overall did not show a reduction in temporary or permanent RLNP. However, the meta-analysis does show non-statistically significant trends to benefit from IONM in some subgroups, for example permanent RLNP in Graves’ disease, transient RLNP in retrosternal goitres, and all RLN palsies for patients in the seven comparative trial subgroup (almost half of the meta-analysis patients). We interpreted from this there is only a small amount of evidence in the RCT and meta-analysis to demonstrate the benefit of IONM. This statement was not intended to be misleading, but agree overall evidence for clear benefit is lacking. However, data show some significant results and trends and therefore the jury must be considered still out on the overall value of IONM. Dralle noted that to show a statistically significant difference for RLNP in multi-nodular goitre, with and without IONM, would require nine million cases in each arm of an RCT.3 Perhaps the greatest value of IONM is in preventing bilateral RLNP. If RLNP occurs, a decision whether to resect the contralateral side can be made.4 It is also of great value as a prognostic tool to reassure the patient who has sustained a temporary RLNP – a visually intact RLN with an initial normal signal, which is then lost, predicts almost 100% recovery from the neurapraxia. IONM is also a valuable research tool, it has facilitated significant advances in knowledge of neuroanatomy, neurophysiology and neuropathology of the RLN, and its ongoing use will enable its place in thyroid surgery to be further evaluated. All thyroidectomies are potentially difficult and it is not possible to predict when a patient will be technically challenging or when unexpected anatomy will be found. Therefore, it is not possible to predict when IONM is likely to be of greatest value. There is a steep learning curve in the use of IONM. Therefore, it is suggested that expertise in its use is developed in cases such as multi-nodular goitres, rather than using it selectively for difficult cancers and re-operative cases. It is stated in the discussion of the RCT that ‘only good understanding of the electrophysiological background of the nerve monitoring method and daily practice in uncomplicated operations allows mastery of this novel technique’. For these reasons, we suggested in the Editorial and consensus statement that routine use of IONM could be considered for all thyroid surgery. We wish to be clear that the use of IONM for all thyroid surgery is not the current standard of care. However, for the next generation of thyroid surgeons, it appears that it may well become so.

References 1. Gough I. Avoiding recurrent laryngeal nerve injury in thyroid surgery. ANZ J. Surg. 2014; 84: 895. 2. Jeannon JP. Orabi AA. Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int. J. Clin. Pract. 2009; 63: 624–9. 3. Dralle H. Sekulla C. Haerting J et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136: 1310–22. 4. Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ. The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J. Surg. 2010; 34: 1274–84.

Letters to the Editor

Jonathan W. Serpell,* MBBS, MD, MEd, FRACS, FACS Stan B. Sidhu,† MBBS, PhD, FRACS *Department of Breast, Endocrine and General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia and †Endocrine Surgery Unit, The University of Sydney, Sydney, New South Wales, Australia doi: 10.1111/ans.12901

Dear Editor, Supraclavicular lymph node metastasis as a first sign of rectal cancer without visceral metastasis Cervical lymphadenopathy is usually suspicious for upper aerodigestive malignancies. To our knowledge, there are only a few case reports of sigmoid and caecal cancers presenting as cervical lymphadenopathy without solid organ involvement. Only one case of rectal cancer presenting as such had been reported in the Japanese literature but none in the English literature.1–3 Herein, we report such a case. A 68-year-old Chinese male presented to the Otolaryngology with an isolated mobile supraclavicular lump. Fine needle aspiration cytology detected an unspecified metastatic carcinoma with glandular architecture. After a normal nasoendoscopy and further questioning, he revealed that he had only experienced a mild change in his bowel habits. There was neither loss of weight nor appetite, or per-rectal bleeding. Therefore, he was referred to our colorectal clinic. Tumour markers came back as normal. Computed tomography of the chest, abdomen and pelvis showed a lesion suggestive of a rectal malignancy with extensive intra-abdominal and intrathoracic lymphadenopathy. There were some isolated non-specific liver and lung nodules. Colonoscopy revealed a circumferential, ulcerative rectal tumour at 6 to 12 cm from the anal verge. The colonoscope could be passed through. Histology came back as moderately differentiated adenocarcinoma. As he was asymptomatic from the primary rectal disease, he was referred for chemotherapy before any consideration for surgery. Cervical lymphadenopathy without other visceral metastasis in colorectal cancer is an uncommon pattern of spread for colorectal cancers. It is unknown about how the rectal cancer cells could have spread to the cervical lymph nodes without grossly involving the liver or lung as colorectal cancers are known to have haematogenous spread as well. Skip micrometastasis between regional lymph node stations have been reported as a possibility.4 As involvement of the supraclavicular lymph node would constitute advanced disease, chemotherapy would be the treatment of choice. Long-term survival has been reported with chemotherapy alone.3 References 1. Aksel B, Dogan L, Karaman N, Demirci S. Cervical lymphadenopathy as the first presentation of sigmoid colon cancer. Middle East .J. Cancer 2013; 4: 185–8. 2. Basso L, Izzo L, Calisi E et al. Cervical node metastasis as the first sign of cancer of the caecum. Anticancer Res. 2007; 27: 3589–92.

