- Thank you, I just wanted to
say my name is Kaniksha Desai and I'm from the endocrinology division. Thank you all for coming out here tonight to listen to me talk about
a topic that's very near and dear to my heart. thyroid diseases, I've been studying them for over a decade now and as Nora said, I have a clinic here that
deals with thyroid cancer and thyroid nodules. But tonight I'm actually gonna talk about all thyroid diseases. Hopefully I'll go over what
the most common questions that some of my patients have and then if at the end
there are still questions, that I'm sure people will have them, I'll be happy to answer them. So topics that we're
gonna cover this evening, so I'm gonna start with
what the thyroid gland is, what does it do, where is it located and then we're going to cover four main topics. We're gonna talk about hypothyroidism which is an underactive thyroid gland. Then we're gonna talk about the other end of the spectrum which is hyperthyroidism and overactive thyroid gland. And for the second half of my talk I'm gonna talk about thyroid nodules, what they are, how we find them, monitor them? And then lastly I'm gonna cover the topic of thyroid carcinoma, staging, prognosis and treatment. So thyroid diseases, I'm sure all of you know, are very common. At some point in most
people's lives they may end up with the thyroid nodule, sorry, a thyroid disease. Over 10% of the population
will have a thyroid problem. It tends to be more common in women, five times more common in women. And thyroid diseases tend
to increase with age, so things specifically
like thyroid nodules and hypothyroidism tend to
occur more as you get older. They can cause fertility
issues in young women as well as cardiac
disease and osteoporosis in both men and women. And iodine deficiency is the
most common cause worldwide of thyroid diseases which causes a goiter in hypothyroidism. Here in the United States we actually iodized our salt
years ago so it tends not to be an issue but outside of the United States they don't do that and so a lot of places
have nutritional issues and one of them is iodine deficiency. So here in the United States
the most common causes of thyroid disease are
autoimmune thyroid disorders which is Hashimoto's or
an underactive thyroid or Graves' disease which
is an overactive thyroid. So there are certain risk
factors that predispose you to having thyroid disease. We covered some of them but age, unfortunately there's not a lot we can do about that risk factor. As people get older they're more likely to get a lot of diseases
including thyroid diseases. Thyroid diseases tend to
be more common in women. And then if you have a family history of either an autoimmune problem or a thyroid cancer you're
at a slightly increased risk of having them. Your children are a
slightly increased risk of having them as well. And lastly, if you have
another autoimmune disease such as type one diabetes or lupus or Crohn's disease then you're more likely to get a thyroid autoimmune disease. Specifically for thyroid
carcinoma we do know that there is one significant risk factor which is radiation exposure
directly to the neck area. In the 1950s and 1960s radiation came out as a treatment option for
a lot of simple problems like acne and large tonsils. The medical community got a little excited about it since it worked so well. Unfortunately there we're side
effects which we found out. And one of them was that
thyroid cancer tends to occur decades after the exposure, especially if it happens
to be during childhood. So the thyroid gland, it is located in the neck area. It's actually located at the bottom of the neck area near
where your collarbones or clavicles are. And it sits in front of your windpipe, also known as your trachea. On the left side is your food pipe, also known as your
esophagus and that's near to the thyroid gland. And lastly, the vocal
cords which help you speak are located near the thyroid gland. As you can see, the thyroid gland is actually similar to a butterfly shape. It has a right side and a left side and then it has a small connector piece that's known as the isthmus. So what does the thyroid gland do? So the thyroid gland regulates
metabolism in the body. It acts on almost every
other organ in the body, your bones, your gut, your heart, your lungs. It's actually regulated by a gland in the brain called the pituitary gland. So the pituitary gland sends a signal that some of you may already
know which is called TSH which stands for thyroid
stimulating hormone. This stimulates the thyroid gland into producing thyroid hormone. So the thyroid gland
produces two main types of thyroid hormone, T4 and T3. The difference between these
two hormones is the number of iodine molecules that
are on the actual hormone. So T4 contains four iodine molecules and T3 contains three iodine molecules. The T4 actually tends to
be more stable than T3 so the majority of the hormone produced by the thyroid gland is T4. And then to both of these
get put in the bloodstream, they go out to where
their target organ is, say your heart, and then often times the
T4 is converted to the T3 so that he can actually
act on the specific organ. So your thyroid gland
actually produces a well, finely tuned, regulated
amount thyroid hormone. So how does it do that, how does it know that it's
not producing too much or too little? So specifically, we have
a feedback mechanism where these particular
two hormones act back on the pituitary gland. I guess you can't see my. So the T4 and T3 act
on the pituitary gland kind of like an inhibition. So think of it as you
trying to drive your car in two different places. So if you're driving your car on a highway you wanna be going faster. So in order to do that you step on the gas to speed your car up to go with traffic. So if there's not enough thyroid hormone and it's kind of going slowly
it sends a little message back to the pituitary gland that says, hey, speed up. So the TSH increases and
causes the thyroid gland to stimulate to make more thyroid hormone. Opposite of that, if you were to be driving
your car in a neighborhood or near a school you
wanna be going slower. So if there's too much thyroid hormone it sends a little message back to the pituitary gland to say, hey, we have too much, you can slow down. And this actually causes the
TSH to stop being produced by the pituitary gland and
that decreases the stimulation to the thyroid and
decreases the production of the thyroid hormone. So this is actually gonna come back and be important when we talk about the different thyroid
diseases that you can have. So we do get pictures
of the thyroid gland. There's two main things
that we use for pictures of the thyroid gland. For anatomy, to look at what
the different structures are, here we use an ultrasound is
the best imaging that we use. We can also use a CT scan but we like to use an ultrasound machine. And as you sort of saw before
