694 and increase with the number of drugs given. In a survey of geriatric units, adverse reactions were the direct or a contributory cause of admission in 12.4% of cases. The greatest risk was with drugs affecting the cardiovascular system (diuretics, antihypertensives, and digitalis) and central nervous system (hypnotics, psychotropic agents, and rigidity controllers). Not surprisingly, failure to comply with prescribing instructions is particularly frequent in old age.6 As long ago as 1962 Schwartz ef a1.7 reported that 59% of elderly, chronically ill patients attending the general medical clinic of New York Hospital made one or more medication errors, of which a quarter were potentially serious. These problems are intractable, but at the symposium Prof. J. Williamson offered some rules which will mitigate them. Ask yourself, is the diagnosis sure and the drug positively indicated ? Give as few drugs as possible and review the regimen regularly’. Placebos should be inert. Give clear, preferably written instructions. Does the patient understand ? Enlist the help of a relative when necessary. We can at least do something about these. On the other hand, although it is important to know about the greater biological variability of the aged and their generally greater susceptibility to drugs, the factors responsible are usually beyond our control.
MANAGEMENT OF PAPILLARY THYROID CARCINOMA CANCER of the thyroid is a rare tumour which has wide diagnostic import in that it must be distinguished from the common benign conditions of adenoma and multinodular goitre. Papillary thyroid carcinoma accounts for approximately 50% of adult thyroid cancers and 70% of those in childhood and it is multifocal in 20% or more.’ The peak incidence of the disease is in the third and fourth decades in both sexes, although the tumour affects women two or three times more commonly than men.2 Most papillary carcinomas contain some follicular elements, but this mixed picture does not alter the natural history of the disease. Diagnosis of papillary thyroid carcinoma is not difficult but opinions differ on the best method of treatment. Since the tumour is rare, extensive experience is hard to come by, and a centre which does handle large numbers naturally tends to favour one particular therapeutic approach. In addition, papillary carcinoma poses special problems: usually an indolent tumour associated with a low mortality, it may follow a highly malignant course,3 especially in patients presenting over the age of 40 and in those with a large primary or extracapsular extension. Not surprisingly there is a lack of consensus about the management of this tumour and often several modalities of treatment have to be combined. Most auth-
orities agree on some form of surgery for the primary lesion. But the extent of surgery in different centres ranges from simple removal of the malignant nodule to total thyroidectomy with bilateral radical neck dissection (and all degrees in between). There is also lively debate over the indications for supplementary radioactive iodine and thyroid-hormone treatment postopera.
tively.4 Mazzaferri and colleaguess have made an important contribution. They assessed the impact of various forms of therapy in a total of 576 patients (355 women and 221 men) treated in many different .hospitals by United States Air Force physicians. The cases were all registered in the United States Air Force Central -Tumor Registry, which holds extensive microfilmed records. This permitted detailed evaluation of a heterogeneous
papillary-thyroid-carcinoma population whose treatment was highly variable and in whom follow-up over a median period of six years was virtually complete. It was also possible to assess the influence of clinical presentation and histology in these patients. There were five deaths in the series directly attributable to the carcinoma. The adverse effects on survival of age at presentation (over 40), large primary tumours (2-5 cm in diameter or greater), and extracapsular extension were confirmed. Large tumours and local invasion through the capsule were also associated with a higher rate of recurrence. On review of the various surgical procedures it was evident that recurrence was more than twice as common after subtotal as after total thyroidectomy, and the mortality was higher in the subtotal group. As might be expected, postoperative complications were more troublesome after total thyroidectomy but, on balance, Mazzaferri et al. felt this procedure should be recommended, especially where the tumour was large, multifocal, or locally invasive. They concluded that local excision of obvious metastatic cervical nodes is appropriate, whereas neck dissection should be reserved for patients in whom the primary cannot be removed without such extensive surgery. Permanent hypoparathyroidism is one of the most difficult endocrine disorders to treat; so identification and preservation of the parathyroid glands, in addition to the recurrent laryngeal nerve, is very important. Information from this large series was also sufficient to permit some conclusions about postoperative 1311 and thyroid-hormone treatment. Mazzaferri etal. recommend thyroid hormone for all cases (irrespective of the extent of surgery) and ablative doses of ’III postoperatively, especially in those with large, multiple, or locally invasive lesions, provided there is adequate uptake of radionuclide. This comprehensive retrospective analysis will not entirely settle the question of treatment in papillary thyroid carcinoma. But the suggestions made by Mazzaferri et al. are sensible and should now be examined in an equally well-documented prospective study. In general, best results will be obtained if patients are managed by a team of physicians, surgeons, and radio-
therapists.
’
.
6. Wandless, I., Davie, J. W. Br. med. J. 1977, i, 359. 7. Schwartz, D., Wang, M., Zeitz, L., Goss, M. E. W.
Am. J. publ. Hlth, 1962, 52, 2018. 1. De Groot, L. T., Stanbury, J. B. (editors). The Thyroid and its Disorders. New York, 1975. 2. Hirabayshi, R. N., Lindsay, S.J. clin. Endocr. Metab. 1961, 21, 1956. 3. Winship, T. Rosvall, R. V. in Thyroid Cancer (edited by C. E. Hedinger); p. 32. London, 1969.
