128 Worid J. Surg. Vol. 16, No. 1, Jan./Feb. 1992 The Medical Team examined approximately 800 person each year. The number of available controls examined changed through loss of follow up, by death from natural causes, refusal for repeated examinations, or drifting in and out of the areas where the examinations are held. The Changing Trend in Surgical Management Early in the operative experience with the first 15 of the exposed Rongelap people. bilateral subtotal thyroidectomy was performed to remove the obvious multiple nodules. Only if a carcinoma was found during surgery was a total lobectomy done. With the discovery of malignancy in 3 of 5 exposed people undergoing surgery in 1969, it became more evident that radiation was the cause and the whole gland might be at msk. Therefore, any palpable irregularities were promptly explored. Furthermore, it was anticipated that the multiple minute atyp- ical lesions found in some of the exposed might further develop or that new lesions might evolve in a remnant of thyroid that might be allowed to remain. At the time of surgery, where there was a known history of radiation, the reasons for doing a total or a very near total thyroidectomy included: 1) the finding of a frankly malignant lesion, 2) an entire gland being replaced by adenomas, 3) histologic uncertainty on frozen section, but suspicion that an atypical lesion might be malignant, 4) gross features such as fleshy salmon pink tissue, scalloped capsular margins of a * lesion, clusters of lesions radiating from a common encapsu- lated point, or puckering of the surface of the gland adjacent to a lesion in spite of a benign frozen section, and, (5) the finding of a spherical or tiny but firm lymph node adjacent to the thyroid, arousing suspicion of metastatic spread. On the other hand, depriving these particular people of all thyroid tissue could not be justified unless there was guaranteed availability of supplemental thyroxine for their life time on these tiny remote atolls. However, since the supply of thyroxine had been fully provided for the exposed Rongelap people this concern became less important. In the past 20 or 30 years, the senior author has developed a philosophy that a clean total thyroidectomy with regional lymph node dissection should be donein any individual found to have carcinoma of the thyroid. It is important to emphasize that, when a total thyroidectomyis indicated, that procedure should be done without mutilation or disfigurement or any risk to the recurrent laryngeal nerves, or the possibility of permanent parathyroid injury. It has been the author’s policy that all patients with palpable nodules should be routinely given a small trace dose of radioiodine pre-operatively, as an adjunct to management during surgery [12]. This permits an assay of the function of the tumorat surgery. If the ratio of radioiodine in a sample of tumor is <1 to 100, compared to an equal weight of normal thyroid tissue. experience has shownthat the lesion will very likely prove to be malignant. Furthermore if a total SOrziGu is to avoid the subsequent confusion that often arises when a scrap of normal tissue remains and later takes up '"'1. This leads to a suspicion of recurrence. Figure 2? shows how carci- nomas do not take up radioiodine. Thus direct counting of tumor tissue at surgery may be supportive of a tentative diagnosis. Surgery It became gradually apparent that the circumstances encoun- tered in this population were not identical with those found in most civilian populations. There were more carcinomas than _might be expected and an unusual number of microscopic and macroscopic atypical adenomas were present. The gross findings at surgery in the most heavily exposed Rongelapese often related to the degree of radiation exposure. In 8 patients operated by the author (BMD), the gland was shrunken and somewhat gnarled. Where these changes were most striking there were also fine tortuous venules on the capsule of the gland and the strap muscles were sometimes moderately adherent to the capsule. These gross findings were similar to thyroids that the author (BMD) had observed in some cases of Graves’ disease that had been inadequately treated with '*'I and subsequently required surgery. These gross features varied from marked to a relatively normal gland in the Rongelap group. This indicates that there was considerable variation in radiation damage within the same group. In contrast, in the lesser exposed Utink group, there were only occasional lobulations, in addition to the discrete nodule(s) that had led to exploration. Frozen section diagnosis was of great value here, but there were some limitations among the irradiated thyroids. Some lesions were so small that capsular, blood vessel, or lymphatic invasion could not be determined yet an accompanying minute positive node was discovered. In some lesions there were aggregates of cells displaying papillary configurations that were presumably related to a decline in thyroid function, but large bizarre nuclear forms with excess chromatin were sometimes also seen. These resembled some nuclei found in malignant cells, but these nuclei also resembled someseen in thyroids of Graves’ disease inadequately treated with '3'I [13-16]. Thus, the difficulty in distinguishing between small atypical adenomas and carcinomasin the frozen sections at the time of surgery prompted the pathologists (although very experienced in thyroid pathology) to be hesitant to make a firm diagnosis of malignancy in some cases. Therefore, the surgical approach that followed was usually based on the assumptionthatthefinal diagnosis might be carcinoma. Amongthe atypical lesions, the tentative report sometimes indicated that the lesion was benign but later it was called malignant or vise versa. It must be recognized that since there is sometimes a difference of opinion on final microscopic preparations, as there has been here, the difficulties on frozen section are obvious. Furthermore, the very small lesions, located with the naked eye in the surgical specimen (grossly millimeters in size), were not submitted for frozen sections but saved for fixed microscopic preparations Stites Nalant Rea Cg over a period of 23 years. Some, who had cometo live on the 3 exposed atolls, were examined repeatedly, others only once. permits a scan of the neck before the woundis closed. This is done to prove the removalof all functioning tissue. The purpose tn to in previous publications varies. The controls were collected thyroidectomy is done, the presence of '°'1 in the patient aeamn and included in the operated group as were other controls found to have masses. It should be emphasized that the numberof controls referred