Ilya Likhterov

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM.

OBJECTIVE The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy. METHODS We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed. RESULTS Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance. CONCLUSION With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patients clinical status.

The Ethical Implications of the Reclassification of Noninvasive Follicular Variant Papillary Thyroid Carcinoma

BACKGROUND Several studies have highlighted the lack of consensus in the diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC). An international multidisciplinary panel to address the controversy was assembled at the annual meeting of the Endocrine Pathology Society in March of 2015, leading to the recent publication reclassifying encapsulated (or noninvasive) FVPTC (EFVPTC) as a benign neoplasm. Does this change in histologic taxonomy warrant a change in clinical practice, and how should it affect those who have been given this diagnosis in the past? We consider the financial and psychological impact of this reclassification and discuss the ethical, legal, and practical issues involved with sharing this information with the patients who are affected. SUMMARY The total direct and indirect cost of thyroid cancer surveillance in patients is significant. High levels of clinically relevant distress affect up to 43% of patients with papillary thyroid carcinoma, as estimated by the Distress Thermometer developed by the National Comprehensive Cancer Network for detecting distress in cancer patients. Although there are currently no legal opinions that establish a precedent for recontacting patients whose clinical status is altered by a change in nomenclature, the prudent course would be to attend to the requirements of medical ethics. CONCLUSION Informing patients with a previous diagnosis of EFVPTC that the disease has been reclassified as benign is expected to have a dramatic effect on their surveillance needs and to alleviate the psychological impact of living with a diagnosis of cancer. It is important to re-evaluate the pathologic slides of those patients at risk to ensure that the invasive nature of the tumor is comprehensively evaluated before notifying a patient of a change in diagnosis. The availability of the entire tumor for evaluation of the capsule may prove to be a challenge for a portion of the population at risk. We believe that it is the clinicians professional duty to make a sincere and reasonable effort to convey the information to the affected patients. We also believe that the cost savings with respect to the need for additional surgery, radioactive iodine, and rigorous surveillance associated with a misinterpretation of the biology of the diagnosis of EFVPTC in less experienced hands will likely more than offset the cost incurred in histologic review and patient notification.

Safety of transoral surgery for oropharyngeal malignancies: An analysis of the ACS NSQIP.

Minimally invasive transoral surgical approaches for the resection of oropharyngeal tumors offer unique opportunities to achieve oncologically sound results while reducing treatment‐related morbidity. The objective of this study is to characterize the mortality and complication rates of transoral oncologic resections in a large, prospective, de‐identified national dataset from multiple hospitals.

Improving the adoption of thyroid cancer clinical practice guidelines

To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer‐based clinical support system.

Approach to en bloc resection and reconstruction of primary masticator space malignancies

The aim of this study was to present our experience with management of malignant lesions arising within the masticator space, and to describe a technique of en bloc resection and reconstruction.

Oral cavity squamous cell carcinoma metastatic to central compartment (level 6) lymph nodes.

Alterations to drainage pathways in the head and neck as a result of surgical manipulation are not well understood. We present two unusual cases of oral squamous cell carcinoma metastatic to the level 6 nodal compartment following extensive treatment. Both oral squamous cell carcinoma cases exhibited metastases to the central neck compartment following extensive surgery and radiation. Each patient had prior history of multifocal oral cavity disease and recurrent neck metastases requiring salvage lymphadenectomy. Surgical interventions may alter the usual lymphatic drainage patterns. In cases of extensive treatment, all levels of the neck should be monitored for lymph node recurrence. Laryngoscope, 126:1803–1805, 2016

Locoregional recurrence following maxillectomy: implications for microvascular reconstruction

Reconstruction of maxillectomy defects offers potential quality‐of‐life improvement, although cavity coverage may impact surveillance of recurrent malignancy. We describe the pattern of postmaxillectomy locoregional recurrence.

Central compartment management in patients with papillary thyroid cancer presenting with metastatic disease to the lateral neck: Anatomic pathways of lymphatic spread: Central compartment management and anatomic pathways of lymphatic spread in PTC

Papillary thyroid cancer (PTC) occasionally presents with metastases to the lateral neck, without clinically evident disease in the central neck. These cases may ultimately manifest as either skip metastases to the lateral compartment or as occult metastases in the central compartment.

The role of surgery in anaplastic thyroid cancer: A systematic review ☆

OBJECTIVE To elucidate the role of surgery in the management of anaplastic thyroid cancer. METHODS Ovid MEDLINE, Cochrane Library, and Google Scholar databases were searched for publications from December 2000 to July 2016. Selection criterion was a focus on the management of anaplastic thyroid cancer in adults. Studies addressing only nonsurgical management and review articles were excluded. Data extraction was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Kaplan-Meier analysis was performed on a subset of patients. RESULTS 40 publications were included in the study. Approaches to unresectability and interpretations of resection varied widely. For patients undergoing primary surgery, the median survival was 6.6months. The median survival for non-surgical patients was 2.1months. In the subgroup analysis, the median survival time for patients undergoing surgery was significantly longer in Stage IVB (p=0.022) but not IVC disease. Negative margins did not afford a statistically significant survival benefit. CONCLUSION Surgery is a mainstay of treatment for Stage IVA and IVB disease. For Stage IVC cancer, distant metastasis was not a strict criterion against surgical candidacy among surgeons. The extent of resection and the definition of resectability remain controversial. Negative margins did not significantly increase survival.

Nerve Management: Invasive Disease

Thyroid cancer which invades the recurrent laryngeal nerve (RLN) and/or visceral axis (esophagus, trachea, larynx) is rare, and the patient with invasion of the recurrent nerve may be completely asymptomatic. Several risk factors and clinical presentations should lead the clinician to perform a thorough and systematic preoperative clinical and radiologic workup, in order to diagnose invasive disease, plan surgery, and inform the patient as to possible consequences of surgery. The recommended preoperative workup of patients with suspected invasive disease will be discussed in this chapter, as well as the pathophysiology of nerve invasion and currently recognized risk factors. There are a number of key factors to consider when deciding intraoperatively to resect, sculpt, or preserve the RLN which are outlined in several algorithms suggested in this chapter.