Postoperative Adjuvant Therapy

Because of the excellent prognosis of most patients with low-risk papillary thyroid carcinoma, it has been difficult to demonstrate any benefit from adjuvant therapy in the form of radioiodine or TSH suppression therapy. Vickery,39 Cady,1'38 and their associates concluded that the usual course of low-risk papillary carcinoma treated by conservative surgery is generally so benign that further beneficial effects of radioiodine, thyroid suppressive treatment, or total thyroidectomy have never been convincingly shown. In a report from the Mayo Clinic,20 where postoperative radioiodine ablation therapy has been used since 1976, Hay

FIGURE 11-5. Cut surfaces of a surgically resected right thyroid lobe and the right jugular chain nodes taken from a 52-year-old woman who had been aware of the enlarged lymph nodes for 4 years. At the operation, the node measured 4.5 cm (curved arrow), and the primary lesion (straight arrow) in the upper pole of the right thyroid lobe measured 1.5 x 1 cm. The patient is currently alive and well 12 years after the operation, and she is euthyroid without thyroid-stimulating hormone suppression.

FIGURE 11-5. Cut surfaces of a surgically resected right thyroid lobe and the right jugular chain nodes taken from a 52-year-old woman who had been aware of the enlarged lymph nodes for 4 years. At the operation, the node measured 4.5 cm (curved arrow), and the primary lesion (straight arrow) in the upper pole of the right thyroid lobe measured 1.5 x 1 cm. The patient is currently alive and well 12 years after the operation, and she is euthyroid without thyroid-stimulating hormone suppression.

presented his own disappointing results in terms of prevention of tumor recurrence and mortality and also reviewed historic trends of this procedure, including published critical opinions against its effectiveness. Once TSH suppression therapy begins, patients must take the hormone daily for the rest of their lives. Such life-long therapy is not easy for either physician or patient, especially in developing countries.

Hemithyroidectomy, leaving enough thyroid tissue to maintain normal thyroid function postoperatively, is easier for patients, unless TSH suppression therapy is required. Approximately 35% of our patients who underwent hemithyroidectomy have an elevated TSH level and have consequently been treated with L-thyroxine (25 to 150 pg daily) to normalize the serum TSH concentration.

Although we adopted TSH suppression therapy in the 1950s and 1960s, when accurate determination of serum TSH concentration first became available in 1970, we were surprised to find poor drug compliance. We also noted no difference in the postoperative tumor recurrence rate or in the cancer mortality rate in patients with a suppressed serum TSH level and those with nonsuppressed TSH levels.56,57 Since then, many institutions in Japan have used hemithyroidectomy to preserve the normal thyroid function after surgery, and if the patients are euthyroid, no thyroid hormone therapy is given. We adopted this strategy in 1970, and so far we have had satisfactory follow-up results.

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