Thyroid Nodules & Thyroid Cancer: What You Need to Know | UCLAMDChat

hi everybody my name is dr. Masha livid this is dr. Michel yay we are endocrine surgeons at UCLA and we'll be talking to you today about thyroid nodules and thyroid cancer what you need to know so please ask questions on twitter using the hashtag UCLA md chat so for my part of the talk I'll be talking first about how common are thyroid nodules how do you work up a new thyroid nodule what are the new advances in diagnosis specifically I'll mention molecular testing I'll be reviewing so a little bit about the new guidelines and recommendations from the American Thyroid Association and then talking about the initial treatment of thyroid cancer dr. EA will then talk about surviving and treatment of recurrent thyroid cancer and then we'll ask we'll have time for questions at the end so to start with let's talk about how common are thyroid nodules in the population so as it turns out dired nodules are actually very common if you were to ultrasound everybody up to half of six-year-olds would have a thyroid nodule and on the illustration there you can see the pink portion there if I go like this I'm not really showing up but so this part is your thyroid you can see some follicles here this is your airway or your trachea and your spine back there so that's where your thyroid is right here in the front of your neck risk factors for thyroid nodules are increasing age females having a radiation exposure or being in an iodine deficient part of the country tired nodules are also more common in women and we need to differentiate whether the nodules identified on physical exam or by an ultrasound so here you can see this is a patient who has a thyroid nodule that you could feel and you could see so that's a palpable thyroid nodule and about 6% of women and 1.5% of men would have a palpable nodule but if you were to ultrasound everybody than the majority of women 75% of women and about 40% of men would have a thyroid nodule seen on ultrasound and thyroid nodules are more common as patients get older so you can see in the graph this is age and again if you ultrasound everybody by the time your age 80 or 90 most patients would have a small thyroid nodule seen on ultrasound but most of these will not be palpable meaning you can't actually feel it in your neck now the next very important point is that most thyroid nodules are not cancer so the first time when a patient is told that they have a thyroid nodule they immediately think you know is this cancerous and the good news is that it's unlikely to be cancer the overall malignancy rate is only about 5% but it is a higher malignancy rate if you're a child or if you're older so the next question is how do we work up a new thyroid nodule so the important point is that as I said most ira nodules are benign so we need to separate the benign nodules from the suspicious nodules that require further workup and potentially treatments so as physicians we always start with a history by talking to the patient and this focus is first on could this nodule be producing excess thyroid hormone so usually those patients will have weight loss trouble sleeping anxiety heart palpitations things like that it's also important to note whether there's a family history of thyroid cancer or any endocrine disorders in the patient or in the family that might suggest a genetic predisposition the next important point is radiation exposure so that doesn't include cat scans or dental exams or x-rays that's really you know if you live next to a nuclear power plant or if you had radiation treatment for something like lymphoma as a child now most thyroid cancers are painless and most thyroid nodules are also painless so pain is not usually a symptom of thyroid nodules sometimes if a nodule is very large it can cause compression so that's usually nodule that's over about four centimeters in size and then the patient may have trouble swallowing the next step would be a physical exam so we'll feel the neck will feel what the nodule feels like if we can feel it and also feel for any lymph nodes and then we'll also check the labs specifically what the thyroid function tests are however the history and the physical exam alone are not very accurate in differentiating between a benign and a cancerous thyroid nodule what is really a key is the thyroid ultrasound and the biopsy the ultrasound is highly accurate for thyroid nodules it's not invasive there's no radiation exposure most patients don't require any other imaging so most patients do not need a CT scan or a PET scan or anything like that there's a lot of benefit to the surgeon performed ultrasound so if a patient does end up needing surgery it's really helpful for the surgeon themselves to do the ultrasound you can see exactly what the nodule looks like other nozzles and the lymph nodes that's really helpful and there is an example here of an ultrasound and this is the thyroid nodule over here so these are some features that are associated with a nodule that's more suspicious for cancer so hypo code means that it looks darker or blacker compared to the surrounding thyroid tissue you can see a little more white you can see some calcifications those are the bright white spots here you can see that the margins here get a little bit irregular so all of those findings would be a little bit more suspicious for a malignancy in the thyroid and we also look back to see if there's any previous ultrasound to see if the nodule has grown and what the lymph nodes look like so there are as I mentioned some new guidelines they came out from