the thyroid gland tends to be butterfly shaped. And we have a right side and a left side that we were talking about
and that connection piece on top of the trachea is your isthmus. And surrounding both
sides are your arteries and you can see the arteries
on the ultrasound as well. And I think it's a little
bit not showing up here but on the left side the
esophagus is located over there. The other scan that we have is a radioactive iodine uptake scan and that basically tells us what is the thyroid gland actually making? So it's kinda like a physiology scan. So here at the bottom we
have the thyroid gland and it's telling us what different parts of the gland are actually
making the thyroid hormone. So this is important and things like an
overactive thyroid gland, we want to see what
part of it's overactive and then we also want to
see if there's inflammation which we can see both on this uptake scan and on the ultrasound. We do use the CT of the neck
area in certain circumstances, basically when we're trying to see if the thyroid gland is
very big and it's outside of the field of the ultrasound. So in the ultrasound we
can't see through bone so we're not gonna be able to
see underneath their clavicle. So if you happen to have
a really big thyroid gland that's going down
underneath your clavicle, the only way we would see
that would be in a CT neck. And we would also see if it
was pressing on something or moving your windpipe
or your esophagus off of the CT scan as well. So our first thyroid disease for tonight is hypothyroidism. So here in the US I talked
about how autoimmune causes are the number one cause of hypothyroidism in the United States. Basically an autoimmune disease is where your body doesn't
actually recognize itself. So normally your body is very regulated to recognize self versus
outside things such as bacteria and viruses so that you
can control what comes in. Here in an autoimmune problem
your body basically thinks that your thyroid gland
is not really part of you, it's like a virus or a bacteria or something that's attacked. So it produces antibodies to kind of attack the thyroid gland. And those antibodies
attack the thyroid gland they prevent the thyroid gland for actually making the thyroid hormone that it needs to make. So that's known as Hashimoto's disease. And then we talked about how iodine deficiency is common worldwide and if you don't have enough
iodine you can actually make the thyroid hormone since they use iodine to make thyroid hormone. Other causes of
hypothyroidism include surgery of the thyroid gland. So if we remove part or all of your thyroid gland then
obviously you're not gonna be producing thyroid hormone. So if we take out half there's
about a 20% chance or one in five that you might need
thyroid hormone replacement. And if we take out the whole gland then obviously you're gonna
be completely hypothyroid and you're gonna need treatment for that. And there's a condition called thyroiditis which is basically inflammation
of the thyroid gland. If you happen to have
thyroiditis you can go through two phases, you actually have both hyperthyroidism and hypothyroidism. They tend to occur at different times but you can get a period of
an underactive thyroid gland if you have inflammation. And of course we all know that medications can cause side effects for practically anything. And one of the side effects of certain medications
can be hypothyroidism. Some of you might be on a cardiac medicine called amiodarone that we know causes hypothyroidism. There's plenty of other medications that cause hypothyroidism as well. And lastly, we talked about how the pituitary gland
regulates the thyroid. So if you happen to have a problem with this master pituitary gland then you're not gonna send
the TSH signal anymore down to the thyroid gland
and if there's no signal it's not gonna know to
produce thyroid hormone. So for hypothyroidism what
are some of the symptoms? Hypothyroidism actually has
a lot of different symptoms. Since the thyroid hormone
acts on pretty much every part of the body you can have
some sort of symptom related to that specific organ. The most common symptoms
that most people present with is that you can get
swelling of your neck which is basically goiter
because your thyroid gland becomes enlarged trying to compensate. A lot of people can get weight gain because you're feeling tired, you're feeling fatigue so
that's another symptom. You can get constipation, you can get cold intolerance, you can get infertility problems with heavy menstrual cycles. So there's a lot of different things you can
get with hypothyroidism. The main thing is that all of the symptoms are actually pretty nonspecific so they can be caused by many problems, a lot of which are not related to the thyroid gland. So that's important to remember, so not everybody who has
constipation actually has a thyroid problem. So how do we diagnose thyroid problems? We do take a history. When you go see your doctor they'll take a history to see how long have you had these symptoms, what are your symptoms? We'll do a physical exam
especially of your neck area and then we'll check your heart and lungs, make sure they're working properly and then the main diagnosis for hypothyroidism actually comes from laboratory tests so we get that lab test the thyroid
stimulating hormone or a TSH, we get thyroid levels, specifically a T4 level, and then if we're concerned about autoimmune problems
then we get TPO antibodies. There a lot of different
thyroid antibodies but specifically TPO antibodies are associated with hypothyroidism. so as I talked about earlier there was that feedback mechanism, so in hypothyroidism the T4, is it gonna actually be low, so the amount thyroid hormone's low and that's going to go back to the pituitary gland
to produce extra TSH. So the TSH is actually
high in hypothyroidism. So how do you treat hypothyroidism? The great news is that
there's one treatment which is thyroid hormone
and they're different drugs that fall under that category treatment but basically everybody gets the same overall category treatment which is thyroid hormone. So the goal of thyroid hormone is to make your TSH normal
and to make you function as you would if you had
a normal thyroid gland. So the mainstay of treatment is actually called
levothyroxine which is T4. Some of you might know the
brand names which are Synthroid, Levoxyl and Tyrosine. Tyrosine specifically
is a newer medication and it's a gel cap with
liquid thyroid hormone. Last year they actually
produced a purely liquid form of thyroid hormone called
Tirosint-SOL as opposed to Synthroid and Levoxyl which are tablet forms of thyroid hormone. Thyroid hormone is
actually very long acting so it last in your body about a week and so we dose it once a day. The other option is a T3 hormone. The brand name is called Cytomel and it tends actually
