Well differentiated thyroid cancers are all curable

All thyroid operations done for proven or suspected cancers should be extra capsular-Jatin Shah

Poorly differentiated need aggressive treatment and
majority of them are also curable

Sight threatening TED are those patients who have dysthyroid
optic neuropathy or corneal breakdown-David Smith

KARACHI: On Day two, May 15th of the Fourth Surgical Week for Endocrine Diseases held at JPMC from May 14-17th 2017 Prof. Jatin Shah from Memorial Sloan Kettering Cancer Center from New York United States made a presentation on Selective Surgical Treatment for differentiated Thyroid Cancer. Its incidence and mortality, he said, is rising in United States. Over the years we have not reduced mortality from thyroid cancer.

There are numerous misconceptions about thyroid cancer. Some of these Dr. Jatin Shah said include the following:

  1. All patients need sub-total or total Thyroidectomy.
  2. All patients need post-operative Radio Active Iodine Ablation
  3. Post-operative TSH should be brought down to zero.
  4. Follow up requires annual whole body radioactive scans.

He then discussed the pathology and biology of thyroid cancer and remarked that almost 85% of these cases present as papillary carcinoma. Up to 85% of these cases have good prognosis, 14% have bad prognosis while the remaining 1% will have worst outcome.   With each recurrence there is progression of tumour and prognosis depends on that. A small proportion about 10% of papillary carcinomas will undergo progression to more aggressive variants. Well differentiated cancers are all curable. Poorly differentiated need aggressive treatment and majority of them are also curable. However those anaplastic are rarely curable. Dr. Jatin Shah was of the view that we need to concentrate on the middle group to improve survival and reduce mortality. Age of the patient has an impact on the outcome. The patient’s tumour size is also important while histology grade and experience of the surgeon also matters.


Prof. Jatin Shah from Memorial Sloan Kettering Cancer Center New York USA and Dr. David Monro Smith from
Ninewells Hospital, Dundee, UK were the two guest speakers at the Fourth Surgical Week for Endocrine Diseases
at JPMC. Group photograph taken on the occasion shows them with some distinguished surgeons

from Pakistan who attended the course.

Continuing Dr. Jatin Shah said that prognostic factors allows risk group stratification which is the mantra in Thyroid Cancer. It permits selective surgical treatment, use of Radioactive Iodine, follow up strategies, delivers cost effective evidence based treatment, and allays anxiety on the part of the patient besides delivering excellent outcomes. Based on the prognostic factors, risk group stratification is the most important clinical parameter for selection of the extent of initial surgery, the need for adjuvant therapy, the degree of rigorous follow up and for the assessment of overall prognosis, for local, regional or distant failure besides survival. He suggested that all thyroid operations done for proven or suspected cancers should be extra capsular. We have performed over four thousand surgeries in my department and we have thirty years data. Five years follow up does not mean anything, we should be talking about ten, twenty and thirty years follow up, he remarked. Subtotal thyroidectomy and Near Total Thyroidectomy transgress thyroid tissue and therefore are not cancer operations which should not be done. There are only two oncologic operations which are Lobectomy or total Thyroidectomy. Talking about the extent of Thyroidectomy for cancer Dr. Jatin Shah said that  in Extra Capsular operations leave no residual thyroid tissue behind thus avoiding the need for RAI ablation.  Pay special attention to the upper pole, pyramidal lobe and the region of the cricothyroid membrane. Following an extra capsular total thyroidectomy, TGb is not measurable at six weeks which allows biochemical follow up.

Discussing the principles of surgery Dr. Jatin Shah opined that all gross tumours should be removed. One should preserve functioning structures as well as vital structures.  One has to create a balance between tumour controls and best functional results. One can use adjuvant treatments like RAI and or radiotherapy. Micro metastases are common in more than 50% of the cases. Occult metastases have no impact on prognosis in low risk patients while elective node dissections is  not recommended in low risk patients. Therapeutic neck dissection is indicated for metastatic nodes identified clinically on imaging studies or intra operatively. Lymph node dissection should be compartmental and comprehensive. In distant metastases Radioactive Iodine is quite safe and effective.  In selected cases external radiotherapy is advisable. Surgery is only palliative. Targeted therapy is still investigational and there are many agents which are currently under trials. As regards mortality, under thirty to forty years patients, there is 100% survival but we do see mortality in patients between the ages of 55-59 years. Extra thyroid extension increased the mortality while PN stage affects the outcome which makes a difference.

Continuing Dr. Jatin Shah said that there should be an indication for use of Radio Active Iodine and every patient should not be given this pill. Single nodule is an indication for lobectomy. Patients with multiple nodules bilaterally will require total thyroidectomy. Extra thyroid function has important impact on extent of surgery. No vertical incision in the neck should be made. In our experience most patients with pT1/T2 No PTC have excellent outcome with surgery alone and they do not need RAI. However, in selected cases with pT1/T2 N1 PTC have good outcomes without RAI but a few patients with pT3 PTC have good outcome when selected for treatment without RAI. Common recurrence is a rare cause of death today. It may be a biased opinion but it is supplemented by our data, he remarked.

