Anaplastic Thyroid Cancer Surgery: Extended/Comprehensive (Appropriate) Surgery Is The Only Way.
Anaplastic thyroid cancer surgery is not simple or ever minimally invasive. Only the most experienced thyroid cancer surgeons should every perform an operation for anaplastic thyroid cancer. In almost every instance which I have operated on an anaplastic thyroid cancer, one of the nerves to the voice box has already been invaded by the anaplastic thyroid cancer and paralyzed half of the voice box. You should not be concerned over this event. You can continue to have a voice although its quality may be hoarse. Often times, the quality of the voice can be improved in patients with anaplastic thyroid cancer following the completion of their treatment.
Anaplastic thyroid cancer surgery has no bleeding associated with it. Literally, a teaspoon or two of blood may be lost in these surgeries. But don’t get me wrong. It must be an extensive surgery. Anaplastic thyroid cancer surgery for the thyroid requires removing all of the thyroid that is involved with the cancer! But unlike other thyroid cancers, although total removal of the thyroid gland (total thyroidectomy) is often appropriate, but it is not always necessary. If the other side of the thyroid gland is not involved with anaplastic thyroid cancer or any other type of nodule or mass, it need not routinely be removed. In that way, the uninvolved nerves of the voice box and glands that control calcium (parathyroid glands) are at no risk whatsoever. The anaplastic thyroid cancer almost uniformly will grow outside of the thin capsule of the thyroid gland and extend into muscles of the neck and esophagus. It often grows into the nerve of the voice box (the recurrent laryngeal nerve) and superficially or deeply may grow into the trachea. Because the surgery on the anaplastic thyroid cancer effected side of the gland will be almost always so extensive, sometimes less on the other side of the gland can be a sound approach. Again, these types of decisions must be made by the most experienced thyroid cancer surgeons.
For anaplastic thyroid cancer of the thyroid to be cured, surgery is the most critical first treatment. In fact, if anaplastic thyroid cancer surgery is not feasible, there is currently no known cure for this disease. It cannot be emphasized enough, that only the most experienced thyroid cancer surgeon is obtained immediately. Anaplastic thyroid cancer surgery should only be done by the most expert of thyroid cancer surgeons. Lesions that are highly suspicious for a risk of anaplastic thyroid cancer (even if under the microscope it may be called “poorly differentiated thyroid cancer”) should be removed with the same surgical approach as for an anaplastic thyroid cancer! The surgery for anaplastic thyroid cancer is often a total or near total thyroidectomy. This type of thyroid surgery should only be performed by highly experienced thyroid cancer surgeons.
Most importantly, if the anaplastic thyroid cancer has not yet spread to distant sites, by choosing the right expert thyroid cancer surgeon and surgery, you can potentially be cured. The wrong choice in surgeon is not correctable!
Thyroid surgery was one of the first ever described surgeries in medicine, but early on it wasn’t very pretty or safe. Over the past 100 years, thyroid surgery has evolved into its current state of the art by some of the most recognized names in surgical history. Today, in skilled hands, anaplastic thyroid cancer surgery may be considered an art form in its own right.
Anaplastic thyroid cancer surgery must be considered in several different lights when you think about the neck:
- Surgery of the thyroid gland itself
- Surgery for the surrounding soft tissues around the thyroid gland
- Surgery for the lateral and central compartments of the neck
Anaplastic thyroid cancer was once thought to be the worst type of differentiated papillary thyroid cancer. Clearly, some anaplastic thyroid cancers appear to develop within long standing existing papillary thyroid cancers. However, other anaplastic thyroid cancers appear to develop in a different manner within the thyroid gland. Whether one of these may be more favorable than the other remains to be determined. However, whichever pathway the anaplastic thyroid cancer appears to develop from probably makes little to no difference regarding the aggressive nature of the cancer. One thing for certain, it certainly makes no impact upon current treatment approaches especially the extent of surgery.
Anaplastic thyroid cancer has a predictable ability to grow into adjacent structures in the neck as well as spread into the lymph nodes of the neck. The surgery for anaplastic cancer of the thyroid must be a true three dimensional removal of the cancer. What I mean by that is that the surgery must get “all around the anaplastic thyroid cancer”. Therefore, for an anaplastic thyroid cancer, the thin muscles that lay on top of the thyroid gland need to be removed with the cancer. These muscles have very little functional importance and most patients note no functional outcome with their removal. It does make the front of the neck slightly concave and the trachea is more noticeably under the skin when you are done healing.