have a short half-life of less than a day and so we actually dose that twice a day to make
sure you're getting enough. And then some of you may know about desiccated thyroid hormone. So the brand names of that include Armor, Nature and WP. so this particular type of hormone is actually poor science. It's derived from pigs and
it actually has a combination of T4 and T3 together in the same pill as opposed to the synthetic versions of T4 and T3. The only thing is that it
does have an increased amount of T3 to T4 in the specific things as opposed if you were to use levothyroxine and T3 separately. So how do you take your medications for thyroid hormones? So this is kind of important
'cause you wanna make sure that you're getting treated properly. So it's actually a little
bit complicated unfortunately to take thyroid hormone. We talked about how it lasts in the body for about a week but to take it you need to take it on an empty stomach because thyroid hormone tends to bind to a lot of things and it won't absorb if it's binding to another medication, if it's binding to a vitamin, then basically its going through your gut without actually getting
into your bloodstream. So the ways that we can make sure that the absorption is better
is that there's no food, there's no other medications and there is no vitamins in your stomach at the time you take a thyroid hormone. So you take it on an empty stomach which we consider three to four hours after the last time you ate a meal. And we take it 60 minutes
before the next meal. So a lot of people ask
me how do you take it with just a glass of water or can I just have a little bit of coffee with it? Well we know that studies have shown that even if you have a little bit of coffee with it its
gonna change the absorption of the actual thyroid hormone. Traditionally it's actually taken in the morning but technically
can be taken any time of the day and it doesn't have to be taken at exactly
the same time of day. So you don't have to take it exactly eight o'clock in the morning. Some days if you get up earlier
you can take it at 06:30. If you want to sleep in on the weekends you could
take it at nine o'clock. There some of my patients actually take it when they get up in the middle of the night to use the restroom because they haven't eaten for a long time and they're gonna to go
back to sleep afterwards so that's a good time for
some people to take it. And then other things that I was talking about is that vitamins,
specifically calcium, iron supplements and
prenatal vitamins do tend to bind the thyroid hormone, so we would prefer if
these we're separated by four hours from taking them, taking the thyroid hormone
as other medications would just be separated by the 60 minutes. I know the answer on the thyroid hormone
packaging says 30 minutes but generally we've shown
that if you can wait the full hour it tends
to be a little bit better than just the 30 minutes. And then the other thing
is that people tend to not exactly remember how long ago it was so 30 minutes
can turn into 20 minutes and then it makes a huge difference. So our second topic of tonight which is the opposite of Hypothyroidism which is actually hyperthyroidism. So causes the autoimmune problem is actually Graves' Disease where your body actually has antibodies that stimulate the thyroid gland into producing more thyroid hormone as opposed in hypothyroidism
the antibodies just prevented the actual thyroid hormone from being formed. So another cause is
actually thyroid nodules, so we're gonna talk about
thyroid nodules next but some of these nodules can actually themselves
produce thyroid hormone. And then thyroiditis which is the inflammation actually starts with a hyperthyroid phase where it just dumps out
all the thyroid hormone in your thyroid gland when it's inflamed. And lastly, there's
certain medications, again, Amiodarone can actually cause
hyperthyroidism as well. So what are the causes or
symptoms of hyperthyroidism? So you can kinda think of it as similar to hypothyroidism
except the opposite. You can still get an
neck swell in your goiter but you get other things comparatively like hypothyroidism caused weight gain, hyperthyroidism causes weight loss. Instead of constipation
it causes the other end of the spectrum which is increased bowel
movements or diarrhea. And then it can cause tremors or shaking and you feel like you're overly energized as opposed to being fatigued
with hypothyroidism. Something that's actually very specific to hyperthyroidism and
particularly Graves' disease is known as thyroid eye disease. So the antibodies that are
stimulating your thyroid gland to produce too much thyroid
hormone can actually deposit in the eye muscles that control how your eyeball actually moves from right to left and up and down. And if they deposit in the muscle it actually causes the muscle to swell and unfortunately there's not a lot of space up here so your
eyes actually stick outward or have bulging eyes. And that's actually what
thyroid Eye Diseases is, you get something called proptosis which basically means your eyes are bulging out and forward. So how do we diagnose hyperthyroidism? Well, we do a history and on our physical exam
we do check your neck but we do other check for eye disease, specifically the proptosis and we'll also check your reflexes and check for things to see if you're having a little
tremor in your hands. But the true diagnosis is
actually made from lab tests. So we get very similar lab tests which is the TSH, the T4. Here we actually get a T3 level as well to kind of compare and then the antibody that we use for hyperthyroidism
is a TSI antibody which is different than
the TPO for hypothyroidism. So what are the treatment
options for hyperthyroidism? There's actually three
main treatment options. The first one is actually
anti-thyroid drugs. So these are things like
methimazole and PTU. They've been around for a long time. Traditionally we used to use
PTU more commonly decades ago but nowadays we use
Methimazole and that's partly because of the side
effects of the medication. So they do have some side effects. Both the medications can
cause damage to the liver. It's rare but if it does happen
it can actually require you to have a liver transplant
if it goes on too long. PTU, we know causes more
significant liver problems than Methimazole which is why PTU has a black box warning against stating that there are liver
problems associated with it, and this is why we traditionally
use Methimazole nowadays. The other medication side effect is that you can actually get a
low white blood cell count from these two medications
and that would prevent you from fighting off an infection. And lastly you can actually
have an allergic reaction as with any other medication which can cause a rash and hives. These medicines unfortunately
