Our ames is true: How an old concept still hits the mark: or, risk group assignment points the arrow to rational therapy selection in differentiated thyroid cancer

T his is the 26th Hayes Martin Lecture to the Society of Head and Neck Surgeons, an organization founded with Grant Ward and Danely Slaughter by the distinguished surgeon, Hayes Martin himself. I am flattered and honored to be selected by you to present this talk and follow such an outstanding group of previous Hayes Martin Lecturers, most of whom I have had the pleasure and privilege of knowing. As a postgraduate trainee at Memorial Hospital, starting in 1965, one of the high points was the 6 months spent on the Head and Neck Service. I learned from the many senior surgeons on the Head and Neck Service the reputation of this surgical giant. In the spring of 1967 we residents invited Hayes Martin to speak to us. Although somewhat disabled by his previous stroke, it was apparent during our evening meeting that he was indeed a leader in demeanor, reputation, conversation, and vision. Known as a superb technician, he developed many new operations. His 1957 textbook on head and neck surgery is still a reference guide. Thus, this year marks not only the 26th year of the Hayes Martin Lecture, but the 20th anniversary of his death and the 40th year after the publication of that major treatise. My interest in thyroid surgery was kindled both at the Head and Neck Service at Memorial Hospital, and later at the Lahey Clinic where thyroid surgery was a major aspect of the practice. During my 6 months on the Head and Neck Service, Dr. Tollefson had one of his memorable sessions with the residents illustrating the difference in morbidity and outcome comparing total and hemithyroidectomy with the dramatic display of two stacks of charts. Dr. Frazell’s previously published intensive analysis of papillary thyroid cancer was a model of a clinical in-depth analysis of patients.’ While on the Head and Neck Service, Dr. Frazell asked me to review all the cases of parotid mucoepidermoid carcinoma. I was struck by the fact that every low-grade mucoepidermoid carcinoma patient survived, regardless of the type of surgery, while every high-grade patient died regardless of the radicalness of the surgery. The biological determination of outcome that superseded operative technical details in this distinctive of cancer made a profound impression. I was also exposed to a 19.year-old woman who had a bilateral radical neck dissection, total laryngectomy, and total thyroidectomy for papillary carcinoma of the thyroid. This was such a striking misapplication of a surgical procedure designed for epidermoid cancer of the larynx to another disease where it was inappropriate that I resolved to study thyroid cancer. As a Staff Surgeon at the Lahey Clinic, I was astonished to find that every young person with regional lymph node metastases from papillary thyroid cancer was receiving 6,000 rads to the entire neck after a formal radical neck dissection. Again this misapplication of fundamental cancer principles appropriate for one disease, but inappropriate for another, served as stimulus to review the large number of thyroid cancer cases at the Lahey Clinic under the guidance of my Lahey surgical mentor, Neil Sedgwick. These encounters led to my major academic interest of studying the biological behavior of cancers and the varied surgical and adjuvant therapies appropriate for different aspects of disease. This interest in the biological aspects of cancer led to studies not only about thyroid cancer but also about breast, gastric, and colon cancers, melanoma, and primary and metastatic cancers of the liver. Over recent years, the basic approach of adjusting the radicalness of surgery to the risk of the particular cancer in terms of its stage, size, aggressiveness, and biological behavior has been accepted in rectal cancers where small lesions can be excised locally, in colon cancer where small cancers and polyps can be treated by endoscopic removal, and in breast cancer where small duct carcinoma in situ or low-grade mammographically discovered tubular carcinomas lend themselves to local excision only, while breast preservation by local excision and radiation therapy has been demonstrated to be the equivalent of mastectomy for the vast majority of contemporary breast cancers. The advent of breast cancer screening and the marked reduction in the size of the disease encountered allows further modifications towards conservation of tissue and simplification of therapy.* At the other end of the dis_( ease spectrum, induction chemotherapy for advanced primary breast cancer now allows subsequent breast preservation in 75% of such patients who respond, and is an accepted practice.’ Similar adjustments of the radicalness or extensiveness of the operative approach to the danger and aggressiveness of the cancer have been established in head and neck squamous cell cancer, melanoma, sarcoma, and primary lung cancer, as well as uterine, cervix, rectal, and renal cell carcinomas. Partial nephrectomy of small reAm J Surg. 1997;462-468. From New England Deaconess Hospital, Boston, Massachusetts. Requests for reprints should be addressed to Blake Cady, MD, Director, The Breast Health Center, Women &Infants Hospital, 101 Dudley Street, Providence, Rhode Island 02905. Presented at the 43rd Annual Meeting of the Society of Head and Neck Surgeons, Can&n, Mexico, April 1 O-l 2,1997.