|Year : 2015 | Volume
| Issue : 3 | Page : 382-386
Pre-surgical road map for thyroid cancer and large goiters: Practical benefits of detailed radiological evaluation by surgeon
Ramakanth Bhargav Panchangam1, Satyam Guntupalli2, Thotakura Seetharamaiah3, Uday Shamrao Kumbhar4
1 Consultant Endocrine Surgeon, Endocare Hospital, Vijayawada; Department of Endocrine and Metabolic Surgery, Ex-Associate Professor of Endocrine Surgery, Mamata Medical College, Khammam, Andhra Pradesh, India
2 Associate Professor of General Surgery, Mamata Medical College, Khammam, Andhra Pradesh, India
3 Professor of General Surgery, Mamata Medical College, Khammam, Andhra Pradesh, India
4 Professor of General Surgery, Employee's State Insurance Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||18-Feb-2016|
Ramakanth Bhargav Panchangam
Consultant Endocrine Surgeon, Endocare Hospital, Vijayawada; Department of Endocrine and Metabolic Surgery, Ex-Associate Professor of Endocrine Surgery, Mamata Medical College, Khammam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Pre-surgical radiological evaluation of neck is often mandatory for surgical planning in high risk thyroid cancer and large goiters. Frequently, surgeons are overdependent on radiologist's report. In this context, we analysed the practical benefits of surgeon's independent radiological evaluation in our institutional experience. Material And Methods: This prospective study was conducted in Endocrine Surgery department of a teaching hospital in South India. Cases operated between January 2011 and June 2012 (18 months) were included. Films of cross-sectional imaging were read in detail by primary and assistant surgeons in correlation with stepwise operative planning and documented. Cases with additional radiological signs on surgeon's evaluation, which were missing in radiologist's report are discussed in detail. Results: F: M ratio is 67:24. Mean age was 45.3 ± 9.8 years (37 – 76). Forty-seven cases of thyroid cancer and 44 cases of large goiters were analysed. Surgeon read additional signs such as obliterated fat plane between goiter and subcutaneous plane; level I lymph nodes; bilateral cervical lymphadenopathy, internal jugular vein thrombus, and pharyngeal invasion helped in pre-operatively planned modification of operative steps for optimal R0 resection and total thyroidectomy. A mean of 1.42 ± 0.83 (1 – 6), additional signs were detected on surgeon's radiological evaluation compared to radiologist's report in 41.7% of cases. These findings modified the pre-operative plan, facilitating better surgical outcome in 28.6% of cases. Conclusion: In high-risk thyroid cancer and large goiters, detailed radiological evaluation by surgeon facilitates optimal surgical resection and superior outcome compared to radiologist report-guided surgery.
Keywords: Cross-sectional imaging, lymphadenopathy, microcalcifications, thyroid cancer, tumour thrombus
|How to cite this article:|
Panchangam RB, Guntupalli S, Seetharamaiah T, Kumbhar US. Pre-surgical road map for thyroid cancer and large goiters: Practical benefits of detailed radiological evaluation by surgeon. Indian J Cancer 2015;52:382-6
|How to cite this URL:|
Panchangam RB, Guntupalli S, Seetharamaiah T, Kumbhar US. Pre-surgical road map for thyroid cancer and large goiters: Practical benefits of detailed radiological evaluation by surgeon. Indian J Cancer [serial online] 2015 [cited 2019 Dec 5];52:382-6. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/382/176751
| » Introduction|| |
Goiter is one of the commonest endocrine disorder and thyroid cancer is the commonest endocrine malignancy., The primary and definitive treatment for follicular differentiated thyroid cancer (DTC) is total or hemithyroidectomy ± prophylactic or therapeutic neck dissection depending on institutional protocol, surgical expertise, and the stage of disease. Radiological evaluation of volume and extent of goiter is frequently essential for confirmation of physical findings and surgical planning. Ultrasonography (USG) and cross-sectional imaging (CSI) with computerized tomography (CT) or magnetic resonance imaging (MRI) are most frequently performed imaging modalities. Although, USG is sufficient for smaller goiters and early malignancy, CSI is often required for large goiters, high-grade thyroid cancer, and staging lymphadenopathy.,, But, radiologist's CSI report frequently comments only on striking features such as calcifications, gross lymphadenopathy, intrathoracic extent, and intra-luminal tracheal invasion. Surgically relevant and finer radiological details as evaluated by the surgeon her/himself, aids in better surgical planning. Based on our experience, we are writing this paper, to specifically highlight the operative steps at which this detailed radiological evaluation by surgeon (DRES) is beneficial.
