Abstract
Optimal upfront surgery with precise and objective image mapping is perhaps the way to go to enhance treatment outcomes and mitigate the use of post-operative radioiodine therapy. With the advent of targeted agents and precision medicine, it is now possible to undertake surgery for very advanced or inoperable differentiated thyroid cancers, followed by appropriate adjuvant treatment.
Keywords: Dual imaging, Comprehensive surgery, Neoadjuvant targeted therapy, Advanced differentiated thyroid cancers
In operable thyroid cancers, it has been our traditional policy to treat them optimally with the best possible preoperative optimization and navigation options. A recent research communication [1] on the neoadjuvant use of MEK inhibitors (dabrafenib and trametinib to doses of 150 mg daily and 2 mg daily, respectively, and lenvatinib up to 24 mg/day) for advanced differentiated papillary thyroid carcinoma (DPTC) has been quite intriguing to me as a head and neck surgeon in a high volume tertiary referral cancer center practicing optimal image-mapped upfront surgery for a long-lasting functional and oncologic resection [2]. In a cohort of 6 cases studied by the group, 1 had recovery of vocal fold (vf) motion within a month, and the rest took more than 3 months for the same. In my opinion, the return of vf function is a distinct possibility but a chance occurrence that could manifest in a very recent onset of vf palsy. We have experience with performing surgery for variably differentiated thyroid cancers after preoperative radiotherapy and preoperative radioactive iodine (RAI) ablation in revision and inoperable cases with very few R0 resections achieved, and I do not recollect recovery of a documented vf palsy. However, it is a distinct possibility that has a bearing on the time of detection, too. The role of preservation of vf function cannot be underrated under any circumstances. The current observation of recovery of vf motion in 6 cases [1] is, in my opinion, a landmark, adding more to the philosophy of optimization of the 1st surgery, which is most often the best chance for a higher outcome.
We are working on our retrospective data on dual baseline imaging-based [Contrast Enhanced Computed Tomography (CECT) with Ultrasound Scan (USS)] initial surgical treatment for all thyroid cancers and evaluating our strategies for airway management during extubation for high airway-risk advanced thyroid cancers. An interim analysis of both of these aspects points towards optimization of survival and mitigating airway-related complications, including avoiding perioperative tracheostomy. Even when nodes are not palpable clinically, combined USS with a CECT screen for any occult nodes or occult posterior spread of the thyroid disease is done, based on which the initial surgery is planned [2]. When the imageologist alerts us to a suspicious lymph node, we would further investigate this with a fine needle aspiration cytology (FNAC) and prophylactically clear the affected echelon and the immediately preceding nodal stations under frozen section control. For example, if there is a posteriorly placed subcentimetric thyroid nodule with a suspected lateral lymph node of size 1 cm on the same side, an initial FNAC would be done for the node. Even if it is negative, we would do a frozen section examination of the node. If positive, we may go for a prophylactic central compartment neck dissection, at least on the ipsilateral side, depending on the per-operative findings. The advantage of this approach is that once the occult nodes are traced, the patient can be categorized into a higher-risk group, and a higher-dose RAI ablation can be planned. Such a dose titration strategy is beneficial for optimizing the consumption of RAI in a high-volume, low-resource facility.
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The author declares no competing interests.
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References
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