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History, Physical examination, risk stratification, structural and functional assessment helps in identifying malignant nodules - Jatin Shah.

Prof. Jatin Shah from Memorial Sloan-Kettering Cancer Center in New York City USA and Dr. David Monro Smith Professor of General and Endocrine surgery at Ninewells Hospital, Dundee UK were the two distinguished Master trainers and Clinical coordinator at the Fourth Surgical Week for Endocrine Diseases organized by Surgical Division of JPMC Karachi from May 14-17, 2017. As usual it attracted surgeons from all over the country including some postgraduates for whom this was an excellent opportunity to listen the world renowned surgeons. There was no Registration Fee which needs to be commended. Such miracles can only happen at a public healthcare facility but unfortunately both print and electronic media has seldom appreciated such efforts aimed at building the professional capacity of healthcare professionals.

During the four day course, there were numerous presentations on various important topics in Thyroid Surgery and Endocrine Diseases besides live demonstration of various surgical techniques from the Operation Theatre to the auditorium utilizing the latest advances in information technology. All this costs lot of money but the organizers deserve appreciation who make it possible every year.

Diagnosis and Work up of Goiter

Prof. Jatin Shah's first presentation in the course on Day-1 of the course was on Diagnosis and Work up of Goiter. He pointed out that in this part of the word we see patients from Stage -5 to Stage-12 and hardly see those who can be classified in Stage-1 or II or III for that matter. This emphasizes the importance of early identification, early referral which will affect the ultimate outcome and may improve prognosis. He advised the participants to start with a clean slate and do not learn bad habits and attitudes in their professional career. The number of thyroid nodules increase with age. Ultrasound will show thyroid nodule in asymptomatic patients. In Korea it is official policy that everybody will have an ultrasound. About 5-10% of all nodules are malignant. Speaking about papillary micro carcinoma he said its prevalence in Finland and Japan was about 25-30% while in Canada it was between 10-15%. Studies have shown that 17.5 Million people in United States have thyroid cancer.

We have still detected 2% of the cancers present in the population and half of these are micro carcinomas. Majority of the patients remain untreated.

Most thyroid cancers, Prof. Jatin Shah stated are slow growing clinically. Thyroid diseases are very common. The nodularity is less common which is about 4-5% in the general population. There are chances that 10-15% of solitary nodules will have cancer characteristics. They can be diagnosed by clinical examination, through needle biopsy and on imaging or during surgery. Identifying malignant nodules is our main concern. History and physical examination will give you risk stratification. He also referred to structural assessment, functional assessment. Thyroid nodule patients with low risk should be kept under observation and clinical follow up and do cytological investigations but in high risk cases, management has to be more aggressive. Patients with prior radiation exposure with mixed cystic/solid nodules is a high risk.

Medical uses of radiation for various diseases like Thymus enlargement, Tinea capitis, Tonsillitis, Cervical adenitis, Bronchitis, Hemangioma, Cystic acne, Eustachian tubes etc., was very popular during 1900-1960 but no more. It is important to ask for radiation history from the patients. Radiation exposure, male, old age, nodule at young age, rapid increase in size, previous thyroid cancer, lymphadenopathy, Evidence of local invasion, vocal cord paralysis, dysphagia, firm and fixed nodules are some of the high risk factors for thyroid cancer. Some patients may have dysphagia, firm or fixed nodules. He also talked about familial syndrome, with ultrasound of thyroid one should look for additional nodule. Palpate the thyroid nodule, ultrasound guided FNA is extremely helpful. He then showed some ultrasound images of papillary thyroid cancer, Hashimoto Thyroiditis, cervical lymph node and discussed in detail the characteristics of high risk and low risk cancer.

