<h4> Editorial :</h4>
<p>
For generations, the surgeon’s legacy was etched in the geometry of inci...
<h4> Editorial :</h4>
<p>
For generations, the surgeon’s legacy was etched in the geometry of incisions and the fidelity of healed tissue. We were master technicians, our worth measured in operative time, complication rates, and the gratitude of the patient before us. This covenant, however, is being quietly but irrevocably rewritten. The operating theatre of the 21st century is no longer an isolated arena of individual skill; it is the most complex node in a vast technological, economic, and human system. Here, the introduction of a robotic platform is not merely a new tool, but a seismic event that reshuffles workflows, redefines team dynamics, and demands new ethical and economic calculations. In this new landscape, our most critical instrument may no longer be the scalpel or the console, but the capacity to design the system itself. It is time to embrace a fundamental evolution of our professional identity: from Surgeon as Technician to Surgeon as System Architect.
</p>
Carcinoma of unknown primary (CUP) in the head
and neck region remains a persistent and complex
ch...
Carcinoma of unknown primary (CUP) in the head
and neck region remains a persistent and complex
challenge for clinicians worldwide. Significant advances in diagnostic modalities-such as crosssectional imaging, molecular diagnostics, robotic surgery, and positron emission tomography (PET)have improved the ability to identify primary sites, especially within the oropharynx, notably HPVrelated cancers. 1,2 With the rising incidence of HPVassociated oropharyngeal carcinomas, the proportion of CUP cases presenting with regional metastases and occult primaries is also increasing, emphasizing the need for updated management strategies.
Introduction:
About 68% of the general population have thyroid
nodules on routine ultrasonograph...
Introduction:
About 68% of the general population have thyroid
nodules on routine ultrasonography. That does not
mean all nodules should be treated by surgery as most of the nodules are benign and are discovered
incidentally. So our primary goal of thyroid nodule
evaluation is to determine whether it is malignant.
After thyroid ultrasonography has been performed,
the next step is measurement of serum thyroidstimulating hormone. Hyperfunctioning nodules are rarely malignant and do not require tissue sampling. Nonfunctioning nodules and nodules in a patient with a normal or high thyroid-stimulating hormone level may require fine-needle aspiration based on ultrasound characteristics and size. Nodules with suspicious features and solid hypoechoic nodules 1cm or larger require aspiration. The Bethesda System (categories 1 through 6) . Benign nodules (Bethesda II) does not need surgery and need to follow –up with regular physical examination and ultrasonography to see the progress of the nodules (increase in size, suspicious) usually in every one year interval. As surgery is not without risk so many unnecessary surgical intervention lead to recurrent & superior laryngeal nerve damage, voice loss, parathyroid insufficiency, neck scar and life long
thyroid hormone replacement. In the UK there is some variation of monitoring of the thyroid nodules. Some hospital clinics discharge patients when cancer has been excluded, whereas other hospitals monitor
nodules with repeat ultrasonography. In Ireland
including our hospital we monitor benign nodules
with repeat ultrasonography every one year interval
that is called surveillance ultrasonography.
What is active Surveillance?
Active surveillance is watchful waiting and monitoring benign thyroid nodules and also in many cases of papillary microcarcinoma without any surgical intervention .There are some situation when benign nodules need surgery like rapidly growing nodules, pressure symptoms and on cosmetic ground. Age, comorbidities and life expectancy should be considered when individualizing treatment, as total thyroidectomy for older adults with low risk PTC has been associated with higher incidence of complications and hospital readmissions So active surveillance is a reasonable option for very low risk patients . In fact, a significant proportion of patients, specifically older individuals with low-risk tumors, may benefit from active surveillance without a surgical intervention. In a large proportion of patients, PTCs are identified as either a papillary microcarcinoma (PMC) or a follicular variant thyroid microcarcinoma, both of which are defined as tumors of < 1cm in diameter with a favorable prognosis . Due to the indolent course of the disease, active surveillance is a strategy implemented by several centers for thyroid nodules up to 1.5 cm in diameter, depending on individual institutional protocols. Tumors larger 1 and less than 1.5 cm (T1bN0M0) appear to have a similar course than tumors < 1 cm (T1aN0M0) None of the patients with low risk PMC showed distant metastasis or died from thyroid carcinoma during the active surveillance period Medical costs and adverse events from surgery
(recurrent laryngeal nerve injury, parathyroid gland
damage and/or anesthetic complications) are higher
in patients that undergo immediate resection.