the American Thyroid Association just a few months ago and they helped us with suggesting how to work up and treat thyroid nodules and well differentiate thyroid cancer now these are just guidelines so ultimately the treatment decisions is up to the patient and the physician working together so do all fibroid nodules need a biopsy and the answer is no it depends on how big the nodule is and how suspicious it may look on the ultrasound so this is based on these new American Thyroid Association guidelines they recommend no biopsy for most nodules smaller than one centimeter in size now there are rare exceptions for example if the nodule looks very very suspicious on the ultrasound if there's a strong family history or known genetic condition things like that but for most patients if you have a nodule less than a centimeter they recommend not biasing and just continuing to watch it with serial ultrasounds nodules that are purely cystic so this would be an example you can see how it's completely black inside so it's filled with fluid those nodules are almost always benign and usually don't require a biopsy now they do recommend by if a nodule is greater than one centimeter in size and looks very suspicious on the ultrasound so this one looks sort of like the previous one where you can see that there are some white spots or calcifications some irregular margins however if a nodule does not look suspicious they recommend waiting it until it's over a centimeter and a half in size to biopsy and the whole rationale behind this is to avoid over treatment so this is an example of what the biopsy looks like it's performed under ultrasound guidance you can see that the operator is holding the ultrasound probe this is the needle going in to do the biopsy this is done after the skin is a locally numbed up so it's an office procedure it's a little bit uncomfortable but has pretty small risks associated with it before we were able to biopsy patients if you had a thyroid nodule the only way we could tell if it's cancerous or not was to remove it now with by of seeing we can screen out a lot of patients have benign nodules and not operate on them so it's decreased the number of patients having surgery by half these are the main categories of what your Bible results may be the first one is non diagnostic we'd rather not see this it means that they just didn't get enough cells during the biopsy so usually those patients require a rebuy of see the next category would be benign that's most results and if it's benign then there's a very high chance over 90% that it truly is the nine so those patients usually don't need any surgery can just be observed now I'll talk a little bit more about this in determinant category this means that there are some suspicious cells but you can't tell that it's cancerous and this can be a little bit frustrating so we'll talk about that one the next two categories are basically that it's cancerous or most likely cancerous and we usually treat that with surgery so this is an example what the cells will look like from a fine needle aspiration biopsy you can tell that they're all small uniform and size nothing suspicious about them okay so what do we do with an indeterminate biopsy this means that the risk of cancer is between about five to thirty percent depending on the wording of the biopsy traditionally most of those patients would have a repeat biopsy and then have a surgical excision because there's no other way that they could tell whether it was cancer or not and you might ask why why can't we tell on this 5c if it's cancerous or not so sometimes what you need to determine that it's cancer is to see those cells coming outside of the capsule of the nodule you can't tell that with just a biopsy a lot of times so this is where the role of molecular testing has come in has really improved the care I believe in these patients so our whole goal is to avoid unnecessary surgery for indeterminate thyroid nodules meaning if your nozzle is benign and not causing any compressive symptoms we'd like to leave it alone and not operate on it so if you look at a nodule that it has an indeterminate biopsy result the risk of cancer about 20% so if you have surgery and it ends up being cancerous then that was good that was the right thing to do and then you may need further surgery to remove the rest of your thyroid depending on the results however most patients will be here they will not have had a malignancy in their thyroid and in that case you've done the surgery they may require some thyroid hormone then you know unlikely but may have had a surgical complication or a difficult recovery so we'd like to minimize this arm basically so there are some molecular markers that have been developed over the past several years and they rely on the fact that cancer cells have a different gene expression profile compared to benign cells so our protocol at UCLA is that whenever a patient is having a bias here of their thyroid nodule we reserved an extra little sample for the molecular testing that way the results of the biopsy are indeterminate we can just reflexively send off them like they're testing the patient does not need to come back for another biopsy and then it will give us some more information that's how we do it and there are several different tests that are out there two of those sort of best validated ones and the ones that we have at UCLA available are this afirma vr site GC and thyroid seek version 2 and the way the results are are either benign or suspicious if it's the 9 then there's about a 95% chance that it's truly benign it's