Thyroid Diseases accounts for 1.5% of all solid cancer-Prof. Fabrice Menegaux


 Surgical week for endocrine diseases at JPMC

Thyroid Diseases accounts for 1.5% of
all solid cancer-Prof. Fabrice Menegaux

Nerve monitoring doesnot prevent nerve injury,
best prevention is meticulous surgery

Prof. Mumtaz Maher commends bravery of visiting faculty
to come to Pakistan, teach and train Pakistani surgeons

KARACHI: Management of various diseases require multidisciplinary team work. There are medical and surgical problems. It is immaterial to discuss whose domain it is. The person who know his job, has developed expertize in a particular field and has good results because of experience should be managing the patients. This was stated by Prof. Mumtaz Maher, an eminent laparoscopic and colorectal surgeon while speaking at the Third Annual Surgical Week for Endocrine Diseases held at JPMC from March 28-31st 2016.  Prof. Fabrice Menegaux from Pitie-Salpetriere Hospital University, Paris France and Dr. Alison J. Waghorn from Royal Liverpool Teaching Hospital were the invited guest speakers and master trainers for this course. The meeting attracted surgeons from all over the country who were interested in surgery for endocrine diseases.

Prof. Anees Bhatti Director JPMC( Second from Left) along with Dr. Naseem,
Prof. Fabrice Menegaux, Prof. Mumtaz Maher and Dr. Alison Waghorn
chairing a session during the Surgical Week for Endocrine Disease
at JPMC on March 29th 2016.

Prof. Mumtaz Maher commended the bravery shown by the two distinguished guest speakers to visit Pakistan despite adverse travel advisory and thanked them to come to Pakistan to teach and train the young surgeons. Addressing the participants Prof. Mumtaz Maher said that these distinguished medical personalities had come from overseas to teach and train us. Let us take home some message as this meeting will have something to teach to each one of us, he remarked. Both the guest speakers also briefly addressed the meeting and said they were delighted to be in Pakistan for participating in this academic activity.

Prof. Anisuddin Bhatti Director of JPMC who joined the meeting on  the second day due to his other professional commitments in his address said that  JPMC now has four CT Scans, two MRIs besides facility of Cyber knife which provides free treatment. He also disclosed that a new cancer institute is planned at the Campus which will be completed in next two years’ time. We are the pioneers of laparoscopic surgery in JPMC. I am proud of our faculty which was doing commendable job in difficult circumstances.  We have started endocrine surgery and during this meeting over two hundred surgeons from all over the country are being trained. They are getting knowledge as to what is happening all around the world. We can do the same surgery after proper training and availability of the required facilities.  CME credit was yet another advantage for the participants.

Earlier Dr. Shamim Qureshi in his introductory remarks said that one learns with life time experience when not to do any procedure or surgery. Surgeon is the decision maker. Let us all develop a passion for learning and repeatedly doing something makes one perfect and excellent which is good for the patient as it ensures patient safety and also assures better outcome. This meeting, he further stated, will add French favour to the course as we earlier had surgeons form other countries. Speaking in a jovial mood, Dr. Shamim Qureshi then remarked that when French go somewhere, British follow them, hence we this time also have Dr. Alison another distinguished surgeon from UK as a clinical faculty. And their both coming together makes it a European Union. We are grateful to them to have accepted our invitation to come to Pakistan and teach and train Pakistani surgeons. As in the past we have no Registration fee for this course and it was absolutely free but a nominal fee will be charged for the CME Certificates which will be given to those who mark their attendance, he added.

Some of the participants in the Surgical Week for Endocrine Diseases organized at JPMC recently
photographed with the visiting faculty members and the members of the organizing committee.

Before the formal inauguration of the course Dr. Naseem presented a few cases. First case he presented was a twenty four years old female with a benign cyst. It had recurred for the second time. It was first aspirated. He asked which of the treatment options should be now used while managing this case.  It was suggested that one should consider Hemithyroidecotmy after aspiration. Another suggestion was to consider mini thyroidectomy while some suggested to wait and observe, re-aspirate while some favored excision with properlobectomy.  Eventually right lobectomy was done in this case followed by radioactive ablation.

The second case he presented was a thirty five years old male suffering from thyrotoxicosis and Grave’s disease affecting the eye. Neck ultrasound was done and he was on anti-thyroidmedications for the last five years. Thyroidectomy followed by anti-thyroidmedications was continued but his eye disease was worsening. He was a smoker. Radio iodine ablation and surgery were mentioned as the other options. Near total thyroidectomy was performed in this case. The patients was diagnosed to be suffering from papillary thyroid carcinoma. Dr. Nasim pointed out that he discussed all the treatment options with the patient. I asked him for observation but he did not like this idea as it was cancer. Radio iodine ablation was the other option for early surgery and suppression of the tumour. He was of the view that in fact this patient should have been operated two years ago. This patient had Grave’s Ophthalmopathy. The patient did improve after surgery. After completion thyroidectomy, post-operativethyroid scan did not show any evidence of residual tissue.

Surgical indications for Thyroid Diseases

Prof. Fabrice Menegaux then delivered a talk on surgical indications for thyroid diseases.  He pointed out that one should not be afraid and make sure that do no harm to the patient. Complications are rare but they do affect the quality of life of the patient. Speaking about the prevalence of thyroid diseases he mentioned almost 50% of the patients are women and it accounts for 1.5% of all solid cancer. He then talked about advantages and disadvantages of surgery.  Post-operative morbidity, he opined, must be kept in mind and it includes nerve injury of 2-2.7%. Surgery can also be harmful. Over fifty thousand thyroidectomies are performed in France every year which includes eight thousand cancer cases and forty two thousand benign thyroid diseases. Speaking about surgical indications, he said that after limited examination if there is some suspicion, it is difficult to follow with compressive nodules and if there is a large cyst. Physical examination findings can further increase concern for malignancy.

