Anaplastic thyroid cancer is fast growing most aggressive malignancy with poor prognosis -Song-Wook Kang


Endocrine surgical week at JPMC-II

Anaplastic thyroid cancer is fast growing
most aggressive malignancy with
poor prognosis -Song-Wook Kang

KARACHI: The visiting Korean Thyroid Surgeon Song- Wook Kang who conducted a workshop on endocrine surgery at JPMC last month gave an over view of Thyroid Surgery on second day of the workshop. He discussed in detail the diagnosis, management, post operative follow up, endoscopic and robotic thyroidectomy.  Slow growing thyroid cancer, he opined, has good prognosis. Thyroid cancer, he further stated, is more common in young people and particularly female. There is no specific cause of cancer but genetic track and radiation exposure does result in cancer. Follicular cancer and Para follicular cancer is common at fourty years of age and adjuvant therapy is needed after surgery.

Medullary thyroid cancer, Dr. Song-Wook Kang said is common in women and surgery is the only treatment of choice. Anaplastic thyroid cancer is most aggressive malignancy in humans, it is fast growing and prognosis is very bad. Speaking about diagnosis, he mentioned, careful history taking, physical examination and serological tests. Ultrasound is most useful for diagnosing thyroid cancer. CT and MRI are also used and are useful but sensitivity and specificity of ultrasound is much better than other modalities. More than one cm nodule need biopsy and they are in high risk group. However, if the size of the nodule is 0.5 cm one should keep these patients under observation. Size of the nodule and ultrasound findings, Dr. Kang opined are important.  He then referred to FNAB, surgery, keeping the patient under observation while there are many guidelines on management by various organizations like ATA, British Thyroid Society and American Associaton of Clinical Endocrinologists. He then discussed the lymph node dissection. He was of the view that endoscopic robotic thyroidectomy can be better in malignant cases. He also discussed the indications for radioactive iodine ablation (RIA). There are some grey zones in RIA in 1-4cm unifocal and multifocal lesions. In solitary tumours between 1-1.5 cm, there is 8% recurrence and mortality of 1%.

Speaking about the post operative follow up, he said that overall recurrence is reported to be 15-30%. He also referred to the dynamic risk stratification by ATA in low risk, mild to moderate and high risk patients. Low risk patients should not be subjected to ablation, followed up on ultrasound, CT and PET scan. Ultrasound should be done 6-12 months after the operation of the neck and then it should be repeated after every two to five years. Anti TG ablation is used in up to 25% of the patients. No additional information is required if TG is negative. Moderate to high rick cases has 20-60% recurrence.

Talking about endoscopic and robotic thyroidectomy Dr. Soong-Wook Kang said that cosmoses are important in ladies undergoing thyroid surgery. He discussed various minimal invasive surgical approaches and pointed out that they started doing endoscopic robotic surgery for thyroids in 2001 and have done 1085 cases till 2010. He also mentioned the benefits of maxillary approach which offers excellent cosmetic effect but it is a difficult surgery. Robotic surgery offers the benefit of cosmesis, post operative pain is less and patient satisfaction is better as compared to open thyroidectomy. He also announced that their institution has started an international fellowship training  programme in endocrine surgery and those interested can get in touch with us for further details.

During the discussion, chemo radiation by oncologists was also discussed.  It was further stated that in case of extensive disease, vocal cords are also involved, one has to clear the disease but some of it may be left which may require   RIA therapy. PET scan is helpful investigation for metastases post operatively. One of the participants stated that residual tissue is left even after complete thyroidectomy. During the live surgery he showed total thyroidectomy with block neck dissection, parathyroid adenoma while on first day he performed open right lobectomy, thyroglossal cyst and endoscopic thyroidectomy.

On Day three, he spoke on surgical treatment of adrenal disease and discussed its pre operative management.  He referred to the use of phecochormocytome, alpha blockade and adrenergic blockers for ten to fourteen days besides calcium channel blockers.  He also talked about conventional open adrenalectomy; surgical strategy as it is one of the most commonly performed procedure. Adrenal gland is the organ in the body. Laparoscopic adrenalectomy was first performed in 1992 and it was Gagner who introduced it.  It has now become a gold standard. He also discussed indications for this surgery. He then talked about Tran’s peritoneal approach, retroperitoneoscopic approach which is direct, fast, safe, and painless and also offers best cosmoses while it was also easy to learn. He also mentioned about the right PRA adrenalectomy, robotic adrenalectomy, post operative management which required intensive monitoring of hemodynamic status. Over all cures is 77%. In Cushing syndrome, there is clinical improvement after four to six weeks. He concluded his presentation by emphasizing the importance of adequate preparation and post operative management after robotic adrenalectomy.

His next presentation was on parathyroid glands. He first talked about hyperparathyroidism, its physiology, intrinsic and extrinsic abnormal changes. Adenoma is seen in 8-10% and it is single in 75-85% cases. There are no symptoms, patients complain of fatigue, weakness, depression and memory loss. Ultrasound, he stated, is effective, non invasive and inexpensive investigation. He also discussed intra operative localization, indication and types of surgery, bilateral neck exploration and pointed out that the cure rate was 95% with 1-2% complications rate. Dr.  Soong-Wook Kang then spoke about secondary hyper parathyroridism, its clinical features, medical and surgical treatment in detail. This, he opined, was a bridge to renal transplantation. Patients undergoing total Para thyroidectomy, sub- total thyroidectomy need long term use of calcium and Vitamin-D. There is a risk of persistent recurrence and there is increasing incidence and prevalence of chronic renal failure, he added.