abstract

On the basis of 8 patients of our own and a survey of the literature, the present state of chemotherapy of thyroid carcinoma is discussed. Chemotherapy is only indicated in cases of progressing disease after exhaustion of all conventional therapies. Only in cases of undifferentiated giant- or spindle-cell thyroid carcinomas can chemotherapy following conventional treatment be approved right from the beginning. The three most widely applied cytostatics are adriamycin, bleomycin and cis-platinum, and it seems that adriamycin monotherapy, is superior to all other therapies, even combinations, except probably for the undifferentiated thyroid carcinoma. In addition to the patient's general condition, a sufficiently high single dose of adriamycin, which should be increased in case of nonresponse, appears to be essential for the therapeutical effect. Due to its low toxicity, especially cardiotoxicity, 4'-epi-adriamycin, which, while being almost as effective, can be applied at higher doses and over longer periods, seems to be promising. Approximately 1/3 of thyroid carcinomas respond to adriamycin monotherapy, the response rate probably being highest for medullary types and lowest for undifferentiated thyroid carcinomas. The highest response is observed in the case of pulmonary metastases, followed by bone metastases and local tumor growth. If thyroid carcinomas respond to chemotherapy--even by no-change behavior only--a prolongation of median survival rates from 3-5 months (nonresponders) to 15-20 months (responders) can be achieved.

No statistically significant differences in treatment efficacy were detected between 20 Gy IF radiotherapy and 1X (COPP + ABVD) chemotherapy following CR after six cycles of alternating chemotherapy in patients with advanced-stage HD. However, limited observations in a non-randomized cohort indicate that patients without consolidation treatment of CR after 6 cycles of chemotherapy may have an elevated risk of relapse.

Fifty-seven (35.6%) of 160 patients with papillary thyroid carcinoma had lymph node metastases at the primary treatment. Children and adolescents were most frequently affected (69.2%), followed by the age group of 21-40-year olds (38.8%). Those older than 40 had the lowest incidence of lymph node metastases (29.6%; p less than 0.05). One fifth of all patients had lymph node metastases as first indication of papillary thyroid carcinoma. Two thirds of these patients were 40 years old or younger. Lymph node involvement affected the jugular vein in nearly all cases (78.8%) and the upper mediastinum as well in just under 15%. Women predominated (67.5 vs. 35.3%; p less than 0.05) if there was intrathyroidal tumor growth with lymph node metastases which occurred most frequently in the age group of 21-40-year olds. On the other hand, men had the highest incidence (67.7 vs. 32.5%; p less than 0.05) of lymph node metastases in connection with tumor growth outside the organ. Fixed lymph node metastases occurred more often in men, particularly in those older than 40 years of age. A pT4 stage (tumor growth outside the organ, 66.7%) was often present at the same time. Especially young patients had a high incidence of lymph node metastases in connection with multifocal intrathyroidal tumor growth, the lymph node metastases often being substantially larger than the mostly occult foci of thyroid carcinomas. Cystic degenerations were occasionally mistaken for cervical cysts.

Twenty-two of 251 patients with differentiated thyroid carcinoma suffered from or had a history of hyperthyroidism. They were hyperthyroid with a diffuse goitre (N=4), a diffuse goitre with a cold nodule (N= 10), a multinodular goitre (N=6), and an autonomous adenoma (N=2). Among the 22 patients, more than one fourth had an occult thyroid carcinoma with a diameter of 1 cm or less, those with the papillary tumour types, less frequently had lymph node metastases than the total group of patients with papillary carcinomas (13.3 vs 35.6%). The clinical courses of the 22 patients resembled those of the other thyroid carcinoma patients whose age and initial findings were comparable. In 643 patients who underwent surgery for hyperthyroidism the incidence of thyroid carcinoma was 2.3%. The increase in coincidence of hyperthyroidism and thyroid carcinoma repeatedly reported in recent years is probably ascribable primarily to extensive and improved diagnostics and not to a direct connection between hyperthyroidism and development of thyroid carcinoma. On the other hand, our findings do confirm that, even in the presence of hyperthyroidism, all thyroid nodules require careful diagnostics for exclusion of malignancy.Opinions differ as to whether a connection exists between hyperthyroidism and thyroid carcinoma. In 1937, Means (1) still considered hyperthyroid¬ ism to be an "insurance against cancer of the thy¬ roid". This assumption was questioned in the early fifties (2,3), and, by the mid-sixties, a connection was even seen between hyperthyroidism and thy¬ roid carcinoma (4). The carcinoma incidence was between 0.2 and 0.5% in the large investigation series of Beahrs et al. (2;3029 patients with Graves' disease), Sokal (3; 13621 patients with hyperthy¬ roidism) and the prospective study of Dobyns et al.