In removing an anaplastic thyroid cancer, the other areas to “get around” are a little more tricky. One big difference between these cancers is that anaplastic thyroid cancer has a significant ability to spread to local lymph nodes, especially underneath the thyroid gland. These lymph nodes are involved in almost all anaplastic thyroid cancers. Even if they are not involved by the spread of anaplastic thyroid cancer, they still need to be removed since the anaplastic thyroid cancer can growth directly into them. Now some things are not reasonable to be removed with an anaplastic thyroid cancer when you attempt to “get around the cancer”. The expert thyroid cancer surgeon needs to make important surgical planning and approaches to dealing with the critical blood vessel like the carotid artery, and the trachea, voice box, and esophagus. These structures need to be preserved in anaplastic thyroid cancer surgery but still providing a high likelihood of removing all of the anaplastic thyroid cancer or at least just leaving microscopic remaining cancer cells. If this sounds complicated, it is but this is the importance of having your anaplastic thyroid cancer treated by an expert thyroid cancer surgeon.
If anaplastic thyroid cancer is incompletely removed following the first surgery, this is called persistent anaplastic thyroid cancer. There is no more meaningful surgery that can then be performed. You only have one opportunity to operate on anaplastic thyroid cancer, make sure it is with a truly expert thyroid cancer surgeon!
If anaplastic thyroid cancer comes back after the first surgery, this is called recurrent anaplastic thyroid cancer. In these instances, there is no ability to perform another surgery which will be meaningful for the patient. There may be the ability to operate but it will not offer the anaplastic thyroid cancer patient any opportunity for cure.
The basic concept is very simple, remove all of the anaplastic thyroid cancer during the first and only surgery!!!
- One is removal of about half of the thyroid gland. This is called a thyroid lobectomy.
- The other is removal of all of the thyroid gland and is called total thyroidectomy.
- The third type of thyroidectomy is called a subtotal thyroidectomy where almost all of the thyroid gland is removed
(Editors note: Subtotal thyroidectomy is largely a surgery for removal of thyroid goiters and is not a commonly indicated surgery. Almost all anaplastic thyroid cancers are treated primarily with removal of the entire thyroid gland (total thyroidectomy) or subtotal thyroidectomy.
Editors note: In very rare circumstances, an anaplastic thyroid cancer will be discovered on final pathologic review of a surgical specimen without knowledge that it was present before the surgical procedure. The first thing to do in such a circumstance is to make sure that an expert thyroid cancer pathologist has reviewed the microscopic examination of the specimens. The second thing to do is to not take this diagnosis lightly. It may be possible that the surgery just coincided with establishment of this very aggressive cancer. These “favorable” anaplastic thyroid cancers may be curable but certainly require interdisciplinary thyroid cancer team evaluation and treatment planning.
One issue that is critically important in the understanding of the treatment of anaplastic thyroid cancer is that the blood marker of thyroid, thyroglobulin, may rarely be detectable with this cancer, but thyroglobulin (or any other protein for that matter), are generally not used in the follow-up of anaplastic thyroid cancer patients.
Anaplastic thyroid cancers are generally quite large and almost never found early in their disease course. In reviewing, anaplastic thyroid cancer staging, you will see that there is no such thing as “early” anaplastic thyroid cancer disease. Although, in concept, an anaplastic thyroid cancer may be so small and the remainder of the thyroid gland may be so normal that a thyroid lobectomy would be a potentially appropriate surgery, however I have never seen such an instance in my entire professional career and I have also not heard of a case as well.