are not curative in most patients and because of the side effects a lot of doctors will treat you
for a short period of time, usually around 18 months, so one to two years to see if you're able to get a actual cure. So that the unfortunately
the cure rate is about 30%. So what will do is put
you in a higher dose of one of these medicines and once your thyroid's normal
we'll decrease the dose, keep you on it for about
a year and then stop it and see if the overactive thyroid gland will continue to occur. If the overactive thyroid gland comes back then we do have some more
permanent treatment options. The two permanent treatment options which cure hyperthyroidism
are radioactive iodine. It's a pill that you take
and we basically attach to the iodine a specific
form of radioactivity so when it gets taken
up by the thyroid cells it basically burns the thyroid cells off. This permanently actually causes you to have hypothyroidism
following the treatment. We used to try to get you to normal but it's
actually quite difficult to just kill off part of the thyroid gland and often times the overactive thyroid would just come back. So now we give you enough
to kind of wipe out the thyroid gland in about 90% of people and then you take thyroid
hormone replacement for the rest of your life. The other treatment option
which is permanent is surgery. So we take out the whole thyroid gland and then you're on treatment
with thyroid hormone for the rest your life as well. The treatment option that
you specifically choose for hyperthyroidism is a discussion with you and your endocrinologist because each of these have
different side effects, and depending on whether you're young and woman or older we might choose one specific
treatment option over another. So our third topic for the night is actually thyroid nodules. So thyroid nodules are basically growths that are located on the thyroid gland. So they tend to be more common in women and they tend to be more
common in older patients. So over the age of 50, over 50% of people will actually have some sort of thyroid nodule, and as you get older you might actually get more thyroid nodules. Usually people don't have any symptoms of them unless they're big. So here we have somebody
with actually a big nodule if you can sort of see
the one on the right side is actually sticking out a little bit. If you do happen have a big thyroid nodule the symptoms include problems breathing because the thyroid gland
is actually located right above or in front of the windpipe. And then when you lay flat
if there's a huge spot on there it can actually cause
you to not get enough air in. And specifically if
you're nodule is located on the left side, your food pipe or esophagus
is on your left side so you can have some
difficulty swallowing. And then of course
specifically as you can see in this picture you can get neck swelling. So how do we find thyroid nodules if most people don't have any symptoms? Well, actually the majority of them are found accidentally on some other sort of picture. So somebody comes in 'cause they we're in a car accident and
we're scanning their neck or their having severe headaches and we're scanning their
head for the headaches, and then we're like ,oh, there's this thyroid nodule now, this needs to be worked up. You can actually think of it kind of like a mole on your skin. So as you get older you
get a lot more moles. As people get older they get
a lot more thyroid nodules. So how do you diagnose them? Well, we do a physical exam. If we can see it then
probably its a nodule and we look at it on an ultrasound. Unfortunately, since we
can't see the majority of them the ultrasound
machine is actually kind of what gives us the best pictures of the thyroid nodules. It tells us the size, the shape, where it's located, if it's pressing on anything? And then we get the
thyroid function tests. So we'll get a TSH and a T4 to see if it's actually producing
too much thyroid hormone. If it happens to be that
your're hyperthyroid and have a thyroid nodule then we'll get an uptake scan and see if specifically the
nodule itself is producing the extra thyroid hormone. And lastly, sometimes depending
on the characteristics we actually do a biopsy of the nodule just to make sure we rule out cancer. So does your thyroid
nodule need to be biopsied? There's certain
characteristics that we look for when we are evaluating what the chances of cancer are. So specifically, things
like irregular borders, so if is not nice and round, if it happens to have sharp edges that's more suggestive of cancer. If you get these micro calcifications, these tiny little spots, they're produced actually by cancer so we have a high suspicion that you're nodule is
can have cancer in it. And then if it's not
just in the thyroid gland but is actually located near the edge and it looks like it's spilling
outside the thyroid gland that's not a very good
characteristic to have. And that's compared to actually down here which is a thyroid cyst. So cysts actually practically a 0% chance of cancer because they're just water. Those don't actually have
to be biopsied at all. So the thyroid biopsy is a
pretty straightforward procedure that I just wanted to quickly talk about. So there a lot of different doctors that do them at Stanford Hospital. We do them in our endocrinology clinic. Our surgeons are ENT and head and neck surgeons do them in their clinic. Our pathology department actually has a walk-in clinic where you can go in for a biopsy without an appointment and lastly you can get an appointment with radiology to do the biopsy in our radiology suite as well. So what we use for the biopsy? We do do ultrasound-guided biopsy. So we use the ultrasound probe to get a picture of the nodule. We want to make sure that
we're biasing only the nodule and not specific areas of the thyroid that are out of where the nodule is. We actually use a very small needle. The needle that we use is smaller than what we draw blood with. So it only collects a couple of cells from that thyroid nodule at a time so we a few passes of the biopsy. Generally speaking, we
do somewhere between two and 10 passes depending
on how many cells come out the thyroid gland per pass. So the good news is
that Stanford is that we have cytopathologist technician who comes in the room with us and he or she will count
the number of cells. So therefore we have to
do less passes as opposed to if you we're to get
it out in the community. In some places they just
make their own slides and they do more usually
around five passes. And its actually relatively
well tolerated procedure. We do use a topical spray to numb the area and then you can use
stronger numbing medicine if you'd like which is lidocaine which is injected into the skin area. Unfortunately there's
no way of getting rid of that feeling of pressure because once the needle
