The surgical treatment of thyroid cancer at Penn Medicine is distinguished by an institutional commitment to all patients with the disease, including patients not cured by primary therapy, patients with RAI-refractory disease, patients with recurrent disease and patients with rare sub-types that require complex care.
Preserving form and function: Better Recovery Through Precise Surgery
There are several aspects of thyroid cancer care that can make surgery complex. For some patients, it may be necessary to alter or resect vital structures during surgery for thyroid cancer. The capacity to perform these necessary procedures while preserving function and aesthetics is a particular forte of Penn Medicine’s thyroid surgery team.
“For these surgeries, the critical element is maximizing tumor resection while minimizing damage to essential tissues,” says Ara A. Chalian, MD, Professor of surgery at Penn Otorhinolaryngology – Head and Neck Surgery. Penn thyroid surgeons have adopted a number of protocols to ameliorate or circumvent postoperative adverse events.
Permanent or temporary parahypothyroidism, for example, can be avoided by preserving the parathyroid nodules, a procedure enhanced by preoperative review of the primary surgery pathology reports. Recurrent laryngeal nerve injury in reoperation for thyroid cancer is also a possibility in the rare instance that it is necessary to resect a nerve invaded by cancer. In this instance, Penn surgeons are able to perform medialization of the vocal cord to return the patient’s voice function to near normal levels.
Moreover, at Penn Medicine, patients with anticipated laryngeal and vocal cord symptoms following thyroid cancer surgery have early and regular access to speech language pathologists and other specialists trained to care for their specific issues. This care team includes Natasha Mirza, MD, Director of the Penn Center for Voice and Swallowing, who has devoted her career to treating patients with vocal cord paralysis following cancer and its treatment.
Differentiated Thyroid Cancer Care
Differentiated thyroid cancer (DTC) is often described as a disease with a relatively bright outcome. In fact, slightly more than 98% of all patients with DTC are alive five years after diagnosis, and despite a rising incidence of thyroid cancers in the United States, mortality has been decreasing.
The overall prognosis for DTC is somewhat dimmed, however, when one considers that up to 30% of patients will eventually recur (some within the five year post-diagnostic window). Moreover, among all thyroid cancers, 25% will be stage III or IV at the time of diagnosis, and among all thyroid cancer patients, approximately 5% are refractory to radioactive iodine (RAI).
Recent large, retrospective, database-driven reports suggest that these populations are best managed at high-volume medical centers to achieve the best long-term outcomes and minimize the risk of complications. [1, 2]
“These studies suggest that resources are the driving force for care in patients having complex thyroid surgery,” observes Dr Chalian. “And what we have at Penn Medicine are the resources—the collaborative team of specialists, the technology, the options for surgery, medical care and post-operative rehabilitation—to optimize care for these patients.”
An example of collaborative effort, the Penn Center for Voice and Swallowing at Penn Medicine provides early and regular access to surgeons, speech pathologists and other specialists trained to address the specific needs of patients with laryngeal and vocal cord symptoms following thyroid cancer surgery. The Center is led by Director Natasha Mirza, MD,who has devoted her career to treating patients with vocal cord paralysis following thyroid cancer and its treatment.
The Path to Surgery for Recurrent Thyroid Cancer
For a substantial subset of patients with DTC, surgery may been needed to address local disease recurrence which presents its own unique set of complexities. Local recurrence occurs in the soft tissues or lymph nodes of the central compartment of the neck (the area surrounding the thyroid), often as a result of residual disease following primary treatment for DTC.
“The extent of the first surgery is the most important determinant of second surgery,” Dr Chalian says. “Surprisingly, it’s often relatively low volume disease, lesions in the 8 to 10 mm range, that trigger the journey back to the operating room.”
Surgery for recurrent thyroid cancer in the soft tissues of the central compartment of the neck can be a particularly formidable undertaking. These procedures must address issues from earlier surgeries, including connective tissue aberrations (adhesions, fibrosis), scarring, nerve impairment and anatomical changes . In addition, thyroid cancer recurrences occurring in the central compartment often adhere to or invade the organs and nervous and vascular structures residing there, including the trachea, larynx, vocal cords, esophagus and parathyroid.
“Fortunately, reoperation within the central thyroid compartment or lateral neck for invasive disease is second nature for our surgeons,” says Dr. Chalian. Penn Thyroid Surgery Services’ capacity to undertake these types of difficult surgeries is enhanced by a team of specialists who provide exceptional preoperative radiological mapping. This enables Penn surgeons to know exactly where the abnormal lymph nodes are and plan the scale and strategy of the surgery.
Then during the surgery, the team utilizes intraoperative ultrasound imaging, nerve monitoring of the larynx and spinal accessory nerve, and intraoperative pathology reports. “CAT scans and MRI prior to reoperation for thyroid cancer are important to rule out the unexpected,” Dr Chalian says. “Nerve monitoring, which involves examining the nerve during surgery to optimize feedback, allows us to minimize the risk of permanent nerve paralysis.”
Because Penn surgeons collaborate with ultrasound radiologists in the operating room, they have the equipment to find small cancerous lymph nodes despite scarring or other issues in the region of the thyroid. Moreover, the team can perform graded or graduated resections, when indicated, based upon an understanding of the cancer’s behavior and the intraoperative analysis of tissue by the Department of Pathology and Laboratory Medicine.
The Future
Reflecting on Penn Thyroid Surgery Services, Dr Chalian notes that the interventions he and his colleagues provide are the foundation for the patient’s eventual return to speech and normal physiological parameters thereafter.
Beyond these key quality and functional outcomes however, is what the future holds.
“What we’re looking forward to as surgeons is the capacity to know who to operate on,” Dr. Chalian says. “ That is, the knowledge to determine whether we need to operate on the 6 mm recurrence in the central compartment or the 10 mm lymph node in the lateral neck, as well as the degree of aggression that we need to incorporate in our surgical strategy for these patients.”
References
- Youngwirth LM, Adam MA, Scheri RP, Roman SA, Sosa JA. Annals of Surgical Oncology 2016;23:403-409.
- Bilimoria KY, Zanocco K, Sturgeon C. Adv Surg. 2008;42:1-12.