In this surgery, about half of the thyroid gland is removed. A small incision in the lower neck is required which is about two inches in length unless the thyroid mass requires a longer length to allow it to be “delivered”. Even if the plan in surgery for an anaplastic thyroid cancer is removal of only half of the thyroid gland, the surround central compartment lymph nodes should be removed with the some side of the thyroid gland. Additionally, at least the muscle which lays immediately on top of the anaplastic thyroid cancer should be removed even in the most favorable of anaplastic thyroid cancer cases. For an anaplastic thyroid cancer, undergoing a thyroid lobectomy, I would prefer to have a good complete excision of this most severe cancer more than saving either of the adjacent parathyroid glands. If the parathyroid glands on the side of the anaplastic thyroid cancer are quite distant from the cancer, they can be spared or autotransplanted. In anaplastic thyroid cancer surgery, it is better to be cautious and not retain parathyroid tissue if there is even remote concern that anaplastic thyroid cancer cells may be present in the immediate vicinity of retained or transplantable parathyroid tissue. Unless the anaplastic thyroid cancer is directly invading either of the critical nerves that provide movement and sensation to the voice box, they should be spared. Although this sounds like straight forward surgery, there is only one opportunity to defeat anaplastic thyroid cancer with surgery!! Anaplastic thyroid cancer patients most important task is to do their homework and choose the right surgeon to do the right surgery.
Editors note: A thyroid lobectomy is not recommended when anaplastic thyroid cancer patients have nodules present in both sides of the thyroid gland or you have a greater than 2 centimeter anaplastic thyroid cancer (almost always anaplastic thyroid cancers are large when they are diagnosed).
- A very effective surgical treatment for small (up to 2 cm or 1 inch) anaplastic thyroid cancer patients.
- The lymph nodes on the side of the thyroid surgery should be removed comprehensively with the cancer on the same side of the cancer
- Cosmetically acceptable incision design
- Essentially little to no risk of hypoparathyroidism (low blood calcium)
- Outpatient surgical procedure
- Return to normal aerobic activities and daily functions in 24 hours.
- No heavy lifting for three weeks
- Remaining thyroid tissue facilitates ease in thyroid hormone regulation.
- Thyroglobulin is really not a blood marker for anaplastic thyroid cancer therefore retained thyroid tissue producing thyroglobulin is not an issue.
- Only one nerve to the voice box is even at theoretical risk of injury.
- Procedure need not be converted to total thyroidectomy if spread to lymph nodes since radioactive iodine therapy plays literally little to no role in the management of anaplastic thyroid cancer patients.
For anaplastic thyroid cancer, total thyroidectomy is frequently the preferred surgery. In this surgery, the entire thyroid gland is removed. A small incision in the lower neck is required which is about 2 inches in length unless the anaplastic thyroid cancer requires a longer length to allow it to be “delivered”. Most anaplastic thyroid cancers are 4 cm or greater and therefore the respective incision must be long enough to accommodate the largest dimension of the anaplastic thyroid cancer or thyroid itself. In anaplastic thyroid cancer surgery, all of the critical nerves that provide movement (recurrent laryngeal nerves) and sensation to the voice box (superior laryngeal nerves) are spared unless directly invaded or functionally involved with the cancer. The lymph nodes along the side and beneath (and the thin overlying muscles covering) the anaplastic thyroid cancer are also removed with the anaplastic thyroid cancer during this surgery to make sure that they are not cancerous as well as making sure that all of the direct extension of the anaplastic thyroid cancer has been removed and adequately addressed .
- The anaplastic thyroid cancer is more than 2.0 centimeters or 1 inches
- The anaplastic thyroid cancer appears to have extended outside of the surface of the thyroid gland (called its capsule)[almost always the case]
- The anaplastic thyroid cancer has spread to the lymph nodes underneath the thyroid gland (called central compartment lymph nodes [also called Level VI or VII lymph nodes] of the neck) or the lateral neck. This is almost uniformly found in anaplastic thyroid cancer patients!
Extended or Complicated Thyroidectomy
Anaplastic thyroid cancer almost always is aggressive locally when it initially presents. Imaging prior to surgery such as ultrasound or CT frequently detects these aggressive anaplastic thyroid cancer’s extension. In some instances, imaging may not adequately predict this invasive component of the anaplastic thyroid cancer. Let me tell you, there is no such thing as a “good” anaplastic thyroid cancer. For anaplastic thyroid cancer, there is no second chance for surgery. The first surgery must be the right surgery and the only surgery!! In anaplastic thyroid cancer, an expert thyroid cancer surgeon that recognizes the typical anaplastic thyroid cancer “more aggressive” intraoperative findings such as growth or extension of the cancer outside of the thyroid gland or invasion of the cancer into adjacent structures such as the nerve to the voice box (recurrent laryngeal nerve), breathing tube (trachea), voice box, or esophagus-must adapt the surgery to adequately address the complete removal of the cancer. Unfortunately, most thyroid surgeons are commonly unprepared to perform the appropriate surgery and another meaningful surgery for anaplastic thyroid cancer is not feasible following an incomplete initial surgery.
