Messages from Kennichi Kakudo, MD, PhD to a person to be an expert of the cytopathology

The following 2 examples were prepared to explain how our different cultural back ground impacts on our decisions making processes. The following two cases, different conclusions, and patients’ reactions in Japan, may not occur in Western societies, but may happen in other Asian societies.

Case 1:

A young woman visited Kuma Hospital for a second opinion consultation. The patient had been treated for Graves’ hyperthyroidism with anti-thyroid medication at the other hospital. She was found to be pregnant after a low dose radioactive iodine (RAI) scintigraphy and she was advised to have an artificial abortion by her doctor. It was her first pregnancy and she wished to have the baby. Her questions to us included what kinds of abnormalities, and the probability that these abnormalities would occur in her baby. Dr Kuma, the president of Kuma Hospital, advised her to have the baby after his thorough explanation. The patient stopped crying and contented with his advice. After she left our consultation room, I asked Dr Kuma how sure about his advice he was. He told me, “At this moment, nobody knows whether her baby will have an abnormality or not (only God knows what will happen to the baby), and she needs someone who supports her choice to have her baby”. Several years later Dr Kuma told me that the patient had a healthy baby. Dr Kuma, as a Christian, thanked God that he could save a life. In Japan, many physicians would probably advise her to have an induced abortion, similar to the advice of her previous doctor, which is the only method to avoid possible abnormalities that might occur in the baby due to RAI radiation; however, she decided to take a chance and have the baby. The author of this chapter believes that diagnostic surgery in all patients with indeterminate nodules, so as not to miss the rare occurrence of malignancy, is similar to a physician recommending an induced abortion to avoid the relatively rare chance of radiation-induced congenital anomalies in an unborn baby. Since thyroid cancer is indolent and a delayed surgery does not create any harm to the patient the author of this chapter believes that the choice to opt for surgical intervention should not be rushed, and should be applied only when high-risk clinical features are observed during active surveillance (watchful follow-up). This is largely because we cannot replace the resected thyroid lobe when the nodule is benign, and a significant number of patients with thyroid lobectomy develop hypothyroidism, which is harmful to patients.

Case 2:

A young woman visited a hospital for her thyroid nodule. A thyroid FNA cytology was performed and it was interpreted as suspicious for PTC type malignancy. The patient was advised to have surgery, according to the clinical guidelines of the Japan Thyroid Association (JTA). She initially did not accept this advice and was followed-up clinically at her hospital, because she knew many thyroid cancers were indolent and that active surveillance was one choice. The doctor advised her 3 times to have surgery. She finally accepted his advice and histological diagnosis of her thyroid nodule revealed it to be a benign adenomatous goiter. The patient filed a lawsuit with the court and asked for damages from the hospital and the cyopathologist. This was the first lawsuit in Japan involving diagnosis of thyroid FNA cytology, using key words “thyroid” and “FNA cytology” and (“false positive” or “false negative” or “missing malignancy”) in a database of judicial precedent in Japan. I was invited to provide a written statement of an expert opinion on cytological diagnosis. Although a small probability of benign diseases had been explained to her before the surgery, she was not happy with the unnecessary alarm caused to her and the surgery. Her biggest concern was a suture wound on the anterior of her neck. Some Japanese people do not like to damage their own body, which they believe was given to them by God/Buddha/Deities/Nature, and believe it is important for them to keep their bodies as natural as possible. Cosmetic surgery and tattoos are not popular in Japan compared to other countries, which is related to this principle. There have been no lawsuits related to missed malignancy of thyroid FNA cytology in Japan, this author assumed that missed thyroid malignancy can usually be rectified by surgery when malignancy was clinically evidenced, and a delayed surgery does not usually create any harm to the patients with low-risk thyroid cancer, which is different from other organ systems where many tumors are lethal and a delayed surgery should be avoided.

Which do you prefer, when you have a small (<1 cm) thyroid nodule with suspicious ultrasound image, American way or Japanese way? The American Thyroid Association released the following statement and recommends physicians not to perform thyroid FNA cytology on nodules (< 1 cm) unless there is evidence of extrathyroidal extension or of lymph node or distant metastases (A). While the Japan Thyroid Association recommended so-called active surveillance (watchful follow-up in lieu of surgery) as a treatment option for papillary microcarcinoma (<1 cm) as far as it is confined to the thyroid gland (Ex0, N0, M0) and biopsy proven low-risk papillary thyroid carcinoma (possible high-risk thyroid carcinomas should be ruled out), which was introduced by Kuma hospital group and National Cancer Institute group from Japan (B,C,D). Both different clinical managements were established for the purpose to reduce over-diagnosis and overtreatment of this indolent thyroid tumor. However, these two clinical approaches were very different from each other probably because of different way of thinking and cultural background. In the Japanese way, I believe, a confirmation of low-risk papillary carcinoma by FNA biopsy is important for a peace of mind to the patient. A confirmation of benign or malignancy with FNA cytology was not recommended  in the American way.   (A): The AMERICAN THYROID ASSOCIATION recognizes that the recent increase in incidence of thyroid cancer in the United States and other countries is, in large part, due to the over diagnosis of indolent papillary microcarcinomas that will never result in symptoms or death, and which only rarely will enlarge or spread beyond the thyroid gland. The issues surrounding this problem are twofold: First, medical imaging is identifying small nodules, well below the limits of clinical detection. Second, these small nodules are subjected to ultrasound-guided FNA, and about 5% reveal cancer cells. The usual next step is surgical removal, often followed by radioactive iodine and life-long thyroid hormone therapy. This approach is costly, creates risks from the treatments, and in most patients offers little or no benefit. AMERICAN THYROID ASSOCIATION Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Thyroid, 2016) address this issue with three important recommendations/suggestions: (1) do not perform thyroid FNA on nodules < 1 cm unless there is evidence of extrathyroidal extension or of lymph node or distant metastases; (2) restrict surgery (currently the Standard of Care) to lobectomy and avoid radioactive iodine in those with low risk features; and (3) conduct further research (preferably in the setting of an IRB-approved clinical trial) to define the role of active surveillance instead of surgery for patients with low risk tumors (as is currently done for men with indolent prostate cancer). While additional scientific and medical knowledge is required, the AMERICAN THYROID ASSOCIATION advises that, in the interim, these recommended clinical measures may reduce the recent increased incidence of thyroid cancer and prevent overtreatment of low risk cancer. (B): Oda H, Miyauchi A, Ito Y et al: Incidences of unfavorable events in the management of low-risk papillary microcarcinoma of the thyroid by active surveillance versus immediate surgery. Thyroid 2016; 26: 150-155. (C): Ito Y and Miyauchi A: A therapeutic strategy for incidentally detected papillary microcarcinoma of the thyroid. Nature Clin Pract Endocrinol Metab 2007; 3: 240-248, 2007. (D): Sugitani I, Toda K, Yamada K et al: Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes. World J Surg 2010; 34:1222-1231.

I recently published a textbook of thyroid cytology, Thyroid FNA Cytology: Differential Diagnoses and Pitfalls from Smashwors. Please examine the link: https://www.smashwords.com/books/view/655745 It is the first English text book of thyroid FNA cytology from Asia and only text book incorporating new disease concept of NIFTP (a borderline thyroid tumor).  This text book also highlighted our differences between Western and Eastern practices, and discuss possible reasons.  To have good performance in your practice, I betlieve this text book serves you as a good references to avoid pitfalls.