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\begin{document}

\title{Thyroid Surgery during COVID-19 Pandemic --~Principles and Philosophies
~}



\author[1]{Ashok R. Shaha, MD}%
\affil[1]{Head \& Neck Service. Memorial Sloan Kettering Cancer Center. New York}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\emph{} \textbf{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 8\textsuperscript{th} 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
features\textsuperscript{1}. 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 \textsuperscript{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.

\begin{itemize}
\tightlist
\item
  \textbf{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 \textsuperscript{3}. A due consideration should be given to
  controlled cricothyrotomy.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{Microcarcinomas} -- As reported by a large series of patients
  from Kobe, Japan; Sloan Kettering, these patients with microcarcinomas
  can definitely be observed \textsuperscript{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.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{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.
\item
  \textbf{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.''
\end{itemize}

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.

\textbf{References}:

\begin{enumerate}
\tightlist
\item
  Shaha, AR. Implications of prognostic factors and risk groups in the
  management of differentiated thyroid cancer. Laryngoscope. 2004, 114;
  393-402.
\item
  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.
\item
  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.
\item
  Miyauchi, A. Clinical trials of active surveillance of papillary
  microcarcinoma of the thyroid. World J Surg. 2016, 40; 516-22.
\item
  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.
\end{enumerate}

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