One thing we have started to do is that, after we have taken out the thyroid, we will inject indocyanine green dye. We have a specialized fluorescence imaging system in the operating room now that can assess the perfusion, or blood flow, to the parathyroid glands. A recent study from Switzerland showed that if you have at least one parathyroid gland that is well perfused, then you don’t need to worry about the low calcium levels after surgery. Therefore, there are some newer techniques we are using to try to make thyroid cancer surgery safer for patients.
Can you comment on technological advancements in surgery over the last couple years?
We have made a lot of advancements. In fact, it is amazing to think about how far surgery has come from the days of Dr Theodor Kocher 100 years ago. Now, we have a variety of tools to help us make the surgeries safer—nerve monitoring, as I mentioned, and this parathyroid imaging.
However, we also have newer, haemostatic agents that help control bleeding, and there are ways we can dissect through thyroid tissue with special instruments. Believe it or not, some people are even doing remote access thyroid surgery through the armpit or through face lift incisions or even through the mouth; they do this in Thailand. We are only seeing the beginning of a new approach to surgery for thyroid and thyroid nodules.
What significant challenges still exist in surgery for thyroid cancer?
The real challenge is to figure out how much to treat and how much to just observe. If you have somebody with a real tiny cancer, perhaps we don’t have to rush and induce surgery right away. On the other hand, the initial operation for somebody with a larger tumor that may have spread is very important because, if the surgeon can go in and really do a good job the first time around then the patient will hopefully avoid a redo operation, which has its own risks, so we try to do a complete job.
The other thing that is a new improvement in the treatment of [patients with] thyroid cancer is preoperative staging with comprehensive ultrasound. That is being done with surgeons in the clinic, and we want to make sure which lymph nodes may be involved in the tumor before we go in there. This is so we can do a good job with our surgery and make sure that we get [all of the tumor] out. Ultrasounds have almost become an extension of the physical exam, and those ultrasound machines are just getting so good. Surgeons and endocrinologists are getting better at ultrasonography in the clinic so they can do their own needle biopsies and plan out thyroid surgery better.