He advised to do TSH and T4 in functional assessment of thyroid. He also showed normal and suppressed TSH scans. Hot nodules account for less than 5% of all nodules and they are rarely malignant. Nuclear medicine thyroid scan is useful. His suggestion was that one should not do thyroid antibodies test, serum calcitonin routinely as their yield is very low. History, physical examination and ultrasound will determine whether the patient should go for surgery or not. FNA is not required of all thyroid nodules if they are less than one cm. It is also not required for cystic lesions. Almost 70% of FNAs are benign, 5-10% are suspicious, and 3-5% are malignant while in 10-20% of cases the report is inadequate. If there is no cancer, no need to operate. If you wish to support science and you have lot of money to throw, go for genome studies. I myself do not do it even in patients who can afford that.

Giving details about clinical approach to nodular management, Prof. Jatin Shah said the patient factors include unwillingness to accept the risk of malignancy, desire to avoid surgery, significant medical comorbidities and age, other risk factors like family history, radiation. The sonography factors consist of nodules more than 4cm, features suspicious for malignancy, suspicious central compartment nodes. Cytological factors include one must know their institutional experience, review all outside slides, AUS/FLUS may not have the same risk of malignancy. Talking about molecular markers Prof. Jatin Shah opined that one should consider Afirma GEC in patients where some of the above indicate surgery which you would rather not perform, consider oncogene panel when observations is preferable but real concern about missing a malignancy or to decrease need for completion of thyroidectomy. Finally mutational analysis should be used only to detect malignancy not to make extent of treatment decisions, he remarked.

During the discussion it was pointed out that FNAC is now becoming very popular in United States and how it was being done routinely. It was the responsibility of the surgeons to train good cyto pathologists. They should send samples to the cyto pathologists which will help them in reporting. Try to get more information through cytology with histopathology. Frozen section is not going to help in some cases. In United States, it is the technicians who are doing these imaging studies not the radiologists, hence we look at the image ourselves rather than relying solely on the cyto pathologist reports because radiologists have not examined the patient and they also do not know the history. Hence, I do not worry about the reports by the radiologist. History is very important hence all images should be interpreted by surgeons. If they do not do it, surgery will be hazardous. Prof. Tariq Mahmood remarked that in Pakistan it is the radiologists who mostly do the Thyroid ultrasound and write reports.

Prof. Jatin Shah stated, Who is doing ultrasound is extremely important. The situation can be different in different countries. Who is doing ultrasound of thyroid nodules matters? Benign goiter will remain benign and rarely becomes malignant. If the nodule is growing and patient feels pressing symptoms, it is important to take it out.

Earlier in the brief inaugural session, Prof. Mumtaz Maher who started this academic activity at JPMC many years ago speaking on the occasion said that he was glad to see that Dr. Shamim and Dr. Naseem Baloch have continued this and invite master trainers every year benefitting many surgeons. A large number of distinguished colorectal surgeons and Thyroid surgeons have come to this course from all over the world. They come and teach us and it helps large number of young surgeons who cannot afford to go abroad for training. These surgeons come to Pakistan to teach and train us despite the advisory against travel to Pakistan which was very courageous on their part and we appreciate all that. Prof. Mumtaz Maher hoped that these courses will improve the surgical skills of the participants helping improve patient care.

Dr. Naseem Baloch introduced the Master trainers form overseas and said that Prof. Jatin Shah from Memorial Sloan-Kettering Cancer Center in New York City USA is a world renowned surgeon. He has three hundred fifty papers, seventy five book chapters and eleven books to his credit. Similarly Dr. David Monro Smith Professor of General and Endocrine surgery at Ninewells Hospital, Dundee UK is a distinguished surgeon with seventy five papers and five book chapters to his credit. Our objective is to improve the endocrine surgery we are doing learning from these patient outcome. Hence it is important that we enhance our surgical skills. Dr. Shamim Qureshi welcomed the distinguished guests and course participants. As usual there was no registration fee for this course and all the expenditures are being met through donations and assistance by the pharmaceutical companies to whom we remain grateful, Dr. Shamim Qureshi added.
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Publication:Pulse International
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Geographic Code:4EUUK
Date:Jun 15, 2017
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