almost like getting a benign biopsy in the first place and most of those patients are observed unless they have a very large nodule or something else if it's suspicious it doesn't mean it's cancer for sure but it bumps up the chance of cancer at about 50 to 80% so most of those patients will have surgery so let's talk now about the initial treatment of well differentiated thyroid cancer so a very important point to mention here is that most patients do not die from thyroid cancer because most thyroid cancers are not as aggressive as some other cancers we know pancreas cancer for example so the mortality is only about one out of every 200,000 patients and this has been stable for a long time so these are the types of thyroid cancer papillary and follicular they make up the majority these are the well differentiated ones that I'm talking about and you can see the 10-year survival is very good medullary thyroid cancer occurs with about 5% of patients sometimes the genetic predisposition also a good tenure survival this unfortunate patient did have what's called anaplastic thyroid cancer that's the very very aggressive kind it often presents with a rapidly growing mass very hard often already metastatic at presentation those patients do have a median survival of 6 months but thankfully that is very rare so let's talk about the different treatment options for thyroid cancer usually the thyroid comes out in halves so it's either half of a thyroid removed which is a lobectomy or the whole thyroid root which is a total thyroidectomy so this also comes from the new guidelines and you can see so this is your thyroid here so if we're doing a lobectomy that means we're removing this half and you still have this half of the thyroid so the new guidelines suggest that a lobectomy alone is sufficient for many patients who have a tumor less than a centimeter get this is well differentiated where the tumor is not going beyond the thyroid into the muscle or the trachea there's no clinical spread to lymph nodes so there actually could be a couple of lymph nodes that have a little microscopic tumor cells in there as long as they're not large and then no high risk features and the family or the patient like radiation exposure the guidelines do recommend doing a total thyroidectomy if the tumors over four centimeters in size extending into nearby structures if there's bulky large lymph nodes and they specify about 2 centimeters so that's a pretty big lymph node and or if you have distant metastases and you can see that's the whole thyroid being removed there you about one slide yes one comment so what tumors less than one but actually there's some data to suggest I don't know if that's a type of it can be up to four yeah so that's gonna be oh sorry perfect so I'm anywhere in between one to four centimeters you know all this is a little bit controversial since these this is all sort of evolving in clinical practice but their suggestion is that between one to four centimeters consider lobectomy alone yeah that's something new yeah the 2015 guidelines is probably an overall movement toward a little bit less aggressive treatment in otherwise that's sort of acknowledging that maybe we were over treating some teri cancers before exactly right so this is all very individualized because you have to be able to do a good altra sound to see what the lymph nodes look like you have to have a good pathologist to really look at the cells is there any extension beyond the thyroid things like that but it's great because it gives us the ability to do less surgery if we feel like that's indicated for the patient and why would we want to consider a lobectomy low risk patient's it's because more surgery does not improve the prognosis that's then we want to avoid patients being on hormone replacement so if you just remove half of the thyroid that about eighty-five percent of patients don't require any thyroid hormone that's great and then especially if it's a lower volume surgeon you can potentially decrease surgical complications by doing less surgery so why should we consider removing the whole thyroid in high-risk patients first that there often will be little microscopic tumors in the other half the other thing is that it enables treatment with radioactive iodine ablation I'll touch on that in a minute and the last thing is that how do we follow patients after they have had a thyroid cancer surgery I think you'll talk about that a little bit more but one of the ways is with a tumor marker called thyroid globulin you can only check that if the whole thyroid has been removed because normal thyroid also produces the same tumor marker so it improves our ability to have surveillance in high-risk patients so in terms of the role in radioactive iodine ablation following surgery there is also a movement just like there's a movement to less surgery there's a movement to less radioactive iodine following surgery so again some points from the new guidelines it is not routinely recommended for low-risk patients and there used to be a time when everybody would get radioactive iodine depletion following surgery now it's definitely not routinely recommended it should be considered in patients who have a tumor over four centimeters some spread beyond the thyroid or metastases to the central or lateral lymph nodes and they're only strong recommendation in the literature is if you have distant metastases in the lungs for example or if it's really gross this buddy beyond the thyroid I would say in clinical practice probably a lot of these patients would get radioactive iodine and certainly all of