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Invited Commentary
Thomas 8S. Reeve, M.D.
Emeritus Professor, Northern Sydney Area Health Service, St.
Leonards, Australia
139
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the level where clinical myxoedema was apparent had complete
atrophyof the thyroid gland and no nodular growth followed. It
is probable that the universality of stromal damageleft it not
able to respond to TSH. As for others, the drift to hypothyroidism was morein the vein observed after a standard dose of
I'3' in hyperthyroidism where 3.5% of patients per year develop
deficient thyroid function. It was observed that patients with
smaller goiters became hypothyroid before those with larger
**Radiation associated thyroid tumor’’ is a term well entrenched
in the literature and usually refers to a patient having a thyroid
neoplasm after known exposureto anirradiating source [i]. The
lesions [3]. It is significant therefore that in the population
ifradiation has usually been part of a therapeutic program and
thyroxine was administered to the population in 1965, a significant time lead was already established before it was com-
was al its most common in the 1930's and 1940’s, when infants
and young children were treated by irradiation for thymic or
tonsillar disorders. The time from irradiation to either presen-
ation or detection of malignancy was approximately 20 years.
The problem still persists as outlined in a recent report on
thyroid disease following treatment of Hodgkin’s disease [2].
Further information of this phenomenon was derived from the
atomic experience in Hiroshima and Nagasaki, where it
was
demonstrated that thyroid cancer wassignificantly increased in
the population heavily exposed to lonizing radiation in 1945 at
the time of atomic bombing{2).
The thyroid pathology in local inhabitants following a serious
fallout accident in the Marshall Islands in 1954 and reported by
Dobyns and Hyrmerin this article has been carefully studied
and provides whatis perhaps the most complete study available
arelation to the dosage, period of exposure. subsequent
‘vion dy progress, and management of those involved in radia-
fects one to the thyroid gland. It is assumed that most of the
half lives of seltyroid were due to short lived radioiodines with
life 8 days) whicnes£0 hours. It is also considered that1'3' (half
tadioiodines but coapresent at 10% of the level of short lived
thyroids. The intensity ohn some of the radiation effect on the
tadioiodines for the thyron radiation and the predilection of
re‘uction of thyroid functian 22" was mooted as causing
.
ind th
.
—_
a
tor sl
ou Pe 2h
ei
n-dules. Those children whose
thyroid function “ nyo
eteriorated to
reported by Dobyns and Hymerthat the children had a larger
dose of I'3! to the thyroid than did the adults [1] and although
menced.
In this very carefully studied group of patients the incidence
of carcinoma was suspect in any person presenting with a
clinically detectable, palpable thyroid abnormality. The surgeon whotreated these patients was confronted with a serious
problem and the solution adopted in the management of the
patients was far seeing. The approach to total or neartotal
thyroidectomy became established, based on sound grounds
which ranged from finding grossly obvious malignancy to
histological uncertainty on frozen section but suspicion that an
atypical lesion might be malignant; the finding of firm lymph
nodes near the gland which were suspected for malignancy
were a further problem in operative decision making. A further
factor had to be considered in taking the step of carrying out
total thyroidectomy in an isolated population, namely, the
supply of T4 and compliancein its taking had to be considered.
As people exposed on Rongelap were well supplied with
hormone, this was not of major concern.
The authors address the value of frozen section, a modality
frequently rejected by histologists, but averred to as useful by
many endocrine surgeons. The problem in the irradiated group
related to small atypical lesions; these made the experienced
thyroid pathologists little diffident in diagnosing malignancy.
An approach was taken therefore to clear as much thyroid
tissue as possible and this overcame the need for secondary