| » Material and Methods|| |
This study was conducted in the Endocrine and Metabolic surgery of a teritiary care teaching hospital in South India. The cohort included 47 cases of differentiated thyroid cancer and 44 cases of large goiter operated between January 2011 and June 2012 (18 months) of our department. Proforma-based documentation of clinico-pathological, radiological, and surgical details was done. Inclusion criteria included operable thyroid cancer, large goiters and those who gave informed consent. Exclusion criteria included reoperative goiters. We have done contrast-enhanced CT in 87 cases and MRI in four cases. MRI was performed in pregnant and lactating women.
Initially, a stepwise surgical plan from skin incision to closure in a systematic manner was charted based on radiologist's report alone. Later, CT and MRI films of all the cases were critically read and details documented. This radiological evaluation was done by the chief operating surgeon, along with intra-departmental discussion. Each evaluation required about 20 minutes (approximately). Ten study categories related to the extent of goiter, vascularity, pattern of calcifications, planes with surrounding tissues, vascular invasion, etc., were studied and documented in all the cases. In case of equivocal findings or technical clarifications (such as artifacts, phasic variation), CSI was discussed with the consultant radiologist. These findings were reconfirmed on the day of surgery again. A stepwise operative road map was prepared based on DRES. The DRES-detected findings and operative plan were compared with surgical plan based on radiologist's report in a pointwise manner.
Ten vital DRES detected signs, which helped in better surgical planning are described in detail. These prototypical case scenarios were labeled in alphabetical order from A to J, for descriptive purposes.
The study design was prospective non-randomized study with comparison of before and after evaluation of surgical plan, based on DRES. This study complied with international ethical norms according to Helsinki Declaration – Ethical Principles for Medical Research Involving Human Subjects, 2004 and informed consent was sought from all the subjects. Statistical analysis was done with SPSS software 12.0 version. Descriptive statistics for categorical variables and Chi-square test for continuous variables was utilized to analyse the data.
| » Results|| |
Clinico-pathological and operative details are displayed in [Table 1]. F: M ratio was 67:24 and mean age was 45.3 ± 9.8 years (37 – 76). No major morbidity or surgical-related mortality occurred in the series, except for mortality due to sudden cardiac death on 7th postoperative day in one case.
[Table 2] displays the proportions and severity of various DRES study points. A mean of 1.42 ± 0.83 (1 – 6), additional signs were detected on surgeon's radiological evaluation compared to radiologist's report in 41.7% (38/91) of cases of the cohort. [Table 3] shows the impact of DRES on surgical planning, when DRES and radiologist's evaluation are compared. These findings modified the pre-operative plan, facilitating better surgery, and optimal outcome in 28.6% (26/91) of cases. The 10 prototypical case scenarios A to J are described below: CT scan films in case scenario A, shows obliteration of fat plane between skin and goiter [Figure 1]a. This sign was found in three more cases, which helped in utilizing an elliptical skin incision overlying the goiter [Figure 1]b. CT films in case B shows a tense, cystic degeneration of goiter with platysmal infiltration [Figure 2]a. Tense cystic goiters were found in five cases. In case scenario C, CT shows a long neck with bilateral lymphadenopathy extending from the level of mandible to clavicle, in conjunction with clinical findings helped in utilizing a MacAfee incision for the surgical procedure of total thyroidectomy and bilateral neck dissection from level I to V [Figure 3]. In case scenario D, radiologist report mentioned only left-sided jugular lymphadenopathy (which is also clinically palpable) along with nodular goiter. CT films showed bilateral jugular lymphadenopathy with deeper retrojugular lymphnodes, which facilitated in bilateral lymph node dissection. In case E, DRES showed internal jugular vein thrombus (IJVT) extending via distended middle thyroid vein in a case of follicular thyroid cancer with spinal metastasis [Figure 4]b. This helped in resection of IJV, middle thyroid vein and goiter in continuity without trying to create plane between goiter mass and lymph nodal mass, thus ensuring enbloc resection. This case was previously reported by us in images section in the literature.
