Thyroid Nodules, Cancers & Treatment

I have a special interest in thyroid disorders so we're going to talk about thyroid nodules thyroid cancer and how we manage that today a brief outline of what we'll talk about for the next 40 minutes or so at the end there'll be a chance for questions we're gonna briefly talk about thyroid function abnormalities it's not really the purpose of the talk but I know there's a lot of questions about it so we'll just talk about that briefly I will talk a little more if I read nodules and cancers focusing especially on how we look at thyroid nodules how we evaluate those then move into how we manage them deride nodules in cancer and throughout I'll try to highlight the way things have changed over the past year just by way of introduction the thyroid gland is located low in the neck sort of below your Adam's apple that you can feel that's your voice box and above your breastbone it is critical and all our body does the simplest way to think of it it's kind of a gas pedal for our metabolism just make sure things are at the right level if it's working fine we don't really notice it this brief Anatomy picture this is without the muscles overlying or the collarbones there I think it drives home the point that there is very rich vascular supply to the thyroid gland it doesn't work by acting in the neck it makes its hormone in the neck and it works everywhere else sort of shaped like a butterfly as people describe it there's talk about those little more the right lobe at the left lobe and connecting them we call that the Isthmus again we're going to briefly talk about thyroid function abnormalities there is some bad information on the internet generally about a lot of things but that's especially true of low thyroid function low thyroid or underactive thyroid is called hypothyroidism some symptoms that could be fatigue depression weight gain constipation course skin or hair feeling cold much of the time feeling forgetful I want you to notice that most of those symptoms are very nonspecific most people who feel that way don't have low thyroid function but certainly if you feel that way it's worth a check but most people with those symptoms don't actually have low thyroid function the most common cause of low thyroid function it's an autoimmune condition called Hashimoto's disease or autoimmune thyroiditis unfortunately sometimes we're sort of told this magic all we need to do is take tired hormone we're gonna feel entirely new lose a bunch of weight ton of energy the bottom line is if it sounds too good to be true it probably is there is rare exceptions that there are some people with very profound low thyroid function that when they're treated they feel a lot different that's the exception rather than the rule contrast that to hyperthyroidism or an overactive thyroid these people may fear feel irritable or nervous may have panic attacks for anxiety some muscle tremor or weakness weight loss infrequent menstrual periods or diarrhea sleep disturbances feeling too warm all the time again there are several types of this it's a little less common than an underactive thyroid there's a subtype called Graves disease some of you may sort of associate this picture with hyperthyroidism the bulging eyes and Graves disease is again an autoimmune condition that gives you hyperthyroidism that causes some swelling and inflammation of the muscles that move your eyes so sometimes you sort of do have that bulging appearance look so how do we test for thyroid function well thyroid stimulating hormone or TSH is a lab that all of us have had whether we knew it or not it's a hormone produced by the pituitary gland and as the name suggests it causes your thyroid to be more or less active it moves inversely with our thyroid function so if you have an overactive thyroid that would be reflected by your TSH being suppressed being very low because your pituitary gland is sort of telling your thyroid to relax if your thyroid is under active that TSH would be elevated we do check that in all patients with thyroid nodules I'll tell you why in just a second t3 and t4 is the abbreviation for the hormones that's made by the thyroid the vast majority hormone in our blood is t4 brand name of that is synthroid or leave both Iraq scene is a synthetic form of that that's what most of the hormone in our body is our body actually uses t3 and our body converts that t4 into t3 sometimes we check those TSH is a great test for thyroid function gives you a good picture of how your thyroids been acting over the past month or so is almost always the only test needed certainly if it's abnormal then it makes sense to check the hormone levels if it's abnormal there are some other tests you can do to try to figure out why it's abnormal it's typically the only test we need and although thyroid function abnormalities are relatively common there's no connection between those and thyroid cancer it's not a sign of thyroid cancer it's not a risk factor for thyroid cancer there is a rare connection between thyroid function abnormalities and thyroid nodules and that's why we check TSH when people have thyroid nodules but not thyroid cancer that's all we're gonna say about thyroid function so thyroid nodules thyroid nodule is just a identifiable mass in the thyroid gland they are very common about 5% of adults have thyroid nodules that their doctor can feel but over half of adults have thyroid nodules if we look for them that's an important take-home point I think if you hear from your