INTRODUCTION
We are quite familiar with the COVID-19 epidemic and its unprecedented
implications. It has clearly changed our lives, healthcare, clinical
practice, urgency of the health problems, financial implications and
mental health. The issues of mental health are applicable both to the
patients and healthcare providers. Obviously, we need to pay special
attention to the patients suffering from COVID-19 especially those who
are symptomatic or having major health crisis such as pulmonary issues
and multiorgan failure.
As of the 8th of April, globally there have been
approximately 1.52 million confirmed cases of COVID-19 of whom 90,000
are dead. In the United States, the confirmed COVID-19 cases are
reported to be 435,564 while the reported deaths are 14,829. New York
State has faced the major brunt of this pandemic with confirmed cases of
147,037 and death number of 6,220.
In spite of this major health crisis patients are always concerned about
their own problems in relation to other health issues especially with
fear of proven or suspicious cancers. Clearly, some of the cancers are
life-threatening and will require urgent attention while other tumors
may be monitored or treated at a later date when the COVID-19 issues are
relatively settled. In a referral center or a tertiary care cancer
center it is fairly common to receive consultations regarding thyroid
problems or thyroid tumors.
Even though, there are no set guidelines in the management of patients
asking for thyroid surgery it would be appropriate to manage these
patients based on the risk group analysis and the overall risks of
progression to life-threatening issues. We need to explain every patient
that thyroid tumors grow slowly and there is no need for active and
emergent intervention. It is quite appropriate to wait for 4-6 months.
If the patient is extremely anxious a follow up ultrasound may be
performed in 3-4 months to document the stability of thyroid tumor. We
have divided thyroid cancer patients for almost 50 years into low,
intermediate and high-risk groups based on their prognostic features1. We popularly described this as good, bad and ugly
tumors. The prognostic factors were described as age, grade of the
tumor, size of the tumor, extrathyroidal extension, distant metastases,
etc. Other prognostic factors such as multiple lymph node metastases and
the molecular analysis should go into the equation of management of
these patients. Needless to say, patients are extremely concerned for
the fear of any cancer whether it is thyroid or pancreatic cancer. It is
our responsibility to explain to the patients the concern about these
cancers on their overall prognosis and the best timeline definition for
active intervention. The new American Thyroid Association guidelines
published in 2015 have done a fantastic job in line with the biology of
these tumors and appropriate management 2. As a matter
of fact, the ATA endorsed observation as a definitive approach in proven
microcarcinomas. This clearly reflects the management of these tumors in
relation to their biology and avoiding over treatment. Let the
punishment fit the crime or let the treatment not be worse than the
disease is quite appropriately applied to thyroid cancer. However, it
would be important to define certain indications and road map of active
management of some these thyroid cancers. If we use the analogy of
management of thyroid cancer during pregnancy and delaying the treatment
by 9-10 months, it would be the same philosophy of managing these
patients during the COVID-19 pandemic. Clearly, some patients will
require urgent or active intervention in a timely fashion. The following
summary will describe some of the decision-making issues.
- Anaplastic Thyroid Cancer – patients with rapidly growing
thyroid tumors with proven anaplastic thyroid cancer will obviously
require emergent management. The decision regarding surgical
intervention should be made based on the extent of the disease and
cross-sectional imaging. Appropriate BRAF based therapies and external
radiation therapy should be implemented.
If the tumor appears to be unresectable there is no reason to bring
these patients to the operating room. The definitive diagnosis could
easily made with ultrasound guided core biopsy, and appropriate
immunohistochemistry. The issue of airway management is always a
difficult problem in anaplastic thyroid cancer and more so during
COVID-19 pandemic. Obviously, testing the patient for Covid-19 is
important since patient may require either active airway intervention
or hospitalization with concern of exposing healthcare workers. As
mentioned in the first anaplastic thyroid cancer guidelines, elective
tracheostomy is best avoided however may be necessary if the patient
is having acute airway distress 3. A due
consideration should be given to controlled cricothyrotomy.
- Medullary Thyroid Cancer – Appropriate evaluation of extent
of the disease with calcitonin, CEA, ultrasound and cross-sectional
imaging is very important before consideration of timely surgical
intervention. If the disease appears to be limited and calcitonin
levels are not high (under 400) patients can be monitored for a few
months without surgical intervention hoping for COVID-19 peak to
settle. Generally, medullary carcinoma is a chronic disease and
observation with close monitoring would be quite appropriate until the
social circumstances get better. Obviously, this will require
extensive discussion with the patient and the family which can be
easily done even by phone conversations or Facebook. A discussion
directly by responsible attending surgeon would give a lot of
confidence to the patient and the family. They need to understand that
waiting for the best time for surgery is unlikely to hurt them or lead
to major progress of the disease. The prognosis essentially would
remain the same.
- Locally Aggressive Thyroid Cancer – These are the patients
who will require detailed evaluation of the extent of the disease, its
involvement in relation to the central compartment vital organs such
as recurrent laryngeal nerve, trachea, esophagus, and major vascular
structures. Appropriate cross-sectional imaging will be of great help.
If patient does require fiberoptic evaluation it would be best done
with the hospital guidelines and appropriate protection to the
healthcare staff. Obviously, COVID-19 testing would be important prior
to any active intervention. The decisions about surgery in light of
COVID-19 pandemic would be quite critical as to how long we can delay
the surgical procedure without compromising the total surgical
resection and encroachment on vital central compartment structures.
