Multimodal therapeutic approach is needed in managing Anaplastic Thyroid Cancer-David Smith


 Surgical Week for Endocrine Diseases at JPMC-III

Multimodal therapeutic approach is needed in
managing Anaplastic Thyroid Cancer-David Smith

Do surgery consciously and do not worry about intra operative
complications but remember anything can happen to anyone-Jatin Shah

KARACHI: Another presentation by Prof. David Monro Smith Consultant Endocrine and General Surgeon at Ninewells Hospital Dundee UK during the Fourth Annual Week for Endocrine diseases held at JPMC Karachi from May 14-17, 2017 was on Anaplastic Thyroid Cancer. He pointed out that patient with such a cancer is the worst one can get. It is a dreadful case. It is present more in female in the sixth or seventh decade of their life and all these cancers are in Stage-IV when diagnosed. We see about seven cases annually in UK. They have undetected long standing metastases as a risk factor. Dr. Mubbashar Ikram from Aga Khan University Hospital moderated this session.

Dr. David Smith

Speaking about its management Dr. David Smith opined that PTDC may be more amenable to surgery. Patient with acute symptoms and capsule invasion has worst outcome. One can chose chemotherapy, surgery or radiotherapy but most of these patients die within eight months. One needs to use multimodal therapeutic approach in managing these cases.  Surgery is possible if cancer is confined to thyroid capsule. Patient selection is extremely important. His advice to his colleagues was not to make the patient worse. Always take patient centered decisions. He also talked about role of Tracheostomy, Diagnosis by FNA core biopsy. Removing pathology at MDT and multimodality approach are good practice points.

Prof. Jatin Shah

This was followed by a live surgery session where Prof. Jatin Shah demonstrated various steps in surgery. Responding to a question he said there was no need for antibiotics if the operation is clean and we are not infecting the patient. PET scan has value but not in medullary carcinoma. Prof. Jatin Shah further emphasized that if you have enough experience there is no need to monitor the nerve. We do not arrange blood while doing thyroid surgery. Head and Neck surgery is bloodless. One of the participants asked him why he was not using diathermy for skin incision to which he responded that because of epidermal scar. He also showed the correct place of incision on the neck. He further opined that there are no contra indications to Head and Neck surgery except medical if the patient is not fit for anesthesia. However, he hastened to add that some people will do anything to make money and living. Endoscopy, Day care lobectomy is routine and we do not use drain in such cases. However, there was lot of unethical practices going on he remarked. He further stated that Surgeon is a Surgeon who makes a decision whether to put in a drain. Institution is not a surgeon hence institutions cannot take a decision and dictate it to the surgeons. One of the participants also asked him how to overcome the initial resistance of not putting in the drain in such cases. Prof. Jatin Shah   further stated that he uses silk sutures. Do not leave clips as they will interfere with imaging. Incision on the neck is made quite low. He then demonstrated how he raises the upper flaps. Replying to a question as to who should be doing the thyroid surgery ENT surgeons or General Surgeons, Prof. Jatin Shah remarked that back ground does not matter. Anyone who is well trained, has proper experience and can do good surgery should be doing it. He also showed the anatomical structure in detail and explained it to the young surgeons. Responding to another question from the audience, Prof. Jatin Shah said that he has rarely done strenotomy for thyroid cancer.

Management of Hyperparathyroidism

Speaking about the management of hyperparathyroidism Prof. David Smith emphasized the importance of making correct diagnosis. He discussed in detail the indications, localization, the procedure and post-operative care. The work up, he said, was getting easier and the surgery can start to become difficult. In making correct diagnosis he referred to several corrected calcium levels, Vitamin D, Phosphate, chloride, twenty four hour urinary calcium excretion, and urine calcium clearance ratio. He also talked about genetic testing in isolated patients and familial cases. Do three site Bone Dexa Density Scan. He also referred to the PHP guidelines for surgery in asymptomatic patients. Make sure the repletion of Vitamin D. Exclude renal dysfunction, ensure good calcium intake and stop interfering drugs like thiazides, lithium if necessary. Secondary HPT can be caused by celiac disease. Make sure that you should operate looking at age, bone and symptoms. He recommended 4D CT for these patients.

Talking about the procedure he mentioned bilateral neck dissection, Minimal Invasive Parathyroidectomy. These are the three different procedures.  If you can find gland, have a plan, look and trace the small vessels. Off the ITA that may supply the adenoma. Then check the Para Recto Esophageal space. Identify and open up the thymus looking for intra adenoma. Reassure your imaging and always mark parathyroid that you have identified. Check calcium and PTH in first and twelve hours. He was of the view that all patients should get Adcal D3 for at least one year. For Hungry bone syndromes use calcium supplements and Vitamin D.  SPECT CT is better but 4D CT is good enough because at times SPECT CT is not available.

Prof. Jatin Shah in the live surgery session demonstrated modified neck dissection. This was an eighteen years old patient and she had secondary surgery. He showed how he was careful in saving some of the structures.  He gave a detailed explanation of the anatomy of the various structures and how to save facial nerve as well as marginal mandibular nerve while raising upper flap. Always do surgery consciously and do not worry about intra operative complications but remember, anything can happen with any one, he remarked. In this patient the nodule was on the right side which was not seen on CT but ultrasound was much better and it did show nodule on the right side of the patient, he added.

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