goes two the nodule we can't actually numb the actual nodule, it would change our biopsy results, and we can't get down in there to numb it. Okay, so what do biopsy results mean? So first of all you can actually get a non-diagnostic result. That generally tends
not to happen a lot here because we have our
cytopathologist technician that tells us that we have enough cells. But basically, this means that
we didn't get enough cells when we went in there. If that happens then we basically have to unfortunately go back and do a second biopsy of the same nodule. Then the good news is that most of these thyroid nodules are not cancer, so about 80% of the results are benign which is considered not cancerous. So they're normal thyroid cells. And then of course you
can have the other end of the spectrum which is
malignancy or suspicious for malignancy which happens to be cancer in about five to 10% of
the biopsies that we do. And then lastly there's this grey category which is called indeterminate. So there are a few different categories that end up in this diagnoses that end up in this category which are follicular
neoplasm or atypical cells. So there's something called AUS or FLUS which basically means that there some sort of atypical cells, they're not normal, they're not cancer. So traditionally people in the category of having this indeterminate nodules had to have them removed to tell what they actually are. But thankfully, now in the last couple of decades we've actually
gotten molecular markers. So we look at your genes
to see what are the chances of this indeterminate nodule
actually being cancer? So the molecular markers are only done, to be clear, in nodules that are indeterminate. So if it comes back as normal we're not gonna send for
these molecular markers. If it comes back is cancer
then we have to remove it and we don't send for
these molecular markers. So the main goal of the
molecular markers is to use to prevent surgery, to take out normal thyroid nodules, there are many different ones of them. The specific one that we use here at Stanford is a Pharma and it basically tells you
if your nodule's normal. So if it comes back that
the molecular markers say that your thyroid nodule's normal it's a very low likelihood of it being cancer so we
don't need to take it out. But if it's positive or suspicious it doesn't
necessarily tell us its cancer but we do need to recommend
surgery to take it out to see if it's actually cancer or not. So what are our treatment options
for these thyroid nodules? So if it's normal or benign
we actually just monitor it. We look at it under
ultrasound in six to 12 months and if it's not grown
then we kinda spaced out, the next ultrasound in
another one to two years and three to five years. So
we kind of space them out to make sure they're not growing. The great news is that the majority of them don't tend to grow over the years. If we do need to take it out the treatment
option's actually surgery. So we consider very large nodules which are over four centimeters, basically the size of an
actual thyroid normal lobe. We do take them out especially
if they're causing symptoms so if you're having breathing problems or swallowing problems then we would recommend to take it out. Specifically for women
if it's bothering you that you can see it
and it's bothering you, we'll take it out. And then of course it is cancer
or an indeterminate nodule that has a positive gene
testing then we take it out. Lastly, we're getting ready to offer something new here at Stanford. So last year a new procedure, which is actually been done abroad for about a decade was approved which is called Radiofrequency Ablation and its basically where we use heat on the end of the needle
that's doing the FNA biopsy and you're burning the nodule. And this is considered less invasive than actually going in and doing surgery. So hopefully we should be
getting our ultrasound machine up and running with the
radiofrequency ablation with our ENT department pretty soon. So the last topic of
tonight's thyroid carcinomas. So why is this important? Well, for women thyroid cancer tends to be the
number six most common cause of cancer occurring in about 4% of women. And the number of new cases we're gonna have this year combined for men and women is gonna be about, predicted to be about 52,000. The good news is that as you
can see in the bottom part these are the cancer estimated deaths. And the number of deaths estimated from thyroid cancer are pretty small so they're not one of the top 10. It's about 2000 deaths estimated. So thyroid cancer has
actually been increasing. So the number of patients diagnosed with thyroid cancer has been increasing in the last decade or so which is another reason why it's important and we need to talk about it. So how do you diagnose thyroid cancer? Thyroid cancer tends to first
present as a thyroid nodule. So as we talked about
earlier most patients of thyroid nodules don't have symptoms and unfortunately most patients with thyroid cancer actually
don't have symptoms. But the symptoms are the
same as the thyroid nodules. You can have difficulty
swallowing, difficulty breathing, neck swelling and then you can also have hoarseness because your vocal cords, your voice-box that control your voice-box are located near the thyroid gland. And the majority of thyroid cancers are
actually found accidentally on imaging for something else, like we talked about how you would get a CT scan for your neck. To evaluate if fully, we get an neck ultrasound, not just a thyroid ultrasound. So we're looking at both
sides of the thyroid gland and we're looking at different structures around the thyroid gland which
are basically lymph nodes. We want to make sure
that the thyroid cancer, if it is thyroid cancer, hasn't spread anywhere else
outside of the thyroid gland. And then lastly we do get an FNA biopsy of the thyroid nodule to rule it, to basically diagnose the cancer. The other thing that I was gonna state is that actually the
thyroid cancer majority of cases does not make the thyroid gland stop producing thyroid hormone. So most people actually
have normal thyroid function and unfortunately there isn't a blood test that we can use to diagnose
thyroid cancer at this time. So there are four different
types of thyroid cancer, Papillary thyroid cancer is the most common type occurring in about 80% of people. The second most common type
is follicular thyroid cancer which occurs in 10 to 15% of
people with thyroid cancer. And then medullary thyroid cancer is a hereditary form of thyroid cancer. Lastly, anaplastic thyroid cancer, which is actually quite aggressive, thankfully only occurs in
around one to 2% of patients. So how do you stage thyroid cancer? Its actually staged