doctor that you have a thyroid nodule you assume there must be something wrong and that it's dangerous but they're very common and most are not dangerous tyree cancer is also relatively common over 1% of us will be identified with hurricane it will be diagnosed with thyroid cancer at some point it is more common in women by now the fourth most common cancer in women in expected over the next 10 years to become the third most common cancer in women and it's becoming much more common just by example from 1975 to 2009 now three times more common than it was then so we wonder why natural question there's some controversy here certainly part of it is that we find a lot more thyroid cancers a lot more people have cat scans of their chest or spine MRIs or carotid ultrasound so we find nodules in some of those are thyroid and it's true we find a lot more small early thyroid cancers if that was it though we would expect the proportion of people dying from thyroid cancer to be much lower if that was true that's that's what we'd expect that bless and less proportionally would be dying of thyroid cancer but that's not what we see in fact we see a lot more early thyroid cancers but more and more advanced thyroid cancers as well so it's a real thing the bottom line is we don't really know why that is there's some regional areas where there's more thyroid cancer thought to be related to environmental exposure although we don't know what that is certainly around things like the Chernobyl disaster over 100 fold increased risk of thyroid cancer thought you know that it could be having to do with increased medical imaging x-rays or cat scans we haven't proved that but it seems feasible the bottom line is we don't know why there are four main types of thyroid cancer by far the most is papillary thyroid cancer followed by follicular thyroid cancer essentially everything we'll talk about from now on is about these two those two together we call well differentiated thyroid cancer medullary thyroid cancer much less common sometimes part of a genetic condition and a plastic cancer thankfully very rare and very severe but most what we're talking about is those first two papillary thyroid cancer and follicular thyroid cancer you can't have symptoms of thyroid cancer if you have a firm rapidly growing mass that doesn't move compared to surrounding tissue that's very concerning if you have dramatic change in your voice and a vocal cord that isn't moving if you're coughing up blood there's big lymph nodes in your back those are all ominous symptoms but most people feel fine they truly do they may feel that there's a bump there but otherwise they don't feel anything a symptom we see all the time in the office is people feeling like there's a lump in their throat or they feel something when they swallow that's a very common symptom usually caused by some chronic throat irritation or Voicebox irritation either related to drainage from the No was acid reflux it is not at all a common symptom of thyroid cancer there are some risk factors of thyroid cancer we know that radiation exposure increases your risk of thyroid cancer having a first-degree family member with thyroid cancer increases your risk those are kind of the only well-defined risk factors when radiation was first used medically it was quite popular and we used it for all sorts of things people would have radiation for swollen glands or acne or colic in babies we have thankfully gotten away from that but people who had that as children certainly are at increased risk more commonly now we'd see it therapeutic radiation for cancers childhood cancer especially increases your risk most people with thyroid cancer don't have identified risk factors this is the 10,000 foot view of how we manage thyroid cancer we're going to get into the details in a bit the primary treatment is taking out the cancer all of their treatment can only be performed if the thyroid cancer has come out first the exact extent of surgery is determined by the disease and we'll talk about that more an internal type radiation is sometimes used what that is it's a radioactive form of iodine thyroid cells and most thyroid cancers concentrate iodine and so we can use the radioactive form to our advantage it's concentrated by the thyroid cancer and then kills those cells sort of a conventional radiation where you'd go to get radiotherapy five days a week for a few weeks or conventional chemotherapy is really quite unusual it's sometimes used for really advanced tumors there are newer chemotherapy agents that are used for some advanced tumors but most of it is surgery and radioactive iodine as needed and there's generally an excellent prognosis this is another important take-home point of those people with thyroid cancer less than 5% of them will die if thyroid cancer that does force us to temper how aggressively we treat thyroid cancer understanding that most of the time it will not kill that patient I would think of it for most people is something that has to be managed but not something that's going to prove to be life-threatening of course there are exceptions to that so we're gonna take a historic look at how we have evaluated thyroid nodules over the years I think some of these strategies may seem familiar to some people in the room who may be been through this themselves or had family members who've been through this the bottom line is things have become much more complicated and in a good way this is how things used to be we felt a thyroid nodule and we took