these patients would but you know if you have a tumor that's a centimeter or a couple centimeters in size that don't have doesn't have any high-risk features then there's really a movement towards not giving radioactive iodine right now do you see why we're using it in about 35 percent of our patients that's down considerably from even a couple years ago when we used it sometimes in almost all of them five years ago so I think this is my last slide the risk of recurrence is really based on the initial extended disease so I said that the overall long-term survival is excellent but that doesn't mean that patients can't have morbidity associated with thyroid cancer can really affect their life cause problems in the quality of life and some of that comes from a local records potentially need for a reoperation that has higher risks associated with that so the overall recurrence rate about 15% and the real high risk features are if you had a really invasive tumor initially that was growing into surrounding structures if you had incomplete tumor resection the first time and certainly if you have distant metastatic disease then I turn over t-thanks um do we have we might have a couple questions that came in already maybe you could help us and if you want to take one or two before we move on sorry we're a little late by the way okay first one before do you recommend sucking on sour candies during radioactive iodine therapy didn't protect the salivary glands I actually think that's a good idea I've heard a lot of our endocrine ologist recommending that I also recommend drinking a lot of water it can help with sort of the read activity washing out sooner so that you're safe to be around your children quicker yeah basically anything to keep up the salivary flow once again the question is about what to do after you've gotten a dose of radioactive iodine page typically our patients are isolated for a few days then and get sucking on sour candies not only helps the Sowerberry celebrate flow but also helps pass the time when you're locked up in that room here's another good question so I have a four centimeter nodule on my left node node some smaller ones on my right thyroid the big one has been biopsied it's four centimeters five seems benign I don't want to have surgery but I'm worried it might be cancer what's the recommendation that's a tough one you wanna take us - sure so traditionally four centimeters has been a little bit of the cutoff the concern being that the biopsy is a little bit less reliable then if you imagine a pretty big nodule if you biopsy one portion of it it's benign that's great but what if there's another portion that you didn't biopsy so the bigger the nodule the higher the false positive rate is having said that it's still pretty low so if the bin not if the biopsy is benign it really most likely is not cancer you have to think about whether it's causing any compressive symptoms because at that size it does often cause little trouble swallowing and so four centimeters is often our cutoff to recommend surgery but most likely it would be benign so I think there's really some room for patient decision-making here yeah I agree you know a lot of patients are 85% of patients when they have a four centimeter knowledge or something something like that are going to have some discomfort when swallowing or sometimes some difficulty breathing a lot of our patients with nodules that size of greater do end up having surgery you know in something that we want to assess in a patient like this is the man or woman are they young or old what are the risk factors for surgery so it's a young woman that's probably going to keep growing over time and also an young patient surgery is very safe so we probably be inclined to do an operation in that patient yeah so maybe I'll show a few slides and we'll then we'll take some more questions - yeah thanks for sticking with us I we know that um you know any given part of this presentation is not going to help everyone but we're just hoping to cover some of the most popular categories that people have questions about I'm going to talk a little bit about thyroid cancer survivorship and I want to thank FICA the thyroid cancer survivors organization for helping us get the word out about this today now I called this talk the fundamentals and I fully realize that there were a lot of emotional and social aspects that the people in the audience are more expert about than I am so I'm just going to about the clinical aspects and at the end we'll will take on a few questions I have a couple disclosures I do a serve as a consultant to these two companies the objectives for the next 10 15 minutes or so is to talk about the prognosis of papillary thyroid carcinoma so popular I'm going to stick to the most common one about 90% of thyroid cancers are papillary in their variety we'll talk about both survival and recurrence these are the two clinical endpoints that we really care about how doctor how mile how long am I going to live and do I have to be concerned that this is come back and harm my health in the future we'll talk about surveillance how do we keep track of these tumors in terms of biochemical testing blood tests and also radiographic surveillance by that I mean scans and then last I'll touch a little bit about dealing with recurrent thyroid cancer and some of the people in our audience have probably already dealt with this and I know many people are concerned about this possibility so it's important that we address this just an overview about the scope of the problem you know if you have differentiated thyroid