similarly to other cancers There's four main stages and the stages actually increase with the amount of cancer that you have. So in stage one the cancer is pretty small and is located just in the thyroid gland, as apposed to stage two, it's larger, it can
spread to the lymph nodes outside of the thyroid gland. Stage three is invasive neck disease and stage four is extensive neck disease or you have thyroid cancer
that's spread outside of the neck area into
the lungs and the bone. Thankfully the majority of people, two thirds of patients actually
have localized disease. So the thyroid cancer is
just in the thyroid gland. Some people, about a quarter of patients have lymph nodes that are involved and advanced thyroid cancer is present in less than 4% of patients. So the other category that we use is that we risk stratify patients. So we used, the American Thyroid
Association recommends a risk stratification procedure. Thyroid cancer staging kinda tells you the overall prognosis, what are your chances of being
alive and mortality at five, 10 years out. The risk stratification
is what are the chances of the thyroid cancer
coming back at some point? So unfortunately with thyroid
cancer you can be cured for decades and it can actually come back like 25 years later. So we want to know when you
have your thyroid surgery what are the chances that is
actually going to come back? Its similar to staging and
that low risk patients, if this only in the thyroid gland, the chances of it coming
back are pretty low. If it's spread to the lymph
node it's a little bit higher. And then if we we're unable to get the whole tumor out
we'd start with a resection. Or if you have cancer
that is located outside of your neck area into your bones, even if we do cure you, it has a high chance of coming back. So the overall prognosis
is actually really great with the patients of thyroid cancer, if you happen to do get thyroid cancer, which is an unfortunate diagnosis. Your overall prognosis for five-year survival is actually high, at 98.2% compared to other cancers. Even if it spread to the lymph nodes it's still pretty great. So if you have localized disease
stage one low risk disease it's basically almost 100%
survival at five years. And even if you have
lymph node involvement in your neck area it's
still pretty high at 98.2%. The prognosis for patients
who have cancer that's located in their lungs and bones is a
little bit lower at about 56%. So what are the treatment
options for thyroid cancer? Thyroid cancer has three
main treatment options. The primary treatment
option is actually surgery. So we take out the actual cancer and a lot of patience nowadays this is enough to cure you. If you happen to have a
very small thyroid cancer that's just located on
one side we can actually just do half of your thyroid
gland out and that's curative. If the thyroid cancer
spreads to the lymph nodes and the neck area then we have to use a secondary treatment
called radioactive iodine. And basically we start with the surgery, the surgeon gets out as much as they can and then we use the
radioactive iodine treatment to kinda kill off any sort of other cells, normal or abnormal cells
that might be remaining. And then the third form of treatment which we use in the majority of people is actually
thyroid hormone replacement. So we talked about how the TSH
stimulates the thyroid gland and if your TSH is high its
actually gonna cause any sort of stuff to grow, some of it which may be cancer. So in patients with
advanced thyroid cancer or extensive disease we actually use a suppressive treatment dose. We use an extra amount of thyroid cancer to keep that TSA signal low so that the cancer cells
don't actually grow. And then lastly, it's very rare, but in patients with
advanced thyroid cancer whose cancer it tends
to be growing we do use, we have some chemotherapy
options but unfortunately none of the chemotherapy options
are curative at this time. We're doing ongoing research to come up to see if we can get a cure but at this time the chemotherapy actually just keeps the cancer from growing rather than
actually curing you. So we do reserve it for
pretty much the worst cases of thyroid cancer and if
it happens to be growing. So the long-term follow-up for patients with thyroid cancer is
that we get pictures. We look to make sure the cancer is gone and it doesn't come back which is based on a thyroid ultrasound. There is actually a tumor marker that we use once you have treatment for your thyroid tumor which is called thyroglobulin. It's basically a protein
produced by thyroid cells, cancer cells and normal cells. So if we take out your entire thyroid lobe and we give you the radioactive iodine there should be nothing left so there shouldn't be any protein produced in your tumor marker, thyroglobulin, should be close to zero. The other test that we use is a TSH to monitor your dose of thyroid hormone. Depending on how extensive your cancer is we have a different goal at TSH. So if you have a low risk and
your cancer is pretty small then we just keep your TSH in
the bottom half and normal. The more advanced your thyroid cancer is the more that we keep
the TSH closer to zero. And then if your thyroid
cancer has spread outside of the neck area we do use
PET scans and CT scans, but unfortunately the PET
scan for the diagnosis of thyroid cancer, it doesn't really do a good job at picking it up because PET scan uses glucose and thyroid cancer actually
has a lot of iodine in it so we used an iodine whole body scan instead of a PET scan for patients who have extensive thyroid cancer. So the take-home points
for today's lecture is that thyroid diseases are common. The amount of thyroid
hormone is closely regulated by the body through a feedback
system which uses the TSH. And labs are needed for
the diagnosis of both hypo and hyperthyroidism since the symptoms are very nonspecific and can be caused by a
lot of different problems and the specific labs that we use included TSH. The thyroid nodules are common and the good news is that
most of them are not cancer and overall if you happen
to do get thyroid cancer the prognosis is an excellent prognosis. We do have a few resources
available for patients So the American Thyroid
Association is an entire group that's dedicated to learning about and expanding research
on the thyroid gland. And they have a lot of
information available on their website for things like hyper, hypothyroidism, thyroid nodules. The American Association of
Clinical Endocrinologists also known as ACE also
has information available for thyroid diseases. And lastly, there is a national Thyroid Cancer Survival group, ThyCa, that produces
information on patients with thyroid cancer. So questions? Okay, we'll start in the front. - [Woman] Years ago I took the first medicine you
came up with, Synthroid. - Oh, thank you. - [Woman] I took Synthroid and I was told that I couldn't take generic for that. And so now I'm taking (mumbles). - What are you taking now?