The decisions may be slightly different if the preoperative FNA has
resulted in poorly differentiated thyroid cancer. It would be quite
appropriate to discuss some of these cases with our colleagues in
multidisciplinary team since we are able to hold virtual tumor boards.
Avoiding surgical compromise is important in these patients however
waiting for a reasonable time would not be inappropriate.
- Patients with Large Primary Tumors and Bulky Nodal Disease –
The history of the presence of tumor and the duration of the nodal
metastasis would be quite helpful to project the best timing of
surgery in these patients. Again, appropriate cross-sectional imaging
and approximation of the tumor to the vital structures is critical in
making the best decision regarding appropriate timing of surgery in
these patients.
- Low and Intermediate Risk Thyroid Carcinomas – These
patients can wait for surgery for a period of time (3-6 months) until
we have a better handle on COVID-19, and they are not a risk to the
healthcare workers. If the patients need extended period of
observation, a repeat imaging with ultrasound in 3-4 months will
encourage the patients to delay the surgery further.
- Microcarcinomas – As reported by a large series of patients
from Kobe, Japan; Sloan Kettering, these patients with microcarcinomas
can definitely be observed 4,5.
Most of these patients can be encouraged not only to delay the surgery
but to remain under active surveillance or deferred intervention.
Again, appropriate ultrasound will define the exact location of the
disease and need of active intervention.
- Recurrent Thyroid Carcinoma – The majority of the
recurrences especially in the central compartment nodes or lateral
neck nodes are essentially the persistent diseases. They could be
observed for an extended period of time with repeat imaging studies in
4-6 months. The only time one would consider active surgical
intervention, if the tumor is plastered against the trachea for the
fear of future encroachment into the trachea. Alternate treatment
choices such as alcohol injection, radio frequency ablation may be
considered for localized nodal recurrences.
- Indeterminate Thyroid Nodules – most of these patients will
be in the group of Bethesda III and IV categories. These patients can
be easily monitored and if the tumors are small even if they’re BRAF
or TERT positive, could be monitored for a period of time before
active surgical intervention. The positivity of the molecular markers
and the quantification of the risk of malignancy is not a determinate
for emergent surgical intervention.
- Large Goiters – the majority of the large goiters have
generally been there for a long period of time and surgery could be
easily avoided even with tracheal deviation and mild compression
unless there is a rapid progression, major compression symptoms or
impending acute airway issues.
- Benign Thyroid Conditions – benign thyroid nodules,
Hashimoto’s thyroiditis, or Graves’ disease could be managed
appropriately as before and probably may not be in-person
consultation. The majority of these patients can be easily consulted
on telephone, Skype or Facetime which will give patients a sense of
confidence and make them feel that the treating physician is actively
involved in their care and follow up.
The guidelines recommended by ATA for fine needle aspirations of
incidental thyroid nodules should be applied vigorously. It would be
best to avoid FNA on smaller and non-suspicious thyroid nodules.
- Moral Dilemma – I am sure there will be many discussion
points in above recommendations.
These are not written in any of the textbooks or guidelines. These are
clinical observations during the early period of COVID-19 pandemic.
Hopefully, God willing, the pandemic will be over soon, and we will go
back to our regular clinical practices. However, until then, it is our
responsibility to manage our patients best, give them a full sense of
confidence and avoiding major progression of their tumors and
life-threatening issues. We also have a responsibility to the
healthcare workers who take the major brunt of exposing themselves to
the COVID-19 which may become lethal in a few individuals. This
definitely raises a major new dilemma to the healthcare workers. Every
profession has certain risks and concerns. For example, a frontline
army personnel, a firefighter, or a policeman where both the
individuals and their families are aware about the life-threatening
risks. However, until the COVID-19 pandemic occurred nobody realized
the life-threatening risks to the healthcare workers. This clearly
creates a major social and ethical dilemma amongst healthcare workers
and their families. Even though the non-essential staff can work from
home, the essential staff such as frontline healthcare workers have to
be exposed themselves to proven and unproven COVID-19 patients. This
may lead to major ethical issues and mental depression amongst
healthcare workers. What would be the answer to the 10-year-old child
when he tells his father, “Dad, please don’t go to work. I’m afraid
you may catch COVID-19 and you are the only one I have.”
We don’t have the answers to these questions, however, I would like to
salute the frontline healthcare workers who have been actively involved
in offering the best medical care to the patients suffering from
COVID-19 and offering them and the society a Glimpse of Hope. These are
the true Noble Laureates.
References:
- Shaha, AR. Implications of prognostic factors and risk groups in the
management of differentiated thyroid cancer. Laryngoscope. 2004, 114;
393-402.
- Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov
YE, et al. 2015 American Thyroid Association – Management guidelines
for adult patients with thyroid nodules and differentiated thyroid
cancer; the American Thyroid Association Guidelines Task Force on
Thyroid nodules and differentiated thyroid cancer. Thyroid. 2016, 26;
1-133.
- Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Berman KD et al,
American Thyroid Association Guidelines for Management of patients
with anaplastic thyroid cancer. Thyroid. 2012, 22; 1104-39.
- Miyauchi, A. Clinical trials of active surveillance of papillary
microcarcinoma of the thyroid. World J Surg. 2016, 40; 516-22.
- Tuttle, RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S et al,
Natural history and tumor volume kinetics of papillary thyroid cancers
during active surveillance. JAMA Otolaryngol Head Neck Surg. 2017,
143; 1015-1020.