World J. Surg. Vol. 16, No. 1, Jan./Feb. 1992 130 Table 3. Thyroid operations). operations Total Diagnosis Carcinoma’ Atypical? Benign Total performed Almost in the Marshallese (80 thyroidectomy total subtotal Bilateral Single lobe excision Local 10 2° I 13 6 3¢ 5 14 4 2 23° 29 3 4 10 17 0 0 7 7 “Based on the opinion of pathology panel. ’Does not include atypical tesions accompanying carcinomas. “One patient was reoperated for regrowth following bilateral subtotal thyroidectomy 10 years earlier. “Two patients were reoperated for regrowth following bilateral subtotal thyroidectomy 10 years earlier. “Includes a previous bilateral subtotal thyroidectomy for benign adenomas. minute adjacent piece of thyroid capsule to preserve the blood supply to that parathyroid. However, such a procedure was essentially a total removal ofall thyroid tissue (Table 3). Among 77 cases operated only one lobe was removedin 17 patients. In 6 patients where carcinoma was suspected and in 3 patients where carcinoma was found only one lobe wastotally removed because of advanced age. physical disability, or doubtful frozen section diagnosis. Among the remaining 29 cases where the presumptive diagnosis was adenoma(s) a bilateral subtotal thyroidectomy was done, preserving non-nodulartissue. Local excision was performed in 7 patients. The more extensive dissections required individual variations in the management ofthe parathyroids. At least 3 parathyroids were identified in each case. Transplantation was required in 2 cases (2 in | case; | in another). It was customaryto salvage for transplantation any parathyroids lying in close proximity to positive nodes on the surgical specimen. These weresliced very thin, leaving the capsule intact on oneside, and placing it under the skin over the sternum where the site could be palpated thereafter. Amongall of the operations by 3 different surgeons, there has been | case of permanent hypoparathyroidism di- Fig. 3. An infiltrating (primarily) follicular carcinoma in a 38 year old female exposed on Rongelap at age 16. The primary lesion was 0.8 cm. Lymph nodes were involved. This represents 1 of 5 cases with one or more positive lymph nodes in which the primary lesion was 1] cm orless in diameter. (*75). recuy attributable to the surgery and a second case in which asymptomatic hypocalcemia developed after the patient had been normocalcemic for 20 years following the surgery. Both anterior and posterior mediastinum, was performed. If positive suspected and a total thyroidectomy had been undertaken. There have been no recurrent laryngeal nerve injuries. There ately adjacent to the contralateral lobe were also removed and inspected. There were 8 cases in which one or more lymph years following exposure and 27 years following the first found and it was lying adjacent to the thyroid. In the remaining 5 cases multiple positive nodes were found in the jugular and or upper mediastinal areas. They were unilaterally abundant in 3 cases and bilateral in one case. In 5 of the 8 cases the primary cases were among thefirst 3 operated; carcinoma had been have been no recurrences of carcinoma as of March 1991 (37 surgery). Precise direct measurementof the size of the carcinomas on the surgical specimen or on microscopic sections showedthat the sizes ranged from microscopic to 3.4 cm. There were 12 patients in which the largest carcinoma was <1I.0 cm in diam- eter, in 2 patients it was 1.0 cm, andin 8 patients it was >1.0 cm. In one patient the size of the lesion was not recorded. Lymph Node Involvement ey or Po 3 St ar Where a diagnosis of carcinoma was made orstrongly suspected after the initial total lobe was removed, an extensive lymph node dissection on the same side, including the upper a node wasfound onthefirst side, the regional nodes immedinodes werepositive. In 3 cases there was but one positive node lesion was 1.0 cm or less in diameter. In one unexposed individual from Utirik, born 1 year and 4 monthsfollowing the accident, the initial mass had been excised elsewhere but it’s diameter had not been recorded. At the second operation by the author (BMD), there were extensive lymph nodes involved. Underthe circumstances the primary probably was >1 cm. It is very significant that of 14 cases where the primary carcinoma was | cm orless, in 5 patients the disease had already spread. There has been no evidence of distant metastases in any case. Thesefindings show that, where surgery happened to have been