Biologicals are not so helpful in management of thyroid nodules.  Neck ultrasound might incidentally discover nodules. After FNA and Cytology, if it is benign, there is no need for surgery and one should follow up these patients. However, in case of hyperthyroidism, toxic multinodular goiter, toxic adenoma and Grave’s Disease may require surgery. Then there are some special cases like pregnancy, thyroid nodule and benign disease, there should be suspicion for cancer. Surgery is difficult. No surgery should be performed in hypothyroidism and hyperthyroidism in Grave’s Disease.  The take home message, he stated, was that improve clinical evaluation, Ask for TSH, Ultrasound and FNAB.  If there are some local signs, look for goiter and cancer.

Responding to the questions during the discussion Prof.  Fabrice Menegaux said that in France we are pursued by the hospital management to perform ambulatory thyroidectomy. Hence we have prepared some guidelines which took us about three years. About 1% of cases are managed through ambulatory thyroidectomy in France in the OPD even after twenty years. Reluctance runs high for thyroid surgery. There are medico legal implications and one has to be mindful of post-operative complications. In view of all this, we have made these guideline. Selection of patients, he further stated, is extremely important and one must take care of the risk factors. Speaking about relative contra indications he mentioned that experience of the surgeon, surgical facilities, and patient related and psychological factors should all be kept in mind. Medico legal implications was the other important factors. In France of the one hundred three noted surgeons in this field, only nineteen are doing ambulatory thyroidectomy surgery. Post-operative risk and infections are important. Theoretically it is possible in carefully selected cases. He laid emphasis on expanding the surgical team, close observation of these patients in immediate postoperative course, close observation of scar swelling besides prevention of complications. Nerve monitoring, he stated, does not prevent nerve injury and best prevention is meticulous surgery. Surgeon is in the front line and his responsibility is to ensure good post-operative care that is why we demand at least one night hospitalization after surgery in case of ambulatory thyroidectomy.

Prof. Alison Waghorn spoke about Nerve Monitoring and preservation of laryngeal nerve.  She pointed out that for undertaking surgery, knowledge of surgical anatomy was extremely important. She then discussed how we find the RLN and EBSL. ENT surgeons, she opined, have a different approach. She then spoke about sub capsulardissection, anterior and posterior branches of recurrent laryngealnerve and nerve monitoring. Responding to a question regarding use of diathermy for cutting, she said, scar was very important.  Responding to yet another question she said that in my practice I do not use vasoconstrictors. Prof. Sikandar Sheikh said that he uses it and wound becomes avascular and there is no or very little bleeding. Participating in the discussion Dr. Shamim Qureshi said that surgery was one of the options for managing Grave’s Disease. How to diagnose it and how to manage it was important.

Management of Thyroid Cancer

On Day-2 of the course Prof. Fabrice Menegaux talked about Management of thyroid cancer. He pointed out that though this was a rare disease but surgeons should know how to manage these patients. During 2014 we had 482 cases in France and in 2015 the number of cases increased to 418.  About 29.3% of all these patients undergo surgery at our unit which is the percentage of cancer thyroid managed at our hospital. Again 85% of these cases are papillary and follicular account for 9% of the cases. Continuing Prof. Fabrice said that though the incidence of cancer was increasing but mortality due to cancer was stable. It is just about 5% and recurrence accounts for 14%. Low risk patients in Stage- I and II has 1.3% mortality but in high-risk cases which are in Stage III and IV the mortality is  24.8% Stage-I and II account for almost  80% of cases and  it has good prognosis.

Speaking about the goals of intervention therapy he mentioned improvement in survival of cancer patient, minimize the risk of disease and management of treatment related mortality. Some people prefer to be watchful waiting for selected T-1 cases.  Surgery, he pointed out, was still the gold standard in small cancer.  The extent of Lymph node dissection was debatable. Disease related mortality in high risk patients was 12-23% and Recurrence is 10-26%. The extent of thyroid dissection was no more debatable. After partial thyroid dissection everyone should have thyroid therapy. As regards lymph node dissection risk of recurrence was 5% but in high risk patients recurrence could be as high as 10%. One should prefer small incision for thyroid surgery but it should not be too small and make sure to expose the upper lobe.

Talking about extra capsular dissection, he said that in Lymph node dissection, one should remove all soft tissues containing LN from the hyoid bone.  Follow and preserve RNL. Protect superior PT glands and also protect inferior PT glands if possible. He also talked about safe control of lymph vessels and preserving the spinal accessory nerve. He also referred to the European Guidelines and pointed out that prophylactic LND control was   disputed issue. American Thyroid Association (ATA) is very aggressive in its approach as compared to European Thyroid Association (ETA). SFA and ATA are close to each other as regards these guidelines. Giving details of another study he said that there was 603patients of which 494 were females. The mean age was forty nine years. One hundred eighty three patients which is about 30% had some complications. Hypocalcaemia accounted for 25% in one hundred fifty one patients. All patients in T1 and T2 had radio iodine therapy. About 515 of these patients had adjuvant therapy. Recurrence was seen in 23 patients which came to 4%.  It was very high in N1 cases.  During 1978-2012 they had 247 cases of follicular carcinoma.  There was no lymph node in majority of the cases. Risk of recurrence was very low though the incidence was very high. Surgery he pointed out was the only cure for MTC and it should include total thyroidectomy. He also talked about minimally invasive thyroid surgery.

Other topics which were discussed during the three day meeting included management of parathyroid diseases, difficulty in localizing Parathyroid Glands and how to overcome it besides surgical overview of Adrenal Tumors. Both the distinguished visiting trainers also showed some live surgical procedures demonstrating various techniques.