world J, Surg, 16, 126-140, 1992








40 1 BO

The Medical Kesearch Center

A Box no. MEMD

Brookhaven National Laboratory


Upton, L. L, New York

TheSurgicalManagement ‘OfBetiigiraiid‘Malignant Thyroid Neoplasmsin
Marshall Islanders Exposed to Hydrogen BombFallout
Brown M. Dobyns, M.D., Ph.D., and Barbara A. Hyrmer, B.S.
Department of Surgery, Case Western Reserve University at Cleveland Metropolitan General Hospital, Cleveland, Ohio, U.S.A.
On March 1, 1954, a serious fallout accident occurred during the United
States atomic testing program at Bikini in the Trust Territory of the

Pacilic Islands. Following the detonation of a large thermonuclear device
(known as Bravo} an unexpected shift in winds resulted in deposition of
radioactive debris on several inhabited atolls in the Marshall Islands.
During the early post-detonation period military, sea, and air surveys
traced the hottest portion of the parabolic cloud as it drifted in an ever
widening pattern of diminishing concentration eastward and southeast of
Bikini. The center of the cloud passed North of the Rongelap Atoll, which
was the nearest inhabited atol]. This report concerns the development of

thyroid lesions, the special circumstances encountered during thyroid
surgery, and the ecaults of the surgical management of benign and

malignant lesions that were subsequentty encountered in this population.
FT mae er cee RR er

After the fallout accident on March 1, 1954 (Fig. 1), attention

was directed first toward the inhabitants of the Rongelap Atoll
and the more peripheral istand of Ailingnae (Sifo), lying 105

nautical miles east of Bikini, and then to Utirik Atoll, 300 miles
castward. The cloud arrived over Rongelap in 4 to 6 hours and
over Utirik in about 22 hours. Sixty-three individuals on Rongelap Atoll and 18 Rongelapese on Ailingnae were evacuated
about S1 hours after the explosion. There were 159 people
removed from Utirik in 72 hours [1].

agdied FA

The calculated amount of radiation received by the Marshallese on the 3 atolls has been subject to considerable re-evaluation [2-4]. Table 1 lists the latest estimates of doses to the
Marshallese. population, based on: t) the distance from Bikini,

>) the decay of the radioactivity with the passage of time, and 3)


the dispersal of the cloud.
The day following the fallout the radiation effects became


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gain os

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evident in the Rongelap people. Gamma radiation, though

diet, drinking water, metabolism, and age [1]. The dose to the
thyroid in children was larger than in adults [4].

After 3 1/2 months the people of Utirik, who had shown none
of the symptoms described above, were returned to theiratoll
because the radiation levels on Utirik were considered safe.
However, the Rongelap people were not returned to their atoll

for 3 1/2 years.
Radioiodines absorbed from the fallout were primarily short
lived (half life seconds to hours) and probably caused most of

the effect to the thyroid. However, '*'I (half life8 days),

calculated to be 1/10 as abundant, also contributed someofthe

radiation effect on the thyroids [1, 2]. These effects on the

thyroid and the development of thyroid growths have now been
studied for many years.

Detailed annual medical examinations, including extensive
laboratory observations, have been carried out on the exposed
persons and on unexposed comparison populations by medical
personnel from Brookhaven National Laboratory and their
invited medical consultants [1, 5-7]. The Utirik people initially
were examined only at 3 year intervals, but later annually as

with those from Rongelap. One of us (BMD)hasparticipated in
9 of these annual examinations in the Marshall Islands.
The Development of Thyroid Abnormalities

Nine years following exposure, thyroid nodularity was first
detected. Reduced thyroid function was suspected as the cause.
Consequently, on the advice of several leading thyroidologists,
the prophylactic administration of 0.2 mg of thyroxine to all

sublethal, caused early gastro-intestinal symptoms and later a

exposed Rongelap people was begun in 1965. This dose was

fallout material on the skin caused transitory spotty
(beta burns) and epilation. There was internal absorption

was provided and its administration supervised at the time of
each survey by the Brookhaven Medical Team.
The first nodules that were discovered in 3 Rongelap chil-

transient depression of blood elements. The deposition of

radioactive material from ingestion of contaminated food and
water from catchments. Wide variations in levels of contamination were found in the people apparently due to differences
; Reprint reque
3: Brown M,
M, Dob yns, M.D., Ph.D., Depar

iment of
v. Cleveland ,Metropolitan General Hospi tal,
Road. Cleveland, Ohio 44109, U.S.A.
3398. Seranton


later reduced dependingon clinical findings. A constant supply

dren, who had been exposed at ages 3, 3, and 4 years of age,
were removed in 1964 at the U.S. Naval Hospital at Guam. At
the time of surgery an initial presumptive diagnosis of carcinomain 1 individual (diagnosis later revised) resulted in a near
total thyroidectomy. The nodules in the remaining 2 patients
were benign. Thereafter, nodules began to appear in young

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