cancer most people ninety percent will be adequately treated with a single operation that forms the base of this pyramid and we're going to come back to this pyramid a bit later on some people out say about 9% require two operations oftentimes the second operation will be to address a lymph node or a set of lymph nodes that may have not have been fully addressed at the first time or as possible that it was a true recurrence that it grew back later and just the very tip of this pyramid are a small number of people with more aggressive thyroid cancer thankfully that's the minority and they may need more than two operations the reason we know about this here at UCLA is because we spend a lot of time doing these repeat operations we reserved one full day a week to deal with people who have recurrent thyroid cancer and it's one of our passions is tell people like that so busy slide just looking at survival and recurrence in papillary thyroid carcinoma you see here in this top graph that based on the size does people with smaller tumors have excellent survival you know in other cancers we talk about things like for colon cancer or for pancreas cancer we talk about five-year survival to end your survival because those diseases are so aggressive you'd rather not have one of those but in fact cancer people we talk about overall survival 10-year 20-year survival we have the luxury of thinking about this because in general it's a slow-growing tumor so even if you have a very large tumor for even 8 centimeters even the lowest number here in terms of survival at 10 years is 80% so thyroid cancer patients do really well having said that on this side you notice that the larger the tumor is the more likely it is to recur or come back sometime in the next 10 years so I'm going to emphasize this point more than once the recurrence rate for thyroid cancer will range from 5 percent to 35 percent based on a number of factors now I don't mean to scare you but you're going to want to know where you are in that risk profile which will which will go over okay um when do these recurrences happen or who is more likely to have a thyroid cancer recurrence so this is work from Ohio State from dr. Matsu ferry who passed away two years ago looking at the age at which somebody got thyroid cancer here and how likely was it that they had a recurrence okay so here you see this classic u-shaped curve and I like to say that if you're going to get thyroid cancer you may as well be a 35 year old woman because those people have the best prognosis they have a very low rate of recurrence and a very low rate of cancer related death so the people to get recurrent disease often thyroid cancer growing back in the lymph node or in lungs more commonly in a lymph node are you're going to be very young teenagers or people over 50 what you see here cancer death is this black line so even though we have teenagers UCLA students people in their teens coming up with thyroid cancer sometimes in the lymph nodes they seem to live forever so they have to deal with the cancer sometimes have more than one operation sometimes have to deal with lymph node metastasis but they don't die from thyroid cancer mortality from thyroid cancer is really occurs in a small group of older tend to be older patients with more aggressive variants of thyroid cancer you may fairly ask your well doc when should i if i have to prepare myself for the possibility of recurrence when could that happen and what you see here is most of the recurrences are detected early on within the first five to ten years after surgery all right so that's when our entire surveillance is probably the most intense and what I'll reveal later is a lot of these recurrences maybe could be avoided if the first operation is done really really well that's a key point for the second half of the talk all right so just a couple of slides here showing a recurrence after initial treatment for thyroid cancer I'm just going to show on this graph from one institution shows the recurrence rate ranges from 20 to 45 percent depending on how patients are treated and this graph you just pay attention to the white line here shows the recurrence rate is 10 to 15% so once again how come we have two different studies showing recurrence rates that are so different this one is double this one how can that be right so there are biologic factors which have to do with the differences in the tumor also there are surgeon factors and it's people experts who've looked at both of these articles have postulated that the surgeons in this organization which I shouldn't name are really focus complete their livelihoods on thyroid cancer and have low recurrence rates than this institution which had many different surgeons doing a small number of thyroid cancer operations so the quality of the neutral operation really matters okay - sir to recap survival from papillary thyroid cancer is excellent recurrence takes place in ten to thirty five percent and recurrence is a function the likelihood of recurrence is a function of tumor biology and the quality of initial surgery in some ways I think these numbers are why FICA the thyroid cancer survivor' organization exists because people are happily living a long time there are a lot of survivors who live ten twenty thirty years and and they do think about recurrences and what's their quality of life and so we're happy to be here to address the the needs of this patient population all right so what are the fundamentals of how we perform surveillance for thyroid cancer meaning how do we stay vigilant that if something were to grow back that