- [Man] Levothyroxine. - [Woman] Levothyroxine, I can't say it. And I've had one pharmacy
filling and I only done that maybe for a year and I was fine. Then I changed pharmacy and all of a sudden I took maybe, I don't know, two or three pills and I got eyes. - Okay, the question was
generic versus brand name and reactions to medications? So years ago brand-name was
considered significantly better than generic because it tends to be a little bit tightly
controlled compared generic. Each generic company, so all the different pharmacies will have a different company
that it contracted for the generic and they make
their tablets differently. So the tablet contains
the thyroid hormone, plus a color, a dye, plus a filler to make it
look like a nice round shape that you take. So a lot of people can
actually have reactions to the different fillers that
they use to make the shape or the color of the actual dye. And if you go from different pharmacy to pharmacy you'll see that
the tablet shape changes and the color actually changes. So if you were to use generics you need to get thyroid hormone testing done every time you change the generic. The generic medications
have actually gotten significantly better 'cause the FDA has tightly regulated them. So theoretically, if
you use the same generic from the same company
from the same pharmacy you could actually use generic
with a pretty good result, depending on how tight you
want your TSH to be controlled. In patients with thyroid cancer or pregnancy we still
do recommend brand-name 'cause it doesn't matter
what pharmacy you get it at or what state you get it in, it's all nationally
produced from one pharmacy or one company. - [Man] So levoxyl brand name? - Yes, so Synthroid and Levoxyl are the two major brand
names that are tablets. Tyrosine is a gel cap or a liquid and then levothyroxine is the generic. Mylan is the most common generic company that produces levothyroxine but there's many different companies that produce levothyroxine. In the back? - [Man] Is a new medication for hypothyroidism better
saturated than the liquid one? - So the liquid one, they have some data showing that it's a slightly better absorption. If you're able to absorb the Synthroid, if you follow the recommended guidelines and you're able to absorb it then I don't think it's
necessarily that much better. But if you're having things, if you've had gastric bypass or you have stomach
problems and you're not able to absorb it or you have
a G-tube and you need to put the medication in through a G-tube then the liquid medication
theoretically would be better. - [Woman] Yeah, I take
Levothyroxine and it is normal that you have the same
quantity for almost 20 year? - Okay. - [Woman] That's one part of the question and the other is I do
my control twice a year, a blood test, and the results goes like one test is down and then goes up and then in
the middle and then goes down. So I want to know if that's normal? - Yeah, so actually, the question was is there variation in the blood test results
and are you gonna remain on the same dose of thyroid
hormone throughout your life? So actually, as you go
through different stages of your life as you grow older, if you happen to be a
woman and you get pregnant, or you happen to be a woman
and you go through menopause, your body actually controls
the amount of thyroid hormone and it actually naturally changes it. So it up regulates it
or down regulates it, depending on a lot of different
things happening to you, what's going on in your environment. We try to give you a thyroid
hormone from the outside and get it as close to
possible to what the thyroid would do normally. So it does change. As you get older the dose will change. If you happen to go through
pregnancy the dose will change and when you go through
menopause the dose will change. This is actually why we recommend
getting a blood test one to two times a year to make sure the dose
is still good for you. There will be variations. So seasonally there's
variations in the TSH. So if you happened to get it in the winter or the summer there's
gonna be slight variations. There's also a lab variability. So if you went into the
lab twice in one day and got it the TSH is never
gonna read exactly the same. It might be pretty close but it's not gonna be
the same exact number. So all of those things, yes, there is variability and yes, your dose can change. The majority of the
people actually are not on the same dose throughout
their whole life. - [Man] Concerning
hypothyroidism and lab testing, what sort of numbers are
threshold numbers for diagnosis? - So there's actually two separate categories of hypothyroidism. There's something called
sub-clinical hypothyroidism where your lab numbers are just right outside the reference range and then there's overt hypothyroidism where your TSH tends to be
significantly higher, over 10. The reference range is created for 95% of the normal population
so there's gonna be 2% that are on both sides of the end and still considered normal. But generally, we try to keep everybody in the normal reference
range if at all possible. Now, some people might feel
better at certain parts of the normal reference range. Everybody's a little bit different in what they need to
make them feel the best. So that's kind of a conversation between you and the doctor. - [Man] What is the reference range? - Actually, it's lab specific. But generally speaking
somewhere between 0.4 and 0.5 is the lower end
in normal and four to five, depending on what lab you use, is the upper end of normal. - [Woman] A couple of related questions. One has to do with the range itself. It seems so broad that I would imagine that some of us would feel better in different parts of the green? - Yes, I know some people do feel better if their TSH is one as opposed to three, even though it's in the reference range. - [Woman] And the other thing is, I don't know if it's just my experience or there's something to
it but my experience is that medicating for hyperthyroidism
is a lot more difficult than for hypo. I have hyper and so many
people that I know have hypo and they're fine on the
same dosage for a year and they get tested once a year. I can be tested two or three months, every two or three months
and it fluctuates so much. It gets increased. It gets decreased. - So the diseases actually for hypo and hyperthyroidism are different. So that's why with hypothyroidism
it's a little bit easier to regulate it with the thyroid hormone and with methimazole which
I'm assuming you're using for your hyperthyroidism, the dose is actually once
your thyroid quiets down and becomes normal sometimes
you can actually taper off the medication and
brin git to a lower dose. We're always trying to bring
you to the lowest possible dose so that it decreases the
risk of side effects. And you know with thyroid hormone, if you're in the normal range
there is no real side effects other than if you have an allergy to the fillers or something else. But if you happen to be
outside the reference range then obviously you have symptoms of hypo or hyper thyroidism. But with methimazole there's
actually side effects of liver damage and then the
low white blood cell count and actually a rash. So we wanna prevent
those kind of side effect by using the lowest possible dose. - [Man] There are gluten free diets are useful for thyroidism? - So there's no evidence that
getting a gluten free diet if you don't have a
gluten allergy is going to improve things like thyroid disease. If you do happen to have a gluten allergy tyresin is the only gluten
free thyroid medication. - [Woman] What are the sources of iodine, since I don't add salt to anything and told to leave the