it out and that meant a lot of people had surgery who didn't have thyroid cancer but it was simple and it meant a lot of people had thyroid surgery then we started using ultrasound not a call Tristana first sort of started in the 70s you had to be in a water bath it wasn't really convenient at all but over the subsequent decades we've started using this and so we said well you have a thyroid nodule let's make sure you have a thyroid nodule it's fine the thyroid nodule and then maybe take it out a test that some of you may have heard of is a thyroid skin or a radio iodine uptake in scan used to do those all the time there were some very low risk patterns on radio iodine scan and if you had that pattern then we could avoid surgery but most of the time you didn't have that pattern so still most people we saw a nodule we took it out again relatively simple the radio iodine is the same radioactive iodine that you'd have to treat cancer with just much much lower doses so how do we do ultrasound that's now an important part of evaluating thyroid nodules it's recommended for all patients with known or suspected thyroid nodules the thyroid itself should be evaluated as well as the lymph nodes around the thyroid it answers a lot of important questions tells us if there's a nodule or not tells us how big the nodule is it tells us what that nodule looks like and it gives us information about the nearby lymph nodes it has a lot of benefits it's cheap it's painless it's widely available no complications from it and it gives us the best information so there are more expensive tests cat-scans radioiodine scans MRI and none of them are as good for thyroid nodules so a lot of times we find thyroid nodules things like cats cans and then we evaluate them with ultrasound which gives us much better detail this is practically how its performed you have ultrasound probe over the neck with gel and based on how much of the sound energy comes back and how long it takes to get back then the computer generates a picture for us I'm gonna walk you through this just a little bit because we're gonna look at a few more ultrasounds but on this kind of picture and on all the ultrasounds imagine that you are lying down your head is away from here and your feet are coming out and we're going up and down over the neck here's the trachea windpipe this is the right-sided carotid artery the left-sided carotid artery these black things are muscles that overlay the thyroid gland and this is the thyroid a normal thyroid is homogeneous it typically looks brighter than the surrounding muscles but these are the big landmarks this is a normal thyroid there's no masses there's no lumps or bumps in there it's a little big because it's extending over the carotid otherwise looks pretty normal contrast that with this this is a more typical look where we're really just looking at the right side of the thyroid gland here is the trachea the right carotid artery muscles overlying the thyroid the thyroid in a well-defined thyroid nodule that's what we're looking for so now that we started using ultrasound regularly we said well how great would it be if we knew what it was before we decide to do surgery maybe we wouldn't have to do as much surgery so that's when biopsy started becoming more common in the 80s and now picking up steam over the subsequent decades and that can give us a couple answers we can find out that it's thyroid cancer we can find out that it is not cancer and unfortunately sometimes we can't really tell about five percent of the time we don't get an answer period which is very frustrating it's frustrating for everyone but it's even more frustrating for patients who had needles in their neck and then we don't have an answer generally recommend to repeat it but this is also frustrating about 20% of biopsies even today with the best biopsy the best cytology techniques still end up in that indeterminate group the challenges here those cells don't look entirely normal but not abnormal enough to be called thyroid cancer or it's not the type of cells we normally see in the thyroid gland we talked about those types of thyroid cancer papillary thyroid cancer follicular thyroid cancer most papillary thyroid cancers are relatively easy to call cancer on needle biopsy follicular thyroid cancer is much more difficult what defines cancer is not the cells but the way they behave if they're invading into surrounding structures and so oftentimes we're gonna be stuck here so now that we have this how do we know when we're gonna biopsy it we can do an ultrasound and see it how are we gonna side if we're gonna biopsy it again used to be very very simple everything over a centimeter about half an inch we biopsied we're doing that less now and the current guidelines would say the size still does matter but the appearance of the on the ultrasound matters a whole lot more and I think this is facilitated by better ultrasound most thyroid nodules do not require biopsy they're either too small or look very reassuring on ultrasound so they need to be evaluated but most don't end up neat being biopsy I'm gonna show you practically what this means how that looks where do that by showing some ultrasounds here so again this is a left thyroid nodule this is the trachea left carotid artery muscles overlying the thyroid this is all the thyroid and there's a large nodule okay must be an inch and a half two inches that's not thyroid cancer that's a fluid-filled cysts we don't need to biopsy that to prove if it's thyroid cancer