we could identify it early that we could treat it early before it became a real problem for the patient we use blood tumor markers most importantly the thyroid globulin level and dr. live as mentioned earlier that thyroglobulin is a prohormone it's the hormone that's made into theater Mon it's made by normal thyroid cells as well as differentiated thyroid thyroid cancer cells so that's why you need to have had a total thyroidectomy in order for that to be a valid tumor marker we do use a lot of ultrasound so you seeing this again ultrasound doesn't sound that high-tech but remember the neck is a surface structure it's shallow and if you have a put your probe on the surface you have an experienced practitioner it is really the best test we use ultrasound for about 95% of our imaging needs functional imaging with radioactive iodine scanning and PET scanning is I think it's it's used less and less in the surveillance of thyroid cancer we're really using biochemistry and ultrasound okay busy slide and and we wanted to give you the most updated information so dr. livets already alluded to the 2015 American Thyroid Association guidelines and these are available the guidelines themselves it's a bit of a lengthy document but it is available at thyroid org which is the American Thyroid Association website it's also available at fight org the thyroid cancer survivors Association I'm just going to touch on this concept that's really been introduced I have to credit Mike Tuttle from sloan-kettering but many of you probably know of him who talks about dynamic risk stratification now that's a big long word but all it means is that as time goes on we learn more about the patient we learn more about the tumor and therefore our concept our ability to provide the patient but with a careful or accurate prognosis like look into the crystal ball of their future that gets clearer with time all right now we meet it if we meet a new patient tomorrow they just had a biopsy that's that's concerning for thyroid cancer they want to know doc how am I going to do how am I going to do and yeah we're going to tell them something on that day but three months later we have more information one year later we know even more okay so that's all this means a lot of people have excellent response meaning after initial treatment surgery with or without radioactive iodine then you can't see they have an ultrasound of the year that's totally blank there's no evidence of disease regrowth on the ultrasound and they have a thyroid globulin that's undetectable I mean sure everybody wants to be in that boat where they have no evidence of disease not not everybody can be in that boat I just want to make sure that most people out there know that a lot of people have what we call biochemical incomplete response which means we can't see anything on altra sound but they have a little bit of thyroglobulin floating around in their bloodstream and if there's one message I have for the survivors audience is that please do not worry too much about that because most people with thyroid cancer many people with thyroid cancer live long healthy full lives with a little bit of thyroid globulin in their bloodstream and I have natural causes when they're 80 or 90 but I am aware you know I'm sensitive the fact that it does cause some anxiety so we're going to address that now a small number of people have what we call a structural incomplete response which means even after initial surgery there is tumor that we can see on imaging usually in ultrasound or CT or even at the end of surgery sometimes their surgeon was saying wasn't able to remove all the tumor and those are the patients who were were quite a bit more concerned about okay so once again we'll go back to this pyramid and the base of the pyramid again excellent response or biochemical incomplete response that resolved many people with initially a biochemical incomplete response have some detectable thyroglobulin if you leave them alone or sometimes and need additional treatment some people would have a second dose of radioactive iodine which we tend not to use they will eventually prove themselves to have an excellent prognosis that's the base of the pyramid the blue part and the top part really this top one most 10% those are the people with structural disease recurrence something we can see a target we can see under an ultrasound and those people are the ones who need a little bit more treatment a little more help we tend to see a disproportionate number of people like that at UCLA because we were passionate about treating people with that sort of complex level of disease on top I'm going to talk to you about a little bit of our about our surveillance protocol what we do here at UCLA we see everybody at three months after surgery and we have some questions for them we want to know did you have radioactive iodine or not again there's a trend toward using less radioactive iodine and you know we did talk about the ATA guidelines but I want to advise it's very important for the patients in the audience to know that these are very newly published and the degree of acceptance of these new guidelines is going to vary from endocrinologist to endocrinologist and something you should be aware of if you approach your physician with some of these new data at one year after surgery we we have a surgeon performed ultrasound so I personally do the ultrasound and all of my patients with thyroid cancer dr. livets will do the same we have an advantage we've been in there we know what we did we have detailed notes and so if there is a recurrence we would be