The surgical treatment of the malignant thyroid adenoma has been the subject of abundant discussion and disparity of opinion in the recent literature, and there seems to be little or no concurrence as to the surgical management of patients with this disease. There is not even any essential agreement as to the incidence of the disease or the pathologic diagnosis and classification, and certainly there are no reliable criteria on which to base a surgical decision as to what to operate and how extensive the surgical procedure should be. In fact, there are few things in surgery at the present time about which there is less standardization of opinion. To this cauldron we propose to add our findings, not with the intention of augmenting the confusion but rather with a view to furthering the criteria of intelligent, rational, and beneficial treatment of the malignant thyroid adenoma. The clinical material in

Among 206 carcinomas of the thyroid, 10 cases of large-cell carcinoma were observed. This type of malignant goiter has been described previously in Switzerland but it is not mentioned in the American literature. It is composed of very large cells but it does not present the pleomorphism seen in giant-cell carcinoma, and it is much less malignant.

1.1. Among 206 malignant goiters observed during twenty-seven years at the Hertzler Clinic, thirteen (6.3 per cent) had the structure of polymorphous cell tumor.2.2. Nine of these tumors were observed in females and four in males. The ages ranged from fifty to seventy-four years; the average was sixty-five years.3.3. Enlargement of the neck was noticed by our patients for from six weeks to forty-eight years. The average duration of the goiter previous to operation was 19.7 years.4.4. In the majority of cases (eight) a clinical diagnosis of cancer was made.5.5. Bilateral subtotal resection of the thyroid was performed upon two patients, total thyroidectomy upon two and lobectomy upon seven. Partial removal of an inoperable tumor was performed upon two patients.6.6. The size of the radically removed tumors varied from 175 to 264 gm. Bilateral involvement was noted in four instances. In most cases the thyroid capsule was invaded. In four patients there was gross invasion of a jugular vein and the neck muscles.7.7. All thirteen cases showed the characteristic structure described in the literature as giant cell carcinoma or polymorphous cell sarcoma. We propose the term “polymorphous cell tumor of the thyroid” until the histogenesis of these tumors has been established beyond a doubt.8.8. All thirteen patients are dead at present. In eleven, the rapid clinical course conformed to the generally accepted view that this type of malignant goiter can be classified with the most fulminating cancers known in humans. Death occurred in less than six months after the diagnosis had been established.9.9. Two patients, fifty-five and sixty-one years old, respectively, were exceptions in having a long survival after operation. Histologic study of the removed goiters showed, aside from benign adenomas, small areas of polymorphous cell tumor still confined to the thyroid. These two patients lived for more than ten years after operation.10.10. From the literature and our own experience, it appears that polymorphous cell tumor of the thyroid is invariably fatal after the surrounding neck structures have been invaded. The long survival of two of our patients can be explained only by the fact that the tumor was excised before it had a chance to invade the thyroid capsule. These two cases strengthen the standpoint of those specialists in thyroid surgery who remove every thyroid tumor before a clinical diagnosis of malignancy can be made.11.11. The history of long-standing goiter in all except one of our patients supports Wegelin's belief that polymorphous cell tumor develops as a rule in a long-standing benign adenoma. The prevention or early removal of an adenomatous goiter seems to be the only chance to eradicate this most malignant tumor of the thyroid.