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Guideline for the Treatment of Graves' Disease in Japan 2011 is made by The Japan Thyroid Associatin and the indication for surgical treatment is shown. Surgical therapy is an established and effective therapy for Graves' disease. However, application of this therapy has become less and there has been a decrease in patients receiving surgical therapy. Indication of the surgical treatment for this disease tends to be limited to special or difficult cases. The number of patients who undergo the total thyroidectomy has increased changing in the indication for surgical treatment.

An 85-year-old postmenopausal woman had multiple lesions in her right breast. Core needle biopsy showed solidtubular carcinoma with positive hormone receptor (ER+++, PgR-). She refused surgery and was then treated with anastrozole as neoadjuvant endocrine therapy. After seven months of the treatment, all lesions were increased or unchanged. The clinical response was judged as stable disease. Letrozole was chosen for the next therapy. After ten months, reductions in the tumors were noted, and the clinical response was judged a partial response. No side effects were observed. These two drugs are nonsteroidal aromatase inhibitors, and it is considered there is a cross-resistance between them. However, several studies have revealed letrozole was significantly more potent than anastrozole in inhibiting aromatase activity in vitro and in inhibiting total body aromatisation in vivo. This may be related to a difference in effect between the two drugs. It is suggested that letrozole as second-line endocrine therapy may be effective for postmenopausal breast cancer even after anastrozole failure.

Poorly differentiated carcinoma is adopted as an independent entity in World Health Organization (WHO) and in General Rules for the Description of Thyroid Cancer by The Japanese Society of Thyroid Surgery (JSTS), but their definitions are significantly different. In this study, we investigated the prevalence and clinical significance of poorly differentiated carcinoma by WHO classification (poorly differentiated carcinoma [WHO]) and that in JSTS (poorly differentiated carcinoma [Sakamoto]), and tall cell variant in papillary carcinoma. In our series of 1,707 patients, 186 (10.9%), 15 (0.9%) and 62 (3.6%) were diagnosed as poorly differentiated carcinoma (Sakamoto), poorly differentiated carcinoma (WHO) and tall cell variant, respectively. Poorly differentiated carcinoma (WHO) and tall cell variant independently affected cause-specific survival (CSS) of patients, but poor differentiation (Sakamoto) did not. Therefore, it is suggested that poorly differentiated carcinoma (Sakamoto) predicted the likeliness of carcinoma recurrence, it is inappropriate to separate it as an independent histology.

Traditional treatment for papillary thyroid carcinoma confined in one lobe was subtotal thyroidectomy with ipsilateral modified neck dissection in Japan. Several guidelines reported from western countries differ in many aspects from Japanese traditional practice. They recommend total or near total thyroidectomy except for a small solitary cancer without nodal metastasis and modified neck dissection only if nodes are clinically involved. They also recommend ablation of remnant thyroid with radioactive iodine and TSH suppression with variable indications and intensities. According to the recent improvements in surgical techniques and change in medical and economical situations, we currently perform total thyroidectomy more frequently and hemithyroidectomy for a small cancer. We abandoned subtotal thyroidectomy basically. We still consider prophylactic neck dissection valuable in reducing nodal recurrence in selected patients.

Surgical therapy is an established and effective therapy for Graves' disease. Application of this therapy, however, became less often recently, because of its negative features such as need for admission, scar formation and possible complications. For patients with Graves' disease surgical therapy is the only available therapy if they are associated with thyroid cancer, or if they are pregnant and antithyroid drugs are contraindicated. Recently, indication of the surgical therapy for this disease tends to be limited to special or difficult cases. Here, we analyze trend in our practice in Kuma Hospital, and explain change in our surgical goal, surgical procedures and results.

Detection of thyroglobulin, CEA, and calcitonin in serum and tissue is very useful to make differential diagnosis among papillary, follicular, and medullary carcinoma of the thyroid. The case was a 70-year-old woman with a nodule of the thyroid, presenting elevated serum level of thyroglobulin and CEA (22.0 ng/ml). Both serum level of thyroglobulin and CEA decreased after surgery. One year and nine months after surgery, she died from systemic metastases of thyroid carcinoma. Histological examination of the tumor presented to be poorly differentiated type of follicular carcinoma, presenting positive of both thyroglobulin and CEA, and negative of calcitonin in the cytoimmunochemistry. This case was identified to be a rare case that tumor cells of poorly differentiated follicular carcinoma produced and secreted both thyroglobulin and CEA.

We experienced a case of bronchospasm during upper gastrointestinal endoscopy under sedation. An 80-year-old man came to our hospital with abdominal distension with pain, nausea and vomiting. He has the history of splenectomy, cholecystectomy for hemolytic anemia and thyroidectomy for thyroid cancer, surgery for bilateral shoulder joints and diabetes. Abdominal X-ray suggested obstruction of the small intestine. On the third hospital day, gastrointestinal endoscopy was scheduled for insertion of a long ileus tube. Under sedation with diazepam 10 mg and local anesthesia of the pharynx with lidocaine spray 24 mg, the endoscope was inserted and when it reached the esophageal-gastrojunction, respiratory rate increased to 30 breaths.min-1 with expiratory stridor. The endoscope was removed immediately. He was oro-tracheally intubated and artificially ventilated. On the fourth hospital day, he was extubated under bronchoscopy. No abnormalities were observed in the trachea, vocal cord, pharynx and larynx. Later, it was revealed that he had a history of hoarseness and dysphasia. His left recurrent nerve and cervical nerve had been resected with thyroid and right cervical nerve anastomosed to the rest of the left recurrent nerve. The insertion of upper gastrointestinal endoscope might have induced bronchospasm stimulating distal esophageal afferent vagal reflex partly by regurgitation of gastric acid under sedation.