Contraindication to active surveillance;
1. A noncancerous nodule may sometimes require
surgery if it’s so large that it makes it hard to
breathe or swallow. We also consider surgery
for people with large multinodular goiters,
particularly when the goiters constrict airways,
the esophagus or blood vessels.
2. Nodules diagnosed as indeterminate or
suspicious by FNAC (Thy 3A or 3F) need
diagnostic hemithyroidectomy to role out so
cancer.
3. Any clinical features of malignancy like
lymphnodes or distant metastasis at diagnosis.
signs and symptoms of invasion to the trachea, oesophagus, recurrent laryngeal nerve. Pabna Medical College Journal Vol. 3, No. 2 November, 2024
4. High grade malignancy on FNAC (Thy 4/5) or tall cell varint and poorly differentiated carcinoma.
Transition from active surveillance to surgery is
considered when
1. Thyroid nodule size increases in the greatest
dimension by at least > 3mm from initial measurement,
2. In cases where a new suspicious metastatic LN
disease shows cytological evidence for thyroid
cancer, and
3. When tumor volume increases by 50 % in threedimensional measurements
Discussion
Over the past three decades the world wide incidence of thyroid cancer has significantly increased and more than 50% of this increase is related to the identification of papillary thyroid microcarcinoma. Two prospective studies from Japan have shown that active surveillance is feasible for low risk papillary thyroid microcarcinoma patients as most of these tumours remain latent or with slow progression. Other studies showed similar results. On the other hand prognosis of papillary thyroid microcarcinoma is excellent with local recurrence rate of 2-6% and a distant metastasis rate 1-2% and a 20 year disease free survival rate is >99%. So for most of the benign thyroid nodules and low risk papillary thyroid microcarcinoma patients, immediate surgery may lead to more problems like surgical complications, neck scaring, hormone replacement. In another study in china showed active surveillance in Chinese patients with highly suspicious subcentimetre thyroid nodules has good oncological outcomes and can be used as a safe alternative to surgery. Younger patients (£30) show a worse psychological status; therefore, more attention should be paid to younger patients. 37
Conclusion
Active surveillance is now well practiced around the
globe including USA, UK Ireland ,China , Japan and
many more countries. Unfortunately it is not practiced in Bangladesh and many unnecessary surgical operations are under going resulting in many surgical complications. So in the treatment of thyroid nodules active surveillance can be used as an alternative treatment option to reduce the incidence of adverse effects without affecting treatment outcomes. Pabna Med. Col. J. 2024;3(2): 36-37
Abdul Matin FRCS
Professor & Consultant ENT Surgeon, Limerick
University Hospital, Ireland
Email; abdul.matin@hse.ie
Secretary ; Justyna Was e mail justyna.was@hse.ie
References
1. Kant R,Davis A, Verma V.Thyroid nodules: Advance
in evaluation and management. Am Fam Physician
(2020):102(5):298-304
2. Sung H, Ferlay J, Siegel RL et al. Global cancer
statistics 2020: Globocan estmates of incidence and
mortality worldwide for 36 cancers in 185
countries.CA Cancer J Clin (2021);71(3):209-49
3. DavisL,Hoang JK.Thyroid cancer in the
USA:Current trends and outstanding questions.
Lancet Diabetes Endocrinol(2021):9(1):11-2
4. Ito Y, Mivauchi A, Kihara M,Higashiyama
T,Kobayashi K, Miya A.Patient age is significantly
related to the progression of papillary
microcarcinoma of thyroid under observation.
Thyroid(2014):24(1):27-34
5. Chunhao L,Zhao H, Xia Y et al. Active surveillance
of highly suspicious nodules cohort in China.
Oncol(2022):12 doi.org/10.3389/fonc.2022.981495.
<p style="text-align: justify;"><strong>Introduction:</strong></p>
<p style="text-align: justify;">...
