world J, Surg, 16, 126-140, 1992 REPOSITORY te BN L Fa wow at, 4 eer ow ete ™ cords 40 1 BO The Medical Kesearch Center A Box no. MEMD “' Brookhaven National Laboratory FOLDER NA 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) 43 the dispersal of the cloud. The day following the fallout the radiation effects became a ~S & rhnechss te ‘43 gain os fe RG e 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 lesions (beta burns) and epilation. There was internal absorption of 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 in ; Reprint reque r sts: 3: Brown M, M, Dob yns, M.D., Ph.D., Depar iment of Surgery, v. Cleveland ,Metropolitan General Hospi tal, Road. Cleveland, Ohio 44109, U.S.A. ospitals 3398. Seranton 5012192 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