or not so we don't contrast that to this this is still a big nodule in about the same place but it looks very different this is actually a very low suspicion nodule this looks like a sponge we'd call that a spongiform nodule this is not papillary thyroid cancer but it could be one of the more unusual types so we'd still biopsy these but only if it's quite big so two centimetres or so is when we'd biopsy those this might be harder to orient yourself this is the carotid artery on the right side that's the trachea this is a much larger nodule aside from the size though it has a fluid-filled the component but it's mostly solid so it's a higher risk nodule it's about 10% risk so these now we'd biopsy if they're a little smaller about one and a half centimeters this can be how that follicular thyroid cancer can look first is this this is another right-sided nodule right carotid artery trachea-thyroid in that nodule it's a little higher suspicion about 20% risk because it is solid because it's darker than the surrounding thyroid this looks a bit like a papillary thyroid cancer that's why we would biopsy those now there are anything bigger than a centimeter there's some ultrasound features that are extremely concerning for thyroid cancer if it's solid and darker than surrounding thyroid and has micro calcifications is what this is showing or there are certain growth patterns if it's invading into the surrounding muscle there's large lymph nodes nearby that's highly predictive of thyroid cancer and so we'd biopsy those if they're pretty small some of you may wonder well if you think it's thyroid cancer why wouldn't you biopsy if it's five millimeters you know why wait for it to be a centimeter it's based on a couple things first we know from autopsy studies that a lot of people who die of unrelated conditions die with thyroid cancers up to 20% or even more people who die have small side cancers and they didn't hurt them they were there and didn't hurt them so that's why we hesitate to biopsy things when they're very very small we also know from some countries Korea and Japan especially have done a lot of screening ultrasounds which is not recommended here but just screening ultrasounds and so they find a lot of small nodules and for a while we're very enthusiastic about by up seeing a lot of nodules so they found a lot of small thyroid cancers and for many of them they decide to do nothing just watch them keep doing ultrasounds see if anything changes and they learned that for a large portion of those patients nothing did change over a long time and so they didn't necessarily have to take them out because of that that's why we tend to wait for it to be about half an inch before we biopsy it that's also not always true if there's large lymph nodes associated with it that cancer is proving that it is dangerous and it should be biopsied even if it's smaller how is that performed we use altra sound almost always that dramatically reduces the risk of falsely normal biopsies basically because your biopsy normal surrounding thyroid perform within needles just trying to send some of the cells to the pathologist that's the tissue they want and it works very well if that test says you have cancer 95% chance you have cancer if that test says it's not cancer it's the nine ninety five percent chance it's but I can be performed physicians office I do that several times every week and sometimes performed in the hospital we call that @fn a fine needle aspiration biopsy this is practically what it looks like an ultrasound showing you where you are in a needle collecting cells and this is what I'm looking for okay this is a nodule in the left side of the thyroid trachea rotted artery muscles this is the thyroid and there is a small nodule there must be a centimeter or so so basically you can't feel that nodule you're being sure that you're sampling the nodule and not that surrounding thyroid it used to be quite common to perform biopsies without ultrasound guidance sometimes it's still done for really large obvious nodules but even in those case they're higher and lower risk portions of nodules so ultrasound can really help I'd say a biopsy performed without ultrasound is useful if it shows cancer if it's benign it's not that reassuring because you don't know that you've actually sampled what you want to sample so here's where we are so far we think you have a thyroid nodule we do an ultrasound to find out if you have a thyroid nodule based on how it looks we decide to do a biopsy and we can get a couple answers it's actually a lot more complicated than this which I'm going to show you in a second but this is just evaluating nodule used to be this you know thyroid nodule let's take it out now this is the fleshed out form of that last slide okay this is just to figure out what to do with that nodule we haven't talked about treatment at all at this point so it's getting a lot more complicated that's very clear now let's talk about what we do this is the historic patterns benign let's do nothing cancer let's take out your whole thyroid one of those in between remember 20% of biopsies end up here the risk of cancer in knees is about 20% let's take out that half of your thyroid let's briefly talk about this most benign thyroid nodules don't need surgery there's exceptions to that if it's very large if it's unsightly that's growing very rapidly and we're concerned even if it doesn't look like cancer on biopsy sometimes with certain thyroid function abnormalities we may remove a