<p style="text-align: justify;"><strong>Introduction:</strong></p>
<p style="text-align: justify;">Cancer is a dreadful name. It is not just a killer, it comprises a lot of human stories- which comprises with fear, cry, depression, financial crisis, love, care, deep sorrow and happy moments of cure.</p>
<p style="text-align: justify;">Cancer is the first or second leading cause of premature death (i.e., at ages 30-69 years) in 134 of</p>
<p style="text-align: justify;">183 countries, and it ranks third or fourth in an additional 45 countries.1</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">Globally in 2020, every 6 deaths include 1 cancer patient and number of deaths by cancer was 1 crore. It may be increased to 1.5 crore by the next decade. Death of two-third cancer patients in the developing countries.2</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">In Bangladesh 114 person per lac has been suffering from various cancer. Approximately 20 lacs cancer patient in Bangladesh. Newly affected are 53 person per lac. 2 lacs affected in every year and about 1 lac died of cancer in every year. In this country 12% death due to cancer. Daily death about 273 in Bangladesh. According to study, there is a definite risk of it to be doubled by upcoming three decades. 3</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">In human body, there are about 100 trillion cells. Uncontrolled and uncoordinated proliferation of cells makes cancer. About 200 different types of cancer may affect human being. 1 out of 2 people affected by cancer in his lifetime. Male are two times affected than female.</p>
<p style="text-align: justify;">3 out of 5 ignore their symptoms of cancer.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">There are at least 30 types of cancer that affects head and neck regions are called collectively Head- Neck Cancers.</p>
<p style="text-align: justify;">Some common are as follows:</p>
<p style="text-align: justify;">- Oral cavity cancer</p>
<p style="text-align: justify;">- Laryngeal cancer</p>
<p style="text-align: justify;">- Thyroid cancer</p>
<p style="text-align: justify;">- Oropharyngeal cancer</p>
<p style="text-align: justify;">- Tongue cancer</p>
<p style="text-align: justify;">- Tonsillar cancer</p>
<p style="text-align: justify;">- Nasopharyngeal Cancer</p>
<p style="text-align: justify;">- Hypopharyngeal cancer</p>
<p style="text-align: justify;">- Sinonasal cancer</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">- Parotid cancer</p>
<p style="text-align: justify;">- Cancer of Minor Salivary gland</p>
<p style="text-align: justify;">- Cancer involving ear</p>
<p style="text-align: justify;">- Skin cancer involving Head and Neck Region</p>
<p style="text-align: justify;">- Lymphoma involving Head and Neck Region</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;"><strong>Head-Neck Cancer Burden:</strong></p>
<p style="text-align: justify;">There are 4 different types of head neck cancer out of top 10 cancer internationally. According to data, 33 head neck cancer patient out of 100 male cancer patient and 11-13 head neck cancer patient out of 100 female cancer patients. Head Neck cancer patients mostly affecting developing countries.</p>
<p style="text-align: justify;">According to various statistics head-neck cancers are the leading cancer in Bangladesh. To understand the scenario some facts should be considered. In Bangladesh there is no complete cancer registry. For this reason, it is difficult to conclude accurately on highest burden of cancer type. There is a published report by National Institute of Cancer Researches and hospital (NICRH) (2015-2017) highest affected cancer was lung cancer (26.1%) in male and breast cancer (30.4%) in female and combinedly lung cancer 16.6%. In this report Head- Neck cancer components are shown separately. Top listed 10 cancer of male shows</p>
<p style="text-align: justify;">4 are head- neck cancer. 2 out of 4 are fully categorized</p>
<p style="text-align: justify;">as head- neck cancer and rest 2 out of 4 are partly categorized as head- neck cancer. Again, Top listed</p>
<p style="text-align: justify;">10 cancer of female shows 3 are head- neck cancer. 1 out of 3 are fully categorized as head- neck cancer and rest 2 out of 3 are partly categorized as head- neck cancer. So, summation of all component of head- neck cancer of this list will go to near highest.</p>