Cosse, J. J., Beierwaltes, W. H., Brooks, J., Thomas, C. G., Jr., Woolner. J. B. Archs Surg. 1975, 110, 783. Mazzaferri, E. L., Young, R. L., Oertel, J. E., Kemmerer, W. T., Page, C. P. Medicine, 1977, 56, 171. Halnan, K. E. in Thyroid Cancer (edited by C. E. Hedinger); p. 332. London, 1969.
4. De 5. 6.
MANAGEMENT OF PAPILLARY THYROID CARCINOMA CANCER of the thyroid is a rare tumour which has wide diagnostic import in that it must be distinguished from the common benign conditions of adenoma and multinodular goitre. Papillary thyroid carcinoma accounts for approximately 50% of adult thyroid cancers and 70% of those in childhood and it is multifocal in 20% or more.’ The peak incidence of the disease is in the third and fourth decades in both sexes, although the tumour affects women two or three times more commonly than men.2 Most papillary carcinomas contain some follicular elements, but this mixed picture does not alter the natural history of the disease. Diagnosis of papillary thyroid carcinoma is not difficult but opinions differ on the best method of treatment. Since the tumour is rare, extensive experience is hard to come by, and a centre which does handle large numbers naturally tends to favour one particular therapeutic approach. In addition, papillary carcinoma poses special problems: usually an indolent tumour associated with a low mortality, it may follow a highly malignant course,3 especially in patients presenting over the age of 40 and in those with a large primary or extracapsular extension. Not surprisingly there is a lack of consensus about the management of this tumour and often several modalities of treatment have to be combined. Most auth-
orities agree on some form of surgery for the primary lesion. But the extent of surgery in different centres ranges from simple removal of the malignant nodule to total thyroidectomy with bilateral radical neck dissection (and all degrees in between). There is also lively debate over the indications for supplementary radioactive iodine and thyroid-hormone treatment postopera.
tively.4 Mazzaferri and colleaguess have made an important contribution. They assessed the impact of various forms of therapy in a total of 576 patients (355 women and 221 men) treated in many different .hospitals by United States Air Force physicians. The cases were all registered in the United States Air Force Central -Tumor Registry, which holds extensive microfilmed records. This permitted detailed evaluation of a heterogeneous
papillary-thyroid-carcinoma population whose treatment was highly variable and in whom follow-up over a median period of six years was virtually complete. It was also possible to assess the influence of clinical presentation and histology in these patients. There were five deaths in the series directly attributable to the carcinoma. The adverse effects on survival of age at presentation (over 40), large primary tumours (2-5 cm in diameter or greater), and extracapsular extension were confirmed. Large tumours and local invasion through the capsule were also associated with a higher rate of recurrence. On review of the various surgical procedures it was evident that recurrence was more than twice as common after subtotal as after total thyroidectomy, and the mortality was higher in the subtotal group. As might be expected, postoperative complications were more troublesome after total thyroidectomy but, on balance, Mazzaferri et al. felt this procedure should be recommended, especially where the tumour was large, multifocal, or locally invasive. They concluded that local excision of obvious metastatic cervical nodes is appropriate, whereas neck dissection should be reserved for patients in whom the primary cannot be removed without such extensive surgery. Permanent hypoparathyroidism is one of the most difficult endocrine disorders to treat; so identification and preservation of the parathyroid glands, in addition to the recurrent laryngeal nerve, is very important. Information from this large series was also sufficient to permit some conclusions about postoperative 1311 and thyroid-hormone treatment. Mazzaferri etal. recommend thyroid hormone for all cases (irrespective of the extent of surgery) and ablative doses of ’III postoperatively, especially in those with large, multiple, or locally invasive lesions, provided there is adequate uptake of radionuclide. This comprehensive retrospective analysis will not entirely settle the question of treatment in papillary thyroid carcinoma. But the suggestions made by Mazzaferri et al. are sensible and should now be examined in an equally well-documented prospective study. In general, best results will be obtained if patients are managed by a team of physicians, surgeons, and radio-
therapists.
’
.
6. Wandless, I., Davie, J. W. Br. med. J. 1977, i, 359. 7. Schwartz, D., Wang, M., Zeitz, L., Goss, M. E. W.
Am. J. publ. Hlth, 1962, 52, 2018. 1. De Groot, L. T., Stanbury, J. B. (editors). The Thyroid and its Disorders. New York, 1975. 2. Hirabayshi, R. N., Lindsay, S.J. clin. Endocr. Metab. 1961, 21, 1956. 3. Winship, T. Rosvall, R. V. in Thyroid Cancer (edited by C. E. Hedinger); p. 32. London, 1969.
Cosse, J. J., Beierwaltes, W. H., Brooks, J., Thomas, C. G., Jr., Woolner. J. B. Archs Surg. 1975, 110, 783. Mazzaferri, E. L., Young, R. L., Oertel, J. E., Kemmerer, W. T., Page, C. P. Medicine, 1977, 56, 171. Halnan, K. E. in Thyroid Cancer (edited by C. E. Hedinger); p. 332. London, 1969.
4. De 5. 6.