© 2014 Royal Australasian College of Surgeons

Letters to the Editor


3. Hirose H, Ikeda M, Miyoshi N et al. [A long-term survival case of rectal cancer with Virchow’s lymph node metastasis by multimodality therapy]. Gan to Kagaku Ryoho 2010; 37: 2545–7. 4. Merrie AE, Phillips LV, Yun K, McCall JL. Skip metastases in colon cancer: assessment by lymph node mapping using molecular detection. Surgery 2001; 129: 684–91.

Dexter Yak Seng Chan, BMedSci, MBBS, MRCS Kon Voi Tay, MBBS, MRCS Surendra Kumar Mantoo, MS, MMed, FRCS Department of General Surgery, Khoo Teck Puat Hospital, Singapore

rhage, as reported frequently, could have been an additional trigger for the emergence of TTS in the present case; and (iii) that as clinicians and investigators are desperately trying to unravel the TTS puzzle, every bit of data counts; indeed the authors reported that ‘an electrocardiogram (ECG) showed low voltage and no signs of acute ischaemia’ and thus it will be useful to provide information whether there was just low voltage ECG noted on admission, or it developed in subsequent ECGs, or it was seen throughout the hospitalization, or it was abolished by the time of the patient’s discharge or in subsequent follow-up ECGs, all of which were recently described in association with TTS.4

doi: 10.1111/ans.12813 References Dear Editor, Could the electrocardiogram aid in the early diagnosis of Takotsubo syndrome? The article by Overton et al.1 about a woman who developed Takotsubo syndrome (TTS) with haemodynamic instability and cardiogenic shock, triggered by multiple trauma and extreme emotional distress, with beneficial effects afforded by the implementation of the intra-aortic balloon counterpulsation pump, prompts one to think: (i) that such episodes of TTS in conjunction with trauma, and in much milder forms than the ones published,2 may be more frequent than currently appreciated, and that widespread implementation of echocardiography (ECHO) may provide insights on this issue; indeed the use of hand-held ECHO devices used by all members of the care team3 may be instrumental to this effect; (ii) that in addition to trauma and distress, the subarachnoid haemor-

© 2014 Royal Australasian College of Surgeons

1. Overton T, Phillips JL, McReynolds D. Takotsubo syndrome with refractory cardiogenic shock after trauma: successful treatment with an intraaortic balloon pump. ANZ J. Surg. 2014; doi: 10.1111/ans.12691. 2. Madias JE. Forme fruste cases of Takotsubo syndrome: a hypothesis. Eur. J. Intern. Med. 2014; 25: e47. 3. Panoulas VF, Daigeler AL, Malaweera AS et al. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur. Heart J. Cardiovasc. Imaging 2013; 14: 323–30. 4. Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur. Heart J. Acute Cardiovasc. Care 2014; 3: 28–36.

John E. Madias,*† MD, FACC, FAHA *Icahn School of Medicine at Mount Sinai, New York, New York, USA and †Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, USA doi: 10.1111/ans.12825

Supraclavicular lymph node metastasis as a first sign of rectal cancer without visceral metastasis.

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