Speaking about the follow up strategy, Dr. Jatin Shah suggested that one should follow up tailored to risk group. All patients in low or intermediate risk groups should have six monthly physical examinant for two years and thereafter annually. High risk group needs more intense and more frequent follow up strategy.

Prof. Jatin Shah, Prof. David Monro Smith and Prof. Mumtaz Mahar speaking at the inaugural session of the
Fourth Surgical Week for Endocrine Diseases held at JPMC from May 14-17, 2017.

He concluded his presentation by stating that there is rising incidence of favorable low risk cancers. One must use pathology and exploit biology to deliver cost effective treatments. Significance of prognostic factors and risk group stratification is well established. One has to use discretion in selection of surgical treatment while research in molecular biology and new therapies offer lot of hope.

Earlier on Day one during the live surgery session, the participants appreciated the live surgery being performed by Dr. Jatin Shah on multinodular goiter. It showed good display of anatomy whereby they could see all the structures very clearly. Dr. Jatin Shah remarked that if he sees a lymph node, he will remove it because it may turn out to be malignant. He then showed the superior, interior thyroid glands. Responding to a question Dr. Jatin Shah remarked that generally we do not use drain but if the patient is oozing, we do put a single drain in selected cases. The decision is taken on patient to patient basis. He however pointed out that the large multinodular goiter seen in Pakistan are not seen in the developed world. If there is late involvement of vocal cords after thyroid surgery, the voice changes. Movement of cord also changes. One has to be very careful doing surgery, make sure not to damage the nerve, the patient will recover.

Therapy for Graves’ disease with Ophthalmopathy

Dr. David Monro Smith from Ninewells Hospital, Dundee, UK made a presentation on Choice of therapy for Graves ’ disease with Ophthalmopathy.  Its etiology he said, is not understood but orbital Fibroblast and muscles have common TSH Receptor Antigen. Ophthalmopathy results from inflammation caused by cytokines release. About 1-2% of patients suffer from dermopathy i.e. glycosaminoglycan’s expression with thickened skin in pretibial region and dorsum of foot. Talking about the symptoms of TED he mentioned change in the appearance of the eyes i.e. usually staring or bulging eyes, as feeling of grittiness in the eyes, dry or watery eyes, swelling or feeling of fullness in one or both upper eyelids, redness of the lids and eyes, blurred or double vision, pain in or behind the eye specially when looking up or down or sideways and difficulty in moving the eyes. He also talked about the different signs in TED which are more useful in its classification.

Speaking about treatment of TED and Graves, Prof. David Smith said that it is important to know whether TED is inactive or active.  Treatment is based on clinical activity of TED and the prognostic factors.  Different options include RAI, RAI with steroid cover and surgery. As regards risk factors for TED, Dr. David Smith mentioned age as there is higher risk of TED in elderly, treatment is worse in men, smoking, thyroid status and RAI therapy. Mild TED patients include those whose features have only a minor impact on daily life. Moderate to severe TED patients are those who have sight threatening TED whose eye disease has sufficient impact on daily life to justify immunosuppression or surgical intervention. Sight threatening TED are those patients who have dysthyroid optic neuropathy or corneal breakdown. In case there is no TED or mild TED with no risk factors, the recommended management is RAI without steroid. However, if there are risk factors use RAI with steroids or consider surgery. Patients with active moderate to severe TED should go for surgery. But if TED is inactive, RAI without steroids is recommended. The center hepatic circulation of thyroid hormones is increased in thyrotoxicosis. The bile-salt sequestrates bind thyroid hormones in the intestine and thereby increase their fecal excretion.

Before surgery for Graves and TED, make sure the patient is euthyroid pre operatively. Opt for near-total to total thyroidectomy. Sub-total thyroidectomy has 8% relapse at five years and 70% hypothyroid at fifteen years. He then talked about the Dunhill procedure in detail.  He concluded his presentation by stating that in the treatment of Graves ’ disease,   one should ensure stopping smoking, RAI with steroids cover can be used but in case of moderate to severe TED surgery is indicated. It is also important to check Vitamin D levels and be careful of eyes on table.

Medullary Thyroid Cancer

Dr. David Smith’s next presentation was on Medullary Thyroid Cancer and he discussed in detail the diagnostic modalities, surgical management besides post-operative follow up. He pointed out that they see about hundred cases in UK every year. While examining these patients one should ask for any un-explained death in the family, aim for loco regional control in patients with first time surgery. He then talked about surgical management of lateral neck. He was of the view that if doubling time is less than two years, calcitonin levels will have worse prognosis. In such patients one should consider further imaging studies. As regards MTC adjuvant therapy, chemotherapy is rarely used now with doxorubicin. It is not popular in UK these days. LA octeriotide is quite useful.

During the discussion it was pointed out that FNAC can diagnose medullary carcinoma while pathology cannot diagnose it easily. Responding to another question Dr. David Smith said that he won’t use PET scan routinely for all cases. You can use it if you do not have other imaging facilities. Radiotherapy is very useful. When asked about the role of TruCut biopsy when FNA is inconclusive, Dr. David Smith said that we do not use it often but it is useful in some cases.