American Thyroid Association 89th Annual Meeting:

Thyroid Cancer Treatment—New Approaches to Improve Patient Outcomes

with Ralph P. Tufano, MD, and Michael C. Singer, MD

In an early morning session on cutting edge procedures in the surgical management of thyroid disease at the ATA annual meeting, Ralph P. Tufano, MD, MBA, FACS, the Charles W. Cummings, MD, Professor and director of head and neck endocrine surgery at Johns Hopkins University Medical Institution in Baltimore, Maryland, advanced the use of transoral surgery as an alternative to open neck surgery for thyroid and parathyroid diseases.1

Minimally Invasive Approaches to Thyroidectomy are Safe and Effective

In building a case for the transoral vestibular approach over conventional thyroidectomy and parathyroidectomy, Dr. Tufano offered some compelling data as if to reassure his audience (and now you) of the likely preference for and benefit to many appropriately selected patients.

He began by citing the work of a research team at Northwestern University Feinberg School of Medicine who assess adverse events that my impact the quality of life of patients following thyroidectomy for thyroid cancer.3

Goswami et al conducted an online survey of 1,743 members of the Thyroid Cancer Survivors’ Association in Olney, Maryland, to capture patient demographics, diagnostic measures, clinical characteristics, treatment history, as well as both short- and long-term, post-surgical adverse events. The PROMIS 29-item profile was used to formulate health-related quality of life scores.3

Quality of life scores were negatively impacted by a high rate of patient-reported surgical complication (P < 0.01), which were worse among younger patients (< 45 years), included:   

  • Scar appearance: 77.4%
  • Dsyphonia: 70.6%
  • Dysphasia: 62.9%
  • Hypocalcemia (transient, permanent): 46.8%
  • Site infection: 3.9%

It is important to note that patient concerns about a postsurgical neck scar—on average seven years after surgery in a cohort whose age averaged 51 years—reported poorer outcomes in three domains: anxiety and depression (P < 0.0001), and social functioning (P < 0.01), reflecting lower overall quality of life scores.3

This offers an important message to clinicians who may have considered it sufficient to offer assurance to patients that the scar will fade in time, the visibility of it may have a greater adverse impact. As such, the option of having transoral neck surgery has the potential to improve post-treatment outcomes when open surgery can be averted,1 Dr. Tufano said.

Visible Scars Leave Lasting Impression with Lastly Adverse Affects  Wellbeing

Beyond the need for lifelong thyroxin supplementation, it behooves the medical community to establish a clearer understanding of the lasting effects — physical, emotional, and psychosocial — that arise from thyroid surgery in order to fully anticipate and address issues affecting the quality of life of these patients,3 the authors wrote.

This is supported by American Thyroid Association (ATA) guidelines for the management of well-differentiated thyroid cancer, which contains a recommendation to provide validated patient-reported outcome assessments and to gather data on the risks and benefits of active surveillance as compared to surgical interventions.

“Endocrinologists (and internists) are not as familiar with removal of the thyroid or parathyroid through the mouth, which represents an innovation and evolution in endocrine surgery,” Dr. Tufano said. Employing the transoral procedure is an excellent option that yields similar clinical outcomes to standard thyroid surgery but with the distinct advantage of having no cosmetic impact.2

At Johns Hopkins, we are doing the procedure endoscopically (ie, non-robotic approach) whereas the procedure is done robotically in Korea.5  "We can do [this procedure] faster with similar outcomes without using robotics, which matters in the US since the higher cost is not reimbursed so would be most costly to our patients," he said. “Insurers are accepting of this procedure and paying for it but there with an unlisted code, but it is required.  Similarly, there is no distinct code for radiofrequency ablation, so reimbursement will require working with patients' insurers." 

Is the robotic endoscopy for thyroidectomy more beneficial? "At present, robotics has a higher cost and a short learning curve to address differences in physiology, for example, there is more cartilage in the neck of some male patients to maneuvering would require greater familiarity with this physiology. “There is a need to gain comfort with the maneuvers and visualization, but we can do it faster with similar outcomes," said Dr. Turfano.

Who is a good candidate for this transoral surgical procedure, and who is not?

“Any patient who has a benign thyroid nodule (up to 6 cm), indeterminant nodules (< 4 cm with confirmed ultrasonography) or other indicates suggestion surgery including Graves’ thyroiditis, the patient with cystic thyroid lesions who wants  definitive management or localized primary parathyroid adenoma (confirmed with two localizing scans), and select type 1 and very select type 2 papillary thyroid cancer with index nodule in favorable location (ie, inferior pole, surrounded by normal parenchymal tissue),” may be referred for this approach, Dr. Tufano said.

Whereas any patient with a suspicion of cancer at the superior pole capsule or mid-posterior pole (along the course of RLN), as well as possible medullary thyroid cancer, invasive or metastatic thyroid cancer with ultrasound confirmation, and finally hyperparathyroidism necessitating four-gland exploration are not deemed good candidates for a tranoral procedure,” said Dr. Tufano.

Dr. Tufano offered six “tenets of safe adoption” when discussing this option with patients, and making a referral,2 the surgeon should:

  • Be dedicated to thyroid and parathyroid surgery (eg, high volume specialist)
  • Provide the procedure ethically and honestly, not as a “gimmick” to gain market share
  • Have familiarity with both outside and inside open neck surgery for benign and malignant thyroid/parathyroid diseases
  • Perform ultrasound as a routine aspect of the procedure
  • Provide outcomes measures with full transparency for quality improvement

There are other potential advantages to the transoral route: less incidental removal of parathyroid glands during thyroidectomy given the enhanced optics and top-down approach, less emg changes during dissection, more reliable removal of Delphian lymph node, and possibly even less reported pain as compared to traditional open surgery, he said. "We are more concerned with changes in lymphatic drainage and affects on mamography, making the tranoral route more common in the US, and women would rather have a scar than consider the transaxial procedure."

In appropriate patients, the transoral route is an excellent option as there is no adverse cosmetic impact (ie, no neck scar), and has a short learning curve for surgeons who are at ease with the conventional open neck procedure,” he said, adding that it is safe for the patient, reducing surgical morbidity and mortality.2

"The advantage for patients in having the transoral procedure at this point is cosmetic," said Michael C. Singer, MD, a surgeon in the ear, nose, and throat division at Henry Ford Hospital in Dearborn, Michigan, specializing in minimally-invasive thyroid and parathyroid diseases, in commenting on the presentation. "What I hope is that the technology will change enough to make this easier for more endocrine surgeons to gain greater comfort; until then, it remains largely a niche surgery in the US."

Other attendess mentioned having received training in the transoral procedure tunless they gained more training first with regular surgeries to follow in order to gain steady experience. 

Next Summary:
Thyroid Disease Advances in Care: Key Insights from ATA Attendees
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