benign thyroid sometimes if they get large enough they're going into the chest makes sense to remove that thyroid if it's suspicious enough sorry if it's suspicious enough that we biopsy it and it proves to be benign it's not as clear what we're supposed to do with that observed doesn't mean do nothing but it means keep an eye on it truthfully it matters exactly what it looked like if it looks like a very high-risk nodule recommendation be to repeat that biopsy in about six months for most we generally look again in a year if it's grown significantly generally agreed to be about 20% in two of the three dimensions or if it's picked up new suspicious features then we'd recommend repeat biopsy versus keeping an eye on it what about this I said this is what we always did it was one of those in between 20% risk of thyroid cancer so we took out that half of the thyroid gland the secret in thyroid cancer surgery is most people who have thyroid surgery are in this group most people who have thyroid surgery don't have thyroid cancer most people with thyroid surgeries strictly speaking don't need thyroid surgery so the question is does that make sense does that make sense on the one hand only 20% risk of cancer it means most of these people don't need cancer a lot of unnecessary surgery with risks complications inconvenience a lot of cost the other hand if I knew that I had something in me that a 20% chance of being cancer and possibly hurting me I think I'd want to know and that's why that's what we recommended when we knew that we took it out now there's some other testing that's available there's genetic testing that's available so people who end up in this indeterminate group trying to figure out do you actually need surgery or not there's a few different types of tests this is the one that I do basically we can look at the genes that that thyroid nodule is expressing it's not a it's not a your body genetic test it's a genetic test of that nodule there are certain patterns of gene expression that are extremely low risk extremely reassuring that goes here and has the same risk of being cancer as if that initial biopsy said it was cancer we can treat it just the same and there are some people that don't have that extremely reassuring pattern it's not to say that it's definitely thyroid cancer but they don't have that extremely reassuring pattern that's called suspicious for those benign ones we treat it just like it was benign as the same risk we treated like benign for those suspicious ones we take out that half of your thyroid the breakdown for the tests I use is 50/50 here if you're in this indeterminate group the results are about 50/50 that you'll end up in one or the other of those that means that here you have about a 40% chance of it being cancer so most people in this suspicious group still don't have thyroid cancer the upside of this is half the people avoid surgery the downside is it's expensive much less expensive than getting half your thyroid out but it's expensive and it's not perfect 5050 cancer here is really 20 80 but the test is 50/50 and this is where the big advances are gonna be over the next decade next 10 20 years they're developing tests that should be able to tell us benign cancer and stuck in between and what I'd hope is we have a test that if it's 80/20 we'll give us something like 75 and 25 so most people can avoid surgery if they don't need it so here we are we talked about this this is historic now a lot of times we can avoid that surgery what about this that's what we always used to do but I said early on the extent of surgery is determined by the disease I used to be what we did you always took out the whole thyroid unless we were taking out half a thyroid and we just incidentally found a small thyroid cancer then sometimes we'd leave it there but if we knew it was thyroid cancer you'd always take out the whole thyroid there are some genetic tests that don't tell you if it's benign or not they tell you if it's cancer versus staying in that middle group the downside of that is everyone still gets surgery you do in half your Surge half your thyroid out or the whole thyroid out but with more recent guidelines maybe that's not true the advantages of this is it allows you to do radioactive iodine you cannot do that radioactive iodine treatment if you have half your thyroid it doesn't work the radioactive iodine would just try to kill the other half and wouldn't treat thyroid cancer you also can't do whole body scans thyroid scans very well if you have half the thyroid it also makes it a lot simpler to follow up lab work is much easier to interpret if you don't have a thyroid the disadvantage there is it increases your complications and it guarantees you will need to be on thyroid hormone if you have half your thyroid out a little under half of those people will end up needing to be on thyroid hormone but if you have your whole thyroid out you will die without taking thyroid hormone you absolutely need to be on it and it does increase your complications simply put having half your thyroid out versus the whole thyroid out means you have half the risk of complication it's not one out of a thousand versus two out of a thousand it's six percent versus twelve percent so it's not nothing so we have learned that more limited surgery is often appropriate we talked about cancer in terms of its tumor staging or T staging now t1 t2 t3 t4 based on the size and how its acting compared to surrounding tissues turns out the people with early thyroid