<p style="text-align: justify;">Moreover, most of thyroid cancers are not included in this report. As because for thyroid cancer after surgery Radioactive Iodine Ablation therapy is the treatment of choice. Only few thyroid cancers are reported to NIRCH for conventional radiotherapy and etc. International study shows almost half of the population harbors Thyroid disorders/ nodules. Almost 10% of thyroid nodule may affected by thyroid cancer. Differentiated Thyroid cancers are exclusively</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">treated by surgery and Radioactive Iodine Ablation therapy. Radioactive Iodine Ablation therapy is given by various institutes of nuclear medicine all over the country. So, Thyroid cancer patients are not reported to NICRH and not included their published report.</p>
<p style="text-align: justify;">In a published report from National institute of nuclear medicine and applied sciences (NINMAS) shows about 2500 Thyroid cancer patients reported annually in all nuclear medicine Centre of Bangladesh. Again, all Thyroid cancer patient are not coming here as because all patient usually not required RAI therapy especially early differentiated thyroid cancer or not willing to take RAI Therapy in spite of offering and explaining about the necessity of it.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">Very recently there is a ‘Evidence from population- based cancer registry’ report named “Distribution of Cancers in Bangladesh” published Epidemiology division of department of public health and informatics of BSMMU. The study was conducted from July 2023 to June 2024 at 4 unions of Hossainpur upazila, Kishoreganj. It aimed to find out the distribution of cancers among Bangladeshi population.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;"><strong>Suffering</strong><strong>s of Head-Neck cancer patients in</strong></p>
<p style="text-align: justify;"><strong>Bangladesh</strong></p>
<ul style="text-align: justify;">
<li>Sufferings of Head - Neck cancer patient in</li>
</ul>
<p style="text-align: justify;">Bangladesh mostly due to 4 reasons</p>
<p style="text-align: justify;">- Advanced presentation</p>
<p style="text-align: justify;">- Insufficient treatment facilities</p>
<p style="text-align: justify;">- Absence of referral system</p>
<p style="text-align: justify;">- Absence of feasible, affordable, and cost- effective treatment</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;"><strong>Wha</strong><strong>t Should we do?</strong></p>
<p style="text-align: justify;">Awareness builds up at all levels. Risk factor should be isolated and understandable to common population. Stop exposure from harmful risk factors. Cessation of all habits that may initiate cancer.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">Preventive steps should be taken to avoid Head-Neck cancer. Educate the common population about Head- Neck cancer. Regular Screening program for early detection of Head-Neck Cancer. Early diagnosis may cure almost all head-neck cancers. Regular physician education is essential to keep them updated. Outcome of treatment regularly monitored and audited. Survived patients carefully and regularly followed up.</p>
<p style="text-align: justify;">Some preventive measures are reflecting in the slogan of World Cancer Day.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;">“Close the care gap”-Slogan of World Cancer Day-</p>
<p style="text-align: justify;">2022-2024</p>
<p style="text-align: justify;">‘United by Unique’-United in our message, Unique in our stories- Slogan of World Cancer Day-2025-2027</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;"><strong>Bangladesh with global partners in Head-Neck</strong></p>
<p style="text-align: justify;"><strong>Cancer</strong></p>
<p style="text-align: justify;">Bangladesh is a member of International Federation of Head and Neck Oncologic Societies (IFHNOS) and Asian Head Neck Societies (AHNS). World Head Neck Cancer Day (July 27) are celebrating every year in Bangladesh together with 55 Head-Neck Societies,</p>
<p style="text-align: justify;">51 Countries and UICC.</p>
<p style="text-align: justify;"> </p>
<p style="text-align: justify;"><strong>Conclusion:</strong></p>
<p style="text-align: justify;">Head Neck Cancer is one of the top-ranking cancers in Bangladesh and Globally. It should be appropriately addressed in policy making level. Treatment facilities should be increased. Manpower should be appropriately trained. Dedicated personnel are required to face the challenge of increased head- neck cancer burden. Awareness program should be observed comprehensively and continuously.</p>
<p>Abstract:<br />In the last century major death toll was due infections<br />and communicable dise...