|Table 3: Impact of DRES on surgical treatment compared with radiologist's report-based plan|
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|Figure 1: (a) CT neck shows infiltration of subcutaneous tissue with obliteration of fat plane (arrow); (b) Intra-operative photograph - Elliptical skin incision (arrow); inset shows infiltrated platysma with tumor after raising skin flaps|
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|Figure 2: (a) CT neck shows tense cyst abutting skin and distended, thrombosed left internal jugular vein pushing aside left carotid artery (black arrow) with normal right IJV; (b) Gross photograph showing left neck dissection with bisected left IJV exposing tumor thrombus (inset showing clinical picture)|
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|Figure 3: (a) CT neck shows punctate calcifications and infiltration of platysma (red arrow), egg shell calcification (hollow arrow), popcorn calcification (white arrow), aberrant vascularity (yellow arrow); (b) Thrombotic filling defect in right IJV (black arrow) extending from goiter via middle thyroid vein (white arrow), normal left IJV (hollow arrow)|
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|Figure 4: (a) CT neck showing right IJV (hollow arrow) and distended, thrombosed left IJV (black arrow); (b) Gross photograph showing total thyroidectomy (black arrow), bilateral MRND with resected left IJV (hollow arrow) – inset showing intraoperative image|
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IJVT was also found in a case of papillary thyroid cancer with lymph node metastasis (case F), seen as a distended and irregular left IJV [Figure 2]a, which was resected enbloc with thrombectomy [Figure 2]b. This feature was found in three cases of follicular thyroid cancer and one case of papillary thyroid cancer. Case G, shows compressed right IJV and non-visualized left IJV with huge bilateral lymph nodes flanking great vessels on both sides of neck sparing carotid arteries [Figure 5]a. Saving both IJV was a herculean task in this scenario. Based on CT scanogram, decision was taken to sacrifice left IJV due to heavier involvement of entire left jugular chain and preserve right IJV due to relatively lesser involvement of right chain. Accordingly, left IJV was sacrificed and though right IJV was injured at two sites, it was repaired preserving normal blood flow [Figure 5]b. According to radiologist's impression, it was compressed IJV on both sides. Without DRES, it was impossible to decide on which IJV to be resected and it becomes a surgeon's nightmare. DRES in case H (case of huge benign multinodular goiter) helped in preventing surgical injury to carotid based on the information that it was engulfed by an unresectable dense calcification in the goiter. Carotid doppler showed normal flow pattern. DRES in case I, showed obliteration of tissue planes with pharynx and laryngeal muscles. This sign facilitated in planned partial resection of the involved pharyngeal muscles in continuity with goiter. Intrathoracic extension occurred in nine cases. Right posterior mediastinal extension, anterior mediastinal extension, combined, left posterior mediastinal extension in 4, 3, 1 and 1 cases, respectively. Only two cases required extra-cervical approach. In seven cases, goiter could be delivered through conventional neck approach alone. In two cases J1 and J2, we utilized a combined cervical and thoracoscopic approach earlier described by us in detail. Excess vascularity, as suggested by collateral and parasitic blood vessels, was found in high grade thyroid cancers [Figure 4]a.