cancers can be treated very successfully by taking out that half of their thyroid you have no increased risk of dying from your cancer and you avoid a lot of complications people with large invasive thyroid cancers absolutely need their whole thyroid out they were less likely to die they have their whole thyroid out those are the patients who need radioactive iodine and that can only be performed if the whole thyroid zone people in between with moderate sized but not terribly invasive therapy answers there are patient factors that can take you either life turns out most people with thyroid cancer are in these groups most people are in those groups this especially is a big recent change that some of those people with a three-centimeter cancer but otherwise looking pretty well behaved they have the same survival if you only remove that half of their thyroid briefly talking about what we do after surgery sometimes we do thorough hormone you have your whole thyroid out you need thyroid hormone thyroid hormone the more thyroid hormone you take the lower your thyroid stimulating hormone will be remember they move inverse to each other high rates stimulating hormone makes your thyroid be more active it also stimulates thyroid cancer it makes thyroid cancers grow more so based on how risk how high-risk your disease is we may want that TSH level to be quite low so sometimes we want to give you extra thyroid hormone sometimes radioactive iodine if you have an advanced tumor we follow it with labs and ultrasound unfortunately some people get dropped and they don't have any following but this allows us to detect recurrences early on and there's a whole host of other possible treatments we can do based on whatever outcomes or specifics of that patient the new standard of care then today treatment includes less biopsies instead of biopsy everything over a centimeter we're a lot more discerning in that less surgery and this is where more advances are going to be made but that's primarily doing less biopsies and genetic testing more limited surgery for people with thyroid cancer less radioactive iodine treatment can't really talk about this today but radioactive iodine has its own possible complications it as risks does increase your lifetime risk of another cancer because it's a radiation exposure it has side effects it's expensive and relatively inconvenient the bottom line is all of this is better it's better for patients it also means it's a lot more complicated okay let's talk about that the American Thyroid Association is an organization with thyroid surgeons and endocrinologists and oncologists and radiation oncologists and radiologists and they get together and review the evidence and published guidelines about how to manage thyroid nodules or thyroid cancers and they've made a couple goes at this the first one is ninety six you've gotten more information and the flowcharts have become more complicated so it's become a more complicated document and it's now ballooned to well over a hundred pages that more individualized care about this is good means less complications it means less inconvenience means less cost for patients the downside is this is harder for your doctors if your doctor spends one or two percent of his or her time taking care of thyroid patients it's probably not that realistic that they would know all that it's just not that realistic that means there's a lot of people today who have thyroid ultrasounds to talk about the size of the modules and that's it not how they look I mean there's a lot of people even with a history of tired cancer no one looks at the lymph nodes in their neck there's a lot of people who have biopsies that they probably don't need or don't have biopsies on pretty high suspicion nodules it means that a lot of people aren't offered genetic testing before they have surgery and it means a lot of people with early thyroid cancer have their whole thyroid out because it's more complicated that's the downside of the more individualized care here are some take-home points thyroid nodules are extremely common having a thyroid nodule in and of itself is not dangerous doesn't mean there's anything wrong just means you have a little bump in your right they do require evaluation with ultrasound and some simple labs most thyroid nodules don't require biopsies most thyroid nodules do not require surgeries third cancer treatment is becoming much more individualized more conservative and being up to date on guidelines and current evidence is important to get the best outcomes while minimizing complication here are some resources for you American Thyroid Association they disseminate evidence-based guidelines for me and other clinicians at thyroid org and you can read those guidelines there's also more patient oriented things there's also guidelines about how to manage hyperthyroidism and hypothyroidism payara disease and pregnancy and children and every other thing you could imagine excellent patient oriented website is this light of Life Foundation it's evidence-based but is really geared towards patients and gives a lot of good information I'd encourage you to check out either of those websites that's all I have and I'd be very happy to take any questions you have now [Music] you [Music]

Channel: Holland Hospital

Views: 51,401

Rating: 4.7372265 out of 5

Keywords: Thyroid Nodules, Cancer treatment, Holland ENT, Lakeshore Health Partners ENT, Peter Hoekman

Id: r0WvjePd62Q

Length: 34min 46sec (2086 seconds)

Published: Tue Dec 20 2016