Anaplastic thyroid cancer Surgery for Central Compartment Lymph Nodes (the lymph nodes beneath and surrounding the thyroid gland, breathing tube (trachea) and swallowing tube (esophagus)
The removal of the lymph nodes of the central neck should be performed initially when the thyroid gland is removed in the treatment of anaplastic thyroid cancer on the side of the cancer. Central compartment dissection extends from the carotid arteries on both sides of the neck, below to the blood vessels of the upper chest, and above to where the blood vessel of the upper portion of the thyroid gland begins off of the carotid artery (called the superior thyroid artery).
In anaplastic thyroid cancer, the central compartment neck dissection is more commonly seen as a method of three dimensionally “getting around the cancer” more often than just removing the lymph nodes themselves.
- In anaplastic thyroid cancer, the central compartment lymph nodes are at risk of containing cancer in at least 90% of patients. That risk increases with the size of the anaplastic thyroid cancer. Even prior to surgery, most central compartment lymph nodes can be well examined with high quality ultrasound to determine if they are cancerous. Enlarged or abnormal lymph nodes seen on ultrasound next to the thyroid gland before surgery should be examined. These abnormal lymph nodes undergo fine needle aspiration (FNA) examination to determine whether anaplastic thyroid cancer is present. Frequently, in anaplastic thyroid cancer, the neck lymph nodes may be more informative when the cells are looked at under a microscope than the cells of the thyroid gland itself.
- In anaplastic thyroid cancer surgery, preservation of nerve function which is not involved by the cancer is of the most critical importance. In every patient that I have operated on for anaplastic thyroid cancer, one of their nerve’s to the voice box was already paralyzed before I did their surgery. You must understand that if both nerves to the voice box are paralyzed in any patient, they likely will never be able to breath adequately unless they have a breathing tube in the neck (called a tracheostomy). Only the most expert thyroid cancer surgeon should ever perform anaplastic thyroid cancer surgery. Anaplastic thyroid cancer surgery not performed by a true expert risks tracheostomy, permanent loss of calcium control in the body, and inability to ever control the cancer! If you or your loved one has an anaplastic thyroid cancer, only let an expert promptly evaluate you and consider surgery!
- In larger anaplastic thyroid cancers which are greater than 2 centimeters (less than an inch!), a very extensive removal of the lymph nodes of the central compartment on the side of the cancer should be always done:
- In anaplastic thyroid cancer there is only one chance for surgery cure. The expert anaplastic thyroid cancer surgeon understands exactly what needs to do done at the time of surgery. There is no margin for error. In the rare circumstance that the nerve to the voice box (recurrent laryngeal nerve) has able to be spared, then all of the surrounding tissue which is both lymph nodes and fatty tissue and a thin muscle on top of the thyroid gland must be removed with the thyroid and cancer. If you can possible imagine, the best anaplastic thyroid cancer surgery would be one that I never really see or touch the anaplastic thyroid cancer throughout the surgery. In that way, the expert anaplastic thyroid cancer surgeon has completely gone around the cancer!
- The risk of anaplastic thyroid cancer going to the lymph nodes in the central neck is over 90%. The removal of these local lymph nodes with anaplastic thyroid cancer also allows surgery to “get around” the cancer.
Anaplastic thyroid cancer Surgery For Spread of Cancer to Lymph Nodes Along The Side Of The Neck (anterolateral neck)
- Just the presence of enlarged lymph nodes does not mean anaplastic thyroid cancer has spread and does not require additional surgery
- A procedure called an anterolateral neck dissection (or modified neck dissection), in untreated patients, should only be performed when:
- ultrasound with fine needle aspiration confirmed anaplastic thyroid cancer spread to lymph nodes in the side of the neck
- the anaplastic thyroid cancer is so large that the expert thyroid cancer surgeon must “get around” the cancer by identifying all the structures to save in the anterolateral neck. This includes the carotid artery, jugular vein, critical nerves to the voice box, critical nerve to the diaphragm (bellows of the lung), nerves to the upper shoulder and arm….just to name a few. Now you understand why you truly need an thyroid cancer surgery expert.