|Figure 5: (a) CT neck shows bilateral level I jugular lymph nodes (arrows); (b) Gross ex vivo photograph showing total thyroidectomy and bilateral MRND with level I jugular lymph nodes (arrow) – inset shows jet black cystic lymph node|
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| » Discussion|| |
Radiological evaluation of volume and extent of neck disease is frequently essential for confirmation of surgical planning in thyroid cancer and large goiters. USG suffices for smaller goiters and low-grade malignancy. CSI is especially informative and often mandatory for large goiters and high-grade thyroid cancer. Moreover, USG is limited by operator dependency and may not delineate invasive/infiltrative areas. Another major limitation of USG from surgeon's point of view is its non-real time nature keeping surgeon in oblivion at critical anatomical areas such as retropharygeal space and mediastinum, till the neck is opened. Moreover, higher grade thyroid cancer tends to involve major vessels of neck and mediastinum, which is better delineated by CSI though Doppler ultrasound can be contributory for surgical planning. Thus, USG leaves the surgeon totally dependent on radiologist's report. Although, in present times, high resolution USG (10 – 14 MHz) armed with Doppler and qualitative reporting systems, helps in better delineation of goiter nature, predicting malignant features, soft tissue and vascular invasion, its practical limitations are still prohibitive to utilize as an exclusive pre-surgical imaging in high risk cancers and large goiters. At best, it can play a complementary role to CSI as shown in few studies. Nevertheless, USG is an essential initial modality due to its easier availability, lower cost and potentiality as an office-based surgeon performed ultrasound.
As seen in Case A, though clinical lack of skin pinchability and skin ulceration helps in diagnosing the skin involvement, large tumors with platysmal infiltration precludes this diagnosis. Diagnosis of skin involvement in large goiters is possible only on radiological confirmation in non-ulcerated cases. Conventional collar incision could preclude R0 resection, due to entrance into a tumor-infiltrated plane. As seen in Case B, a wider elliptical incision helps in avoiding the rupture of cyst in trying to raise subplatysmal flaps overlying the goiter, as in conventional thyroidectomy. This planned incision based on detailed radiological evaluation, speeds up surgery without messing up the operative field due to rupture of cyst or bleeding or tumor spillage from goiter. In case scenario C, it can be seen that the MacAfee incision facilitated in oncological R0 resection of all lymph node levels from levels I to VI. In Radiologist's report, gross and larger lymphadenopathy (usually mid and lower jugular lymph nodes in thyroid cancer) tend to get highlighted, thus less conspicuous lymph nodal involvement and their entire extent are under-reported. This could lead to erroneously taken single incision in a long neck leading to incomplete lymph node dissection. In case scenario F, the extent and nature of IJV thrombus could be predetermined with DRES and accordingly, vascular instruments and sutures could be kept ready for this surgery beforehand. Longer thrombus needs IJV resection and small extensions spanning one or two thin slices can be dealt with phlebotomy and thrombectomy without resection.,, This information was provided by radiologist's report in only one case. In case G, DRES facilitated in planning extent of resection pre-operatively and benefitted both patient and surgeon alike with minimal morbidity and best oncological clearance. As seen in case H, benign goiters can involve great vessels of neck and but there are only anecdotal reports of it. As shown in case scenario I, though edema, fibrous reaction, neo-vascularization may be confused with infiltration on CSI, this obliteration of tissue planes at least alerts surgeon during the step of separating goiter from neck viscera. Larger caliber nasogastric tube helps in locating the pharynx, esophagus by palpation during surgery, as they may be grossly shifted, distorded, infiltrated or engulfed by huge goiters and invasive cancer. Though few studies show reasonable sensitivity of USG for tracheal and esophageal invasion,, CSI had better accuracy for advanced and high-risk thyroid cancer.,,,,,,
As occurs in cases J1,2, though >90% of intrathoracic goiters can be delivered by cervical route, few cases require alternate approaches such as sternotomy, thoracotomy, claviculotomy, or thoracoscopy. But, these techniques require specialized equipment and single lung ventilation. DRES guides in anticipatory arrangement of requisite anesthetic and surgical equipment. Moreover, the definition of intrathoracic extension is not uniform and radiologist's interpretation may not match surgeon's criterion. The information of excess and aberrant vascularity, helps in anticipating the excess intra-operative need of blood transfusion and arranging it before surgery. Apart from surgical planning, DRES has a diagnostic advantage with findings such as clustered microcalcifications [Figure 4]a, cystic lymph nodes [Figure 5]a and infiltration to surrounding structures. Often, in large cystic or heterogenous goiter masses with central hemorrhage or necrosis, fine needle aspiration cytology can be inconclusive or non-diagnostic. In such cases, the type of calcification and lymph node nature immediately diverts the attention to thyroid cancer rather than large benign goiters with colloid degeneration as seen in endemic goiters.
