German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors

Introduction

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable (“low risk”) papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

Methods

The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

Results

The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

Conclusion

These evidence-based recommendations for surgical therapy reflect various “treatment corridors” that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.     

Changing patterns in the management of locally advanced breast cancer: a preliminary report

Over the 8 years from 1976 to 1983, 28 patients with stage IIIB (T4a,b,c, NX-2, M0) and inflammatory breast cancers without evidence of disseminated disease at the time of diagnosis were treated at Ellis Fischel State Cancer Center in Columbia, Mo. This group comprised 4% of all cases of primary breast cancer seen during that period. Radiotherapy was the primary treatment in one half of the group during the first 4 years of the study (group A). Since 1981, locally advanced breast cancer has been treated by multidrug chemotherapy followed primarily by mastectomy (group B). The rate of local control was the same for both groups (78%). However, the median survival for group A was 11 months, only one patient being alive 5 years after diagnosis, whereas in group B, 12 of 14 patients were alive and clinically free of disease 9 to 31 months after diagnosis with a median follow-up of 16.5 months. This preliminary report confirms recent findings, supporting the use of polychemotherapy followed by mastectomy in the management of patients with locally advanced breast cancer.     

Application of mammary serum antigen assay in the management of breast cancer: a preliminary report

A monoclonal antibody (3E1.2) based serum test using an enzyme immunoassay has been used to determine circulating levels of the breast cancer associated antigen--mammary serum antigen (MSA). Of 157 patients with early breast cancer (stage I and II) and 199 patients with advanced breast cancer (stage III and IV), 73 per cent and 87 per cent respectively had elevated MSA levels (i.e. greater than 300 inhibition units (IU). Furthermore, 40 of 44 patients (91 per cent) had a significant fall of MSA levels with reduction in tumour load by mastectomy. In addition, there was a correlation of MSA levels with the clinical course: changes in MSA levels correlated with changes in disease status (progressive disease, stable disease, disease regression) in 54 of 61 patients and antedated disease progression or recurrence by up to 8 months in some patients; and in 32 of 36 patients (89 per cent) with no clinical evidence of recurrence MSA levels did not vary by more than 25 per cent of the original MSA value over a period of 2-15 months. MSA is therefore a useful tumour marker in the diagnosis and staging of breast cancer. There is also evidence that serial estimations of MSA levels may be used to detect subclinical recurrence and the fluctuations in MSA levels might be useful in assessing response to therapy. Furthermore, it was also noted that surgical procedures such as fine needle aspiration biopsy or incisional biopsy could lead to a rise in MSA levels.     

Surgical training: a report to the Association of Surgeons of Great Britain and Ireland

During the author's tenure (1990-1991) of the British Journal of Surgery Travelling Fellowship of the Association of Surgeons of Great Britain and Ireland, a study was made of surgical training in this country and abroad. This report outlines certain beneficial changes which may be made in UK training programmes.     

Althesin in the management of head injuries: a preliminary report

The aggressive treatment of major craniocerebral trauma has received recent attention. Barbiturate administration has been beneficial in some cases of sustained, uncontrolled intracranial hypertension. One major disadvantage of pentobarbital narcosis is the long half-life of the drug (15 to 48 hours). We have used Althesin, an intravenous steroid anesthetic (alfaxalone and alfadolone acetate; Glaxo Laboratories Ltd., Greenford, Middlesex, England), in eight seriously head-injured patients. Althesin combines the theoretical advantages of pentobarbital in the management of head trauma with almost immediate reversibility (serum half-life, 1.6 minutes). Raised intracranial pressure and clinical outcome seem to be influenced favorably and the side effects are negligible when the drug is administered by continuous intravenous infusion over several days. Further study of this compound in the management of head trauma seems warranted.     

A short history of the European Association of Plastic Surgeons — 1990–1994

Summary EURAPS was founded in Istanbul in 1990 by a group of 31 European plastic surgeons. Over the first five years of its existence, the Association's membership has grown to 130. Its principal aim is to promote the excellence of plastic surgery within Europe and this is largely mediated by the presentation of selected scientific papers during a two day annual meeting.