Surgical Treatment of Thyroid Cancers With Concurrent Graves Disease

Original Articles


Background: Thyroid cancers with concurrent Graves disease are relatively rare. Accordingly, the natural history and optimal surgical treatment of thyroid cancers with Graves disease are controversial.

Methods: Sixty-one thyroid cancers with concurrent Graves disease were retrospectively reviewed. Histopathologic diagnoses included 58 papillary thyroid carcinomas (95.1%), 1 follicular carcinoma (1.6%), 1 medullary carcinoma (1.6%), and 1 Hürthle cell carcinoma (1.6%).

Results: The sample included 54 females and seven males. Subjects’ ages ranged from 20 to 73 years (mean ± SD, 35.9 ± 10.6 years; median, 37 years). Average tumor size was 10.7 ± 15.9 mm (range, 1–70 mm). Forty-nine tumors (80.3%) were 10 mm or smaller. Surgical procedures included subtotal thyroidectomy (40 patients), total thyroidectomy (16 patients), total thyroidectomy plus neck dissection (2 patients), near-total thyroidectomy (1 patient), and lobectomy with contralateral subtotal lobectomy (1 patient). Thirty-seven patients (60.7%) underwent postoperative 131I ablation for thyroid remnant. Neck lymph node metastases occurred in three patients and lung metastases in two patients. Patients who developed metastases were younger and had significantly larger tumors and higher pretreatment serum T3 level than those who did not develop metastases. No deaths occurred during the 6.2 ± 4.1 year follow-up period (range, 1 year and 2 months to 18 years and 11 months).

Conclusions: Most thyroid cancers with concurrent Graves disease were 10 mm or smaller. Subtotal thyroidectomy is adequate for patients with Graves disease with concurrent carcinoma 10 mm or smaller.

Key Words:

Carcinoma Graves disease Incidentaloma Thyroid Thyroidectomy Thyrotoxicosis 


  1. 1.
    Sokal JE. Incidence of malignancy in toxic and non-toxic nodular goiter. JAMA 1954; 154: 1321–5.Google Scholar
  2. 2.
    Farbota LM, Calandra DB, Lawrence AM, Paloyan E. Thyroid carcinoma in Graves disease. Surgery 1985; 98: 1148–53.PubMedGoogle Scholar
  3. 3.
    Shapiro ST, Friedmann NB, Perzik SL, Catz B. Incidence of thyroid carcinoma in Graves disease. Cancer 1970; 26: 1261–70.PubMedCrossRefGoogle Scholar
  4. 4.
    Belfiore A, Garofalo MR, Giuffrida D, et al. Increased aggressiveness of thyroid cancer in patients with Graves disease. J Clin Endocrinol Metab 1990; 70: 830–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Hales IB, McElduff A, Crummer P, et al. Does Graves disease or thyrotoxicosis affect the prognosis of thyroid cancer? J Clin Endocrinol Metab 1992; 75: 886–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Ozaki O, Ito K, Kobayashi K, Toshima K, Iwasaki H, Yashiro T. Thyroid carcinoma in Graves disease. World J Surg 1990; 14: 437–41.PubMedCrossRefGoogle Scholar
  7. 7.
    Behar R, Arganini M, Wu T-C, et al. Graves disease and thyroid cancer. Surgery 1986; 100: 1121–7.PubMedGoogle Scholar
  8. 8.
    Kraimps JL, Bouin-Pineau MH, Mathonnet M, et al. Multicenter study of thyroid nodules in patients with Graves disease. Br J Surg 2000; 87: 1111–3.PubMedCrossRefGoogle Scholar
  9. 9.
    Stocker DJ, Foster SS, Solomon BL, Shriver CD, Burch HB. Thyroid cancer yield in patients with Graves disease selected for surgery on the basis of cold scintiscan defects. Thyroid 2002; 12: 305–11.PubMedCrossRefGoogle Scholar
  10. 10.
    Pellegriti G, Belfiore A, Giuffrida D, Lupo L, Vigneri R. Outcome of differentiated thyroid cancer in Graves disease. J Clin Endocrinol Metab 1998; 83: 2805–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Edmonds CJ, Tellez M. Hyperthyroidism and thyroid cancer. Clin Endocrinol 1988; 28: 253–9.CrossRefGoogle Scholar
  12. 12.
    Carnell NE, Valente WA. Thyroid nodules in Graves disease: Classification, characterization, and response to treatment. Thyroid 1998; 8: 647–52.PubMedGoogle Scholar
  13. 13.
    Chao T-C, Lin J-D, Jeng L-B, Chen M-F. Thyroid cancer with concurrent hyperthyroidism. Arch Surg 1999; 134: 130–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Mazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med 1994; 97: 418–28.PubMedCrossRefGoogle Scholar
  15. 15.
    Gilliland FD, Hunt WC, Morris DM, Key CR. Prognostic factors for thyroid carcinoma. A population-based study of 15,698 cases from the Surveillance, Epidemiology and End Results (SEER) program 1973–1991. Cancer 1997; 79: 564–73.PubMedCrossRefGoogle Scholar
  16. 16.
    Simpson WJ, Mckenney SE, Carruthers JS, Gospodarowicz MK, Sutcliffe SB, Panzarella T. Papillary and follicular thyroid cancer: prognostic factors in 1578 patients. Am J Med 1987; 83: 479–88.PubMedCrossRefGoogle Scholar
  17. 17.
    Torring O, Tallstedt L, Wallin G, et al. Graves hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine–a prospective, randomized study. J Clin Endocrinol Metab 1996; 81: 2986–93.PubMedCrossRefGoogle Scholar
  18. 18.
    Weetman AP. Graves disease. N Engl J Med 2000; 343: 1236–48.PubMedCrossRefGoogle Scholar
  19. 19.
    Lazarus J. Hyperthyroidism. Lancet 1997; 349: 339–43.PubMedCrossRefGoogle Scholar
  20. 20.
    Leech NJ, Dayan CM. Controversies in the management of Graves disease. Clin Endocrinol 1998; 49: 273–80.CrossRefGoogle Scholar
  21. 21.
    Mishra A, Mishra SK. Thyroid nodules in Graves disease: implications in an endemically iodine deficient area. J Postgrad Med 2003; 47: 244–7.Google Scholar
  22. 22.
    Livadas D, Psarras A, Koutras DA. Malignant cold thyroid nodules in hyperthyroidism. Br J Surg 1976; 63: 726–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Wiest PW, Hartshorne MF, Inskip PD, et al. Thyroid palpation versus high-resolution thyroid ultrasonography in the detection of nodules. J Ultrasound Med 1998; 17: 487–96.PubMedGoogle Scholar
  24. 24.
    Cantalamessa L, Baldini M, Orsatti A, Meroni L, Amodei V, Castagnone D. Thyroid nodules in Graves disease and the risk of thyroid carcinoma. Arch Intern Med 1999; 159: 1705–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Belfiore A, Russo D, Vigneri R, Filetti S. Graves disease, thyroid nodules and thyroid cancer. Clin Endocrinol 2001; 55: 711–8.CrossRefGoogle Scholar
  26. 26.
    Lacey NA, Jones A, Clarke SEM. Role of radionuclide imaging in hyperthyroid patients with no clinical suspicion of nodules. Br J Radiol 2001; 74: 486–9.PubMedGoogle Scholar
  27. 27.
    Wang C-Y, Chang T-J, Chang T-C, Hsiao Y-L, Chen M-H, Huang S-H. Thyroidectomy or radioiodine? The value of ultrasonography and cytology in the assessment of nodular lesions in Graves hyperthyroidism. Am Surg 2001; 67: 721–6.PubMedGoogle Scholar
  28. 28.
    Noguchi S, Yamashita H, Murakami N, Nakayama I, Toda M, Kawamoto H. Small carcinomas of the thyroid: a long-term follow-up of 867 patients. Arch Surg 1996; 131: 187–91.PubMedGoogle Scholar
  29. 29.
    Miki H, Oshimo K, Inoue H, et al. Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland. J Surg Oncol 1993; 54: 78–81.PubMedCrossRefGoogle Scholar
  30. 30.
    Allo MD, Christianson W, Koivunen D. Not all “occult” papillary carcinomas are “minimal.” Surgery 1988; 104: 971–6.PubMedGoogle Scholar
  31. 31.
    Grant CS, Hay ID, Gough IR, Bergstralh EJ, Goellner JR, McConahey WM. Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important. Surgery 1988; 104: 954–62.PubMedGoogle Scholar
  32. 32.
    Wanebo HJ, Andrews W, Kaiser DL. Thyroid cancer: some basic consideration. Am J Surg 1981; 142: 474–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Farrar WB, Cooperman M, James AG. Surgical management of papillary and follicular carcinoma of the thyroid. Ann Surg 1980; 192: 701–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Schroder DM, Chambors A, France CJ. Operative strategy for thyroid cancer: is total thyroidectomy worth the price? Cancer 1986; 58: 2320–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Vickery AL Jr, Wang C-A, Walker AM. Treatment of intrathyroid papillary carcinoma of the thyroid. Cancer 1987; 60: 2587–95.PubMedCrossRefGoogle Scholar
  36. 36.
    Hay ID, Grant CS, van Heerden JA, Goellner JR, Ebersold JR, Bergstralh EJ. Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery 1992; 112: 1139–47.PubMedGoogle Scholar
  37. 37.
    Mazzaferri EL. Thyroid remnant 131I ablation for papillary and follicular thyroid carcinoma. Thyroid 1997; 7: 265–71.PubMedCrossRefGoogle Scholar
  38. 38.
    Baldet L, Manderscheid JC, Glinoer D, Jaffiol C, Coste-Seignovert B, Percheron C. The management of differentiated thyroid cancer in Europe in 1988: results of an international survey. Acta Endocrinol 1989; 120: 547–58.PubMedGoogle Scholar
  39. 39.
    Attie JN, Bock G, Moskowitz GW, Margouleff D, Dubner S. Postoperative radioactive iodine evaluation of total thyroidectomy for thyroid carcinoma: reappraisal and therapeutic implications. Head Neck 1992; 14: 297–302.PubMedCrossRefGoogle Scholar
  40. 40.
    Mazzaferri EL, Young RL. Papillary thyroid carcinoma: a 10-year follow-up report of the impact of therapy in 576 patients. Am J Med 1981; 70: 511–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Sanders LE, Rossi RL. Occult well differentiated thyroid carcinoma presenting as cervical node disease. World J Surg 1995; 19: 642–7.PubMedCrossRefGoogle Scholar

Copyright information

© The Society of Surgical Oncology, Inc. 2004

Authors and Affiliations

  1. 1.Division of General Surgery, Department of SurgeryChang Gung University College of Medicine and Chang Gung Memorial HospitalTaoyuanTaiwan
  2. 2.Division of Metabolism and Endocrinology, Department of Internal MedicineChang Gung University College of Medicine and Chang Gung Memorial HospitalTaoyuanTaiwan
  3. 3.Department of SurgeryChang Gung Memorial HospitalTaoyuanTaiwan

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