Thus, DRES-directed CSI with or without USG offers surgeon with pre-surgical look into the native surgical anatomy. But, the ground reality is surgeon's overdependency on radiologist's interpretation and surgical venture without himself evaluating the radiological films at majority of surgical centers. One of the reasons for this could be surgeon's confidence to deal with any surgical surprise. This fact frequently leads to operative mishaps and complications due to an underprepared and under-equipped surgeon. These practical problems are especially more glaring in non-specialized (oncology) or general surgery units of developing countries. Apart from this, the goiters are larger, thyroid cancer have higher grade and is more invasive than in developed countries. This is probably due to delayed medical consultation, under-literacy, lower socio-economic status and larger benign goiters in iodine deficient geographical areas. Another ground reality is that a huge work load and multi-tasking in most of the radiology departments, forces a resident or junior consultant to give the report, often unsupervised or hurriedly supervised by the senior consultant. Each detailed radiological evaluation of CSI consumes at least 20-30 minutes. That much time for a single case, can be rarely allotted by a senior radiologist in many centers. The time constraint in radiology departments is existent both in developed and developing countries alike.
Only specialized endocrine surgery and oncology units of reputed institutes conduct interdepartmental clinico-radiological sessions and tumor board meetings, frequently enough. The tumor board meets or pre-planning sessions are known to educate the clinicians, radiologists, pathologists, and provide optimal management to patients. These meets are conducted for pre-surgical planning through critical evaluation of CSI films based on clinical information. Despite numerous advantages of this exercise, the fact is that most of the surgical units rarely practice it. Only few experienced general surgeons, head and neck surgeons and specialist endocrine surgery/oncology units perform pre-surgical radiological evaluation as a routine. Lack of this exercise could lead to potential morbidity, inadequate surgery, residual disease, under-staging, and complicates adjuvant therapy or repeat surgery. Most of the radiologist's reports, comments on striking features such as calcifications, gross lymphadenopathy, intrathoracic extent, and intraluminal tracheal invasion. These findings are hardly of any utility to the surgeon as they are obvious to him on plain radiography and clinical evaluation. Subtle and finer radiological details with surgical planning is better performed by the surgeon with experience in radiological evaluation, as it gives the best road map for surgery. The present study objectively highlights the better pickup rate of subtle radiological features by DRES compared to radiologist's report alone. This exercise has the added advantage of first-hand knowledge of clinical picture and neck anatomy from surgeon's perspective. Routine practice of DRES with frequent tumor board and clinico-radiological meets helps in mastering this art. Thus, it facilitates better surgical planning, reserves the radiologist's time for highly selected cases, ensures optimal management and oncological cure.
| » Conclusions|| |
- In high-risk thyroid cancer and large goiters, DRES facilitates optimal surgical resection and superior outcome compared to radiologist report-guided surgery alone
- DRES is especially relevant in developing countries and non-regional cancer centers dealing with thyroid cancer
- In developed countries and specialized regional cancer centers, DRES is complementary to radiologist's evaluation apart from its educative role.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]