- The anaplastic thyroid cancer anterolateral neck dissection is not the same neck dissection as for other cancers that occur in the neck. All thyroid cancers spread to particular areas of the neck called levels. Removing just some of the lymph nodes has been called “cherry picking” and is the wrong surgery! A thyroid cancer expert surgeon trained and experienced to perform modified neck dissections specifically for anaplastic thyroid cancer is needed to potentially cure this dreaded cancer. There is no second chance to cure anaplastic thyroid cancer!!!
- The anterolateral neck dissection, in skilled hands, spares all critical nerves, muscles, and blood vessels which are not directly involved with cancer (critical structures may be involved by anaplastic thyroid cancers). In anaplastic thyroid cancer surgery, only directly invaded critical structures need to removed. Only an expert anaplastic thyroid cancer surgeon should make such critical decisions. Anaplastic thyroid cancer neck dissection is an approximately 40 minute surgery that removes lymph nodes and fatty tissue.
- In some circumstances, anaplastic thyroid cancers may show extensive growth into the the soft tissues of the neck. In such circumstances, a special surgery that can “get around” the anaplastic thyroid cancer can be safely performed to remove all of the cancer by an expert thyroid cancer surgeon.
Anaplastic thyroid cancer Surgery in Sites Other Than The Neck
Anaplastic thyroid cancer surgery is uncommonly proposed as a treatment approach when disease has spread to distant sites. Although surgery is not commonly proposed for distant spread of anaplastic thyroid cancer, consideration for surgery for distant disease is based upon the expert thyroid cancer team evaluation and considers the following issues:
- Where is the anaplastic thyroid cancer distant disease located?
- What are the risks and benefits of surgery?
- Are there other sites of distant spread?
- What anaplastic thyroid cancer treatments have already been used?
- What were the outcomes of other treatments for the anaplastic thyroid cancer?
- How fast is the anaplastic thyroid cancer growing?
- What are the patient’s treatment desires?
- What are the other treatment options?
- What are the anaplastic thyroid cancer genetic mutations found?
Anaplastic thyroid cancer Robotic Surgery
Robotic surgery for the thyroid was developed largely in South Korea and brought to the United States several years ago as a “tool” in thyroid surgery. Its proposed benefits were to be the following:
- Absent or less noticeable neck incisions
- Improved visualization
- Less Surgeon Fatigue
Although we have been trained and performed robotic thyroid surgery, the following is the reality of robotic thyroid surgery:
- Incisions are tremendously longer but just not located on the front of the neck
- In anaplastic thyroid cancer, it is the wrong surgery! You risk spilling the cancer!
- Anaplastic thyroid cancer that is able to undergoe surgery, must also have immediate post surgical chemotherapy and radiation therapy. The radiation treatment field would have to include the entire area of surgery from underneath the arm to the entire neck. This should never be done!
- In anaplastic thyroid cancer there is only one chance for surgery and this is the wrong surgery!
- Multiple surgeons are required
- The surgeon has no ability to “feel” in the neck. The fingers are the surgeon’s third eye. Subtle changes in feel, hardness or extension of cancer can be totally unappreciated.
- It is not minimally invasive by any measure. It is maximally invasive but just at a distance from where the surgery is focusing.
- It is a much longer surgical procedure by any measure (the set up of the robot is longer than the average thyroid lobectomy).
- It is an inferior surgical approach to manage anaplastic thyroid cancer
- Unanticipated findings during surgery may not be able to be adequately addressed robotically.
- It may be an acceptable surgical approach for clearly known benign thyroid surgery. Anaplastic thyroid cancer is one of the most aggressive cancers known to mankind!
Most importantly, the ability to perform a surgery well, is not an indication for a surgery!!! Robotic thyroid surgery is never indicated in managing anaplastic thyroid cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer.
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