<p>Abstract:<br />In the last century major death toll was due infections<br />and communicable diseases, but at present major<br />causes of death are non-communicable diseases like<br />cerebrovascular diseases, ischemic heart diseases,<br />chronic respiratory diseases and cancer. Etiology of<br />these listed disorders is multifactorial. Snoring and<br />obstructive sleep apnea was considered as social<br />problem, studies revealed obstructive sleep apnea is<br />important risk factor of life threatening diseases.<br />Morbidity, quality and cost of life depends on good<br />quality sleep which is fragmented by obstructive sleep<br />apnea.<br />Introduction:<br />Obstructive sleep apnea (OSA) is the most common<br />sleep-related breathing disorder and is characterized<br />by recurrent episodes of complete or partial<br />obstruction of the upper airway leading to reduced<br />or absent breathing during sleep. These episodes are<br />termed “apneas” with complete or near-complete<br />cessation of breathing, or “hypopnea” when the<br />reduction in breathing is partial. In either case, a fall<br />in blood oxygen saturation, a disruption in sleep, or<br />both, may result. A high frequency of apneas or<br />hypopneas during sleep may interfere with the<br />quality of sleep, which – in combination with<br />disturbances in blood oxygenation – is thought to<br />contribute to negative consequences to health and<br />quality of life.<br />1<br /> The terms obstructive sleep apnea<br />syndrome (OSAS) or obstructive sleep apnea–<br />hypopnea syndrome (OSAHS) may be used to refer to<br />OSA when it is associated with symptoms during the<br />daytime (e.g. excessive daytime sleepiness, decreased<br />cognitive function).<br />At present about 85% of adult deaths were due to<br />non-communicable diseases, with ischemic heart<br />disease (21.1%), stroke(22.1%) and chronic respiratory<br />disease(16.4%) comprising about 60% alone among<br />the 65% of community death reporting in<br />Bangladesh<br />1<br />. Almost all of the causes of death (COD)<br />due to non-communicable disease are related or very<br />much influenced by obstructive sleep apnea. But<br />unfortunately we are unaware about this problem.<br />Methods:<br />PubMed and Google Scholar were searched using<br />the keywords obstructive sleep apnoea without<br />limiting the years of publication. In PubMed 42148<br />article was found with key ward obstructive sleep<br />apnea (OSA). Most recent articles were reviewed in<br />this article.<br />Results and discussions:<br />Prevalence of obstructive sleep apnea: Prevalence<br />of obstructive sleep apnea (OSA) ranged from 9% to<br />38% and it is higher in men. It increased with<br />increasing age and, in some elderly groups, was as<br />high as 90% in men and 78% in women<br />2<br />.<br />Hypertension and OSA: According to a report from<br />American Heart Association prevalence of HTN in<br />the United States adults was 45.6% and OSA is<br />estimated to have a prevalence of 30% to 50% in<br />patients with hypertension<br />3<br />.<br />OSA causes Stroke: Stroke is directly influenced by<br />OSA. In a study it is determined that 91.2% of the<br />patients had OSA in the acute stage of ischemic<br />stroke, and 70% of the patients had moderate to severe<br />OSA<br />4<br />. Apneic and hypoxemic episodes initiate the<br />process of inflammation and there is a cascade of<br />inflammatory markers such as IL, 1, IL 6, TNF a, and<br />interferon g. These inflammatory markers damage the<br />endothelial lining of the blood vessels, and there is<br />an increased aggregation of platelets which lead to<br />further oxidative stress and vascular endothelial<br />damage. This repetitive oxidative stress and vascular<br />damage in OSA patients along with fluctuation of<br />blood pressure due to sympathetic activation can<br />cause CVD and stroke.<br />Pabna Medical College Journal Vol. 2, No. 2 November, 2023<br />Type-2 Diabetes and OSA: Sleep fragmentation and<br />intermittent hypoxemia causes sympathetic<br />activation, oxidative stress, inflammation, and<br />neuroendocrine dysregulation which alter glucose<br />homeostasis. Type-2 diabetes has been estimated to<br />be 15% to 30%, with higher prevalence in those with<br />severe OSA<br />29<br />5<br />.<br />OSA causes hypogonadism: It is reported an<br />association between sleep disorders and plasma<br />testosterone levels and estrogens and progesterone<br />impact on upper airway stability and respiratory<br />control during the menstrual cycle. Sleep<br />fragmentation, disorganization of sleep cycles and<br />stages, sympathetic activation, intermittent<br />hypoxemia and systemic inflammation has a direct<br />central effect on neurotransmitters, with disturbances<br />in the normal production of hypothalamic pituitary<br />hormones and as well as gonadal functions<br />.<br />Conclusions:<br />Obstructive sleep apnea is emerging health problem<br />in developing countries when nutritional deficiency<br />disorders and communicable diseases are near to<br />erased. OSA is important risk factor or predisposing<br />condition of major life threatening non-communicable<br />diseases. To prevent cerebrovascular diseases,<br />hypertension, ischemic heart disease and diabetes<br />OSA management is crucial. Hypo-gonadism, hypo<br />fertility and infertility are also associated with OSA,<br />which is newer problem in our community. So<br />obstructive sleep apnea is not only a social problem<br />and cannot be ignored to achieve healthy life.</p>