salt off everything I eat? - So iodine comes from a
lot of different foods. Dairy is actually pretty common. So things like eggs will have it. If you eat a lot of Asian foods, seaweed will actually have it as well. I'm trying to thin of other things. We have specifically patients
that go on a low iodine diet for thyroid cancer and it's
actually very difficult. So a lot of foods to contain iodine. If you're concerned about
an iodine deficiency you can actually talk to your doctor about getting an iodine
level but it's really rare to have iodine deficiency. - [Woman] In the United States, you mean, 'cause you said it could
be possible elsewhere? - Yes, so if you happen
to eat out at restaurants then they do use iodized salt at the majority of restaurants so you're probably getting
iodine somewhere even if you don't add salt to
your food directly at home. Your probably getting it somewhere
if you happen to eat out. - [Woman] I just put it on my
food in the restaurant too. - It's possible but it's really rare to have it here in the United States. - [Man] Hearing the results of the test, if THS is very high that
means it's hypo, right? - Yes. - [Man] It's very low that means hyper? - Yes. - [Man] So if it's very
high that means your glands are producing stimulative hormone to make your gland produce more T3 and T4? - Yes, but if it's running high that means your body can't actually, it's over driving to
send it to keep it normal which is more than it needs to be doing. - [Woman] Do doctors
know whether the level of thyroid problems now are about the same as they were 50 years ago, 100 years ago, 200 years ago? - So there are certain thyroid
diseases like thyroid cancer that are actually
increasing in the incidents. The other thing is that we
do know that as a population, as you get older your TSH does rise and since we're having an older
population a lot more people do tend to get diagnosed
with thyroid diseases. I don't know if there's some
data whether the incidents is actually rising, but we don't know why that is, we don't have a specific cause. - [Woman] You touched on
this but how do you know if you're allergic to the fillers? - You usually get rash or hives, yeah. (laughing) - [Woman] How do you
know if you're allergic to the fillers, I think? - Yes, so it's the hypothalamus
above the pituitary gland. - [Man] Is it possible that the problem is associated with that, with that part of the regulation system of the thyroid itself? - That's actually why for
a lot of the diagnosis we get both the thyroid level and the TSH. So normally they're opposites, right. So in hypothyroidism the actual level of thyroid hormone's low and
the the THS is gonna be high. And then in hyperthyroidism
the THS is gonna be low but the thyroid hormone's gonna be high. If they both happen to be low then you have a pituitary problem. So we do get both of them. So we're ruling out a pituitary
problem since we're getting both of them at the same time. - [Man] You didn't touch
on any of the causes of thyroid problems. Is there any general
rule or diet or anything for avoiding thyroid problems? - So this goes back to your topic. If you were technically
iodine deficient then you would have an increased
chance of getting thyroid, a goiter or thyroid nodules. But other than that there is not a lot of dietary restrictions or
encouragements that we use. You could, technically, if you took a lot of iodine supplements you can actually overdose on iodine and cause hyperthyroidism, the other end of the spectrum. But again, you have to be
taking a lot of iodine, it's more than just food you'd have and you take some supplements. The other thing is if you take some of the thyroid supplements that
are available on the market, they're not FDA regulated and they do actually
contain thyroid hormone. So you can actually make
yourself have hyperthyroidism with thyroid supplements too. So you just have to be careful. You can actually read the
back of the supplement and they have to state if
they contain thyroid hormone. They should state if they
contain thyroid hormone in them. Other questions? - [Woman] How do you prevent
going into osteopenia or osteoporosis from
treatment for the thyroid? - Okay, so osteoporosis is associated with too much thyroid hormone. So things like hyperthyroidism
can predispose you to having osteoporosis. And then if we give you
extra thyroid hormone and in cases of advanced thyroid cancer there is an increased risk of
osteoporosis or osteopenia. Generally, we recommend to
have good bone health habits as well and then we try to put you on the least possible
dose of thyroid hormone or we try to treat your hypothyroidism to prevent the osteoporosis
and osteopenia. - [Man] Is anyone doing
research on serum markers of hyper or hypothyroidism,
the hormone itself? - Can you just repeat the question, sorry? - I'll put it a different way. Is anyone doing tests on serum
markers for the presence, absence of thyroid cancer? Serum markers? - So blood markers, we don't have a specific one
other than thyroglobulin. You can get gene mutations
that predispose you to having thyroid cancer. We don't use them
routinely for every patient that comes in but there is a panel of gene that predisposes you to
having thyroid cancer and there are gene mutations
that actually cause the cancer that we do know about. We're updating the list regularly. - [Woman] I want to know if it's prudent to be treated for hypothyroidism, only by the tribal decision without no seeing endocrinologist? (laughing) - I would like to say that everybody with thyroid disorders come
see an endocrinologist. That my be possible. We do have a limited
number of endocrinologists, depending on how your
thyroid disorder is going, how comfortable your primary
care doctor is in managing it. Is the treatment working or not? You can't always come
see an endocrinologist. Feel free but it kind of
depends on your relationship with your primary care doctor. - I have treated by primary physician and never gave me the chance
to see an endocrinologist. - So actually, board medicine, internal medicine certification
includes thyroid diseases so all primary care physicians
are board certified trained in thyroid diseases. So they'll tell you if it's more advanced than what their training is
and then they'll just refer you to an endocrinologist at that point. - Good to know, thank you. - [Woman] I wasn't quite finished. In osteopenia, is it possible
that the doctor told my sister that since she was getting
mail order thyroid drug for 10 years that the
mail order comes plus or minus the active ingredient by 15%. It's not specific and
she was getting too much and it caused to push her into osteopenia because it took the
calcium out of her body to neutralize the extra hormone, is that possible? - Yes, that is possible. So the FDA actually recommends closer to five to 10%, plus or minus for the
medications nowadays. The way we would know that
actually is to do the blood test so you would have seen
that on the blood test if the thyroid hormone does is too much, then we just lower it. - [Woman] I'm thinking
she's gone with taking them and they haven't tested
her and noticed it? They should be telling
her it's going higher? Something went wrong. Osteopenia, that's not a good condition. - It's not and I agree. But that's how you actually regulate it. So we do know that it changes. The amount you need actually changes so your dose can be the same but as you get older you
may need a little bit less or a little bit more and we do that based on the blood tests. - [Woman] I think we're out of time. - Oh, okay. Okay. - [Woman] Thank you so much. - Thank you. (audience applauding)
