Professor Akira Miyauchi (Figure 1) is President and COO of Kuma Hospital, Center of Excellence in Thyroid Care, Kobe, Japan. He is a Japanese endocrine surgeon, and a pioneer in active surveillance, and visionary in regard to treatment of thyroid cancer.  World renowned researcher, and lecturer. As the associate professor of the Department of Surgery, Kagawa Medical University, he proposed and initiated a clinical trial of active surveillance for low-risk papillary micro cancer in collaboration with Kuma Hospital in 1993. In 2001, he was appointed the President of Kuma Hospital. Since then, he has been keen on the study of evaluating treatments for papillary micro cancer, observation versus surgery.

During this episode, the following topics are discussed:

1. Financial burden of surgery versus total cost of active surveillance over ten years. 
2. Setting patient expectations prior to FNA to manage anxiety
3. When the laryngeal nerve is severed during thyroid surgery, it can and should be repaired, with proper surgeon skill and training. 
4. Rather than being stationery and immobile, patients should practice neck stretching exercise within 24 hours proceeding surgery.  There should be no fear about separating the incision. 
5. The most common question asked to Dr. Miyauchi by surgeons from around the world. 

Total cost of surgery is 4.1x the cost compared to the cost of active surveillance.  In the U.S., the cost is higher. 

By providing patient an active surveillance brochure prior to FNA, they are more open to not proceeding with surgery for small thyroid cancer management. 

Patient voice restores to near normal when repair of laryngeal nerve is done correctly.  All surgeons should be executing this to perfection.

When doing next stretches one-day post surgery, patients report feeling much better and less pain, even one year after surgery.

Protocol for delaying surgery depends on the patient’s age.  Older patients are less likely to require surgery.  75% of patients will not require surgery for their lifetime. 

NOTES

Akira Miyauchi, MD

American Thyroid Association

35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering

PAPERS and RESEARCH

Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance

Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid.

Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery

TSH-suppressive doses of levothyroxine are required to achieve preoperative native serum triiodothyronine levels in patients who have undergone total thyroidectomy.

Stretching exercises to reduce symptoms of postoperative neck discomfort after thyroid surgery: prospective randomized study.

Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve.

Ezra Cohen, MD, is a board-certified oncologist and cancer researcher. He cares for patients with all types of head and neck cancers, including esophageal, thyroid and salivary gland cancers.

Dr. Cohen is also an internationally recognized expert on novel cancer therapies and heads the Solid Tumor Therapeutics program at Moores Cancer Center. Much of his work has focused on squamous cell carcinomas and cancers of the thyroid, salivary gland, and HPV-related oropharyngeal cancers. As a physician-scientist, he is especially interested in developing novel therapies and understanding mechanisms of sensitivity or resistance; cancer screening; and using medication and other agents to delay or prevent cancer (chemoprevention). He was recently appointed chair of the National Cancer Institute Head and Neck Cancer Steering Committee, which oversees NCI-funded clinical research in this disease.

Dr. Cohen is editor-in-chief of Oral Oncology, the most respected specialty journal in head and neck cancer. A frequent speaker at national and international meetings, he has authored more than 120 peer-reviewed papers and has been the principal investigator of multiple clinical trials of new drugs in all phases of development. 

In this episode, topics include:

• Drug therapy for patients that fail standard therapy; including surgery and RAI
• Not all patients have same behavior for their cancer
• Some cancers are aggressive
• Not many thyroid cancer patients are affected by this; maybe a few thousand in the U.S., but not tens of thousands
• What is the treatment protocol for therapy?
• Lenvatinib or Sorafenib is the treatment for refectory thyroid cancer
• Lenvatinib tends to be more effective
• Sorafenib is tolerated by the patient better
• Other options to consider include, molecular profiling or some thyroid cancers carry mutation that is targetable, or BRAF
• BRAF inhibitors used with thyroid cancer patients
• Molecular profiling
• DNA sequencing
• Side effects include, what patient will feel and those that appear in blood tests
• Side effects include fatigue in 60% patients, hand or foot blisters, nausea and vomiting
• Side effects in blood tests include high blood pressure, increase in liver enzymes, and a reduction in blood counts
• VEGF receptor
• CT scans and ultra sounds or thyroglobulin as an indicator that thyroid cancer not responsive to traditional therapy
• We don’t want to make the patient feel worse; the question is when to treat the patient with drug therapy
• Drug treatment does no cure the disease
• Holidays from the drug and be rid of side effects
• When restarting drug, disease responds again
• Pediatric care
• Immunotherapy

NOTES

Ezra Cohen, MD

American Thyroid Association