+7 from the areas of the more heavily exposed groups. Three other subjects from this island with the same exposure have had surgical excision of noduies which proved to be benign adenomas. A fifth lesion that was papillary (the size of a match head) was found in a subject from an island where the exposure was intermediate (Ailingnae); several other individuals exposed there have de- veloped benign lesions after a latent period some- pathologists are unable to reach a firm opinion as to a diagnosis of malignancy. Someofthese lesions ultimately proved to have been malignantas evidenced by a distant metastasis some years alter re- movalof the primary lesion. It seems that a neoplasm must reach somesignificantsize beforeit can unequivocally satisfy the criteria for a diag- nosis of malignancy even though smaller lesions may have cellular characteristics that suggest what longer than for those exposed on Rongelap. After review of this papillary lesion by eleven pathologists,* opinion is divided as to whetherit should be considered malignant (Figure 344); we have recordedit in ourstatistics as benign in view of the majority opinion. A few lesions of the thyroid fall into an uncer- malignant capabilities. In clinical practice many lesions are of sufficient size that the criteria for malignancy arereadily fulfilled. Among the Marshallese patients most of the thyroid nodules either were detected by palpation whenscarcely 1 cm in “Drs. S. Warren, W. Meissner, and M.A. Legg, New England Deaconess Hospital; J.D. Reid, Cleveland Metropolitan Gen- usuai criteria upon which a diagnosis of malig- tain category in which even the most experienced eral Hospital: T. Winship (deceased); L.B. Woolner, Mayo Clinic: L.V. Ackerman, SUNYat Stony Brook; R.V. Rosvoil, Emory University; and S. Robbins, A. Vickery, and B. Castleman, Massachusetts General Hospital. Aye s AVE Set8 yy eg: Psat ical cellularity were so small that perhaps they had not yet had an opportunity to manifestail the nancy maybe based. Figures 33C and 34A show one such minute lesion. This emphasizes the im- portance of the early diagnosis and treatmentof Marshalleselesions. SOeTee T OF ea Voy. eeFh AG Ne 3 ‘“ Mee q.! , San 4 vs ‘ee: , Sek He ' ae ae F2S% diameter or were found coincidentally to removal of palpable adenoma. Manylesions showing atyp- fe s- , % "> e t) é : 39D tot. etmeab. Viesers,yt wes ea &e e * aie a rrwe 4 “sae ft a7 a “gi | “ es rs : x wy oe,ia 4 aid - 8 OSes9faeNaat Sy re Spt ayers Oeese OL, .. “— ge Soh - ees eto a wm iy a ' Pene : ed ogs 7 a xs pate: o VSereesin aeAamoeager _ Figure 34. Examples of very minute neoplasms, only a few mmin diameter and completely éncapsulated but composed of cells whose pattern suggests thatif the lesions were larger they might display fearures prompting a suspicion of malignancy. In both examples shown (4, x 162, sub- ject No. 8, 1972; B, x 91, No. 36, 1969) evidence of blood vessel or lymphatic invasion is lack- ing, and the capsule, which was very thin, was not breeched. Theentire lesion of 4 is shown in Figure33C, where its size can be compared with that of surrounding normalfollicles. Both these examples are from thyroids that had no frankly malignant lesions elsewhere in them.