the most likely to see that early and then we we measure by then we usually have several thyroglobulin levels and we obtain a stimulated thyroid globulin level on virtually everyone at one year and for those of you who are new to this topic a stimulated thyroid globulin is something you get when the patient's TSH is high all right so TSH is a tumor as a hormone made by the pituitary and it's basically a more sensitive way of looking at our globulin there are two ways to achieve that either by stopping thyroid hormone for a while and letting the TSH nor and naturally rise or you can give injections a recombinant human TSH now after one year I'm going to show you that most of our patients are disease-free and we follow that quantitatively here at UCLA with our quality dashboards and so there are some patients at that point we will return them to the surveillance of the render chronologist and others who we might think have a higher likelihood of having a recurrence we'll keep them a little closer to us so if there's any hint of recurrence we'll be on top of that okay real quick this is a slide this is Mike Tuttle slide talking about dynamic risk stratification and he and I were sitting in the back of a cab a few months ago and we started to talk about this concept that as the time goes on the patient's prognosis becomes closer comes closer and closer into focus sort of like a photograph and he ruthlessly stole my idea and Ruth literally showed it at a national meeting so I am ruthlessly stealing his slide I feel right in doing that but essentially as time goes on as we get to the three-month mark and a year mark we have a much clearer picture of the patient's long-term future if you have a negative ultrasound and an undetectable thyroglobulin one year the likelihood that you're going to have a significant clinical disease recurrence Falls to less than 1% and so we love to give patients that sort of get-out-of-jail-free card you know just go go live your life it's not going to be a problem again that's often a very happy day that one-year mark so a couple scenarios so scenario the first scenario complete resection negative nodes or microscopically positive just a few little specks of tumor that's that's about the same you know the microscopically positive nodes is not you can't we have an able to prove that it's worse than negative nodes on one-year surveillance we have an undetectable fabric libel and an ultrasound negative everybody wants to be in that boat it has the best prognosis okay so a lot of you may be fortunate to be in that scenario here's another scenario just slightly different complete resection negative nodes or microscopically positive nodes this is a low-risk patient and at one year the ultrasound is negative but we have a little bit of thyroglobulin that's detectable okay lots of people are in this boat plots and oftentimes there's a lot of anxiety is a little bit of thyroglobulin lurking around remember thyroid globulin is not harmful it doesn't hurt the patient in any way and a lot of these people these people have an excellent prognosis they're going to go on and live long and healthy lives we're going to have some ongoing surveillance of them but likelihood those people needing a reoperation is actually quite low different scenario complete resection with macroscopically positive nodes or you could say what's of an invasive tumor you bought about our t3 and t4 invasive tumors or nodes that are that are visibly abnormal or visibly are normal an ultrasound at one year a lot of these people have another negative ultrasound assuming that the first operation was done to clear all those notes that were abnormal and a lot of them will have a thyroid globulin that's detectable for instance a lot of our patients who present present with lateral neck disease who need lateral neck dissection a lot of the majority of them are going to have some detectable a small amount of thyroid globulin again these people still have a very good prognosis and they have a small chance at reoperation do you want to comment on this group of folks yeah I would agree with exactly that I think you know at some point if there's a couple of it's often about the biology of the actual tumor if it's already sort of clinically spread to those lateral lymph nodes is kind of telling you a little bit about his biology and at some point there might be a little bit of tumor that decides to grow back in a lymph node I'm still very unlikely to have distant metastatic disease which is what I think a lot of patients worry about yeah so so we like to say that if there is some in the neck we can manage that right we can do operations to fix that sometimes when thyroid cancer gets outside of the neck into the bones and lungs it's that becomes a little harder to treat here's another scenario a complete resection with macroscopically positive nodes or an invasive tumor and at one year if we can find some thyroid globulin what's different about this scenario is that the ultrasound is positive so we see something on the ultrasound and if that's the case this patient will likely need a reoperation so once again I want you to conceptually separate structural positive disease or structural incomplete response those people need a little bit more work same goes for this scenario where you have it if you have an incomplete surgical resection those people you know we try to give them additional therapies like radioactive iodine sometimes targeted therapies and these are the patients we're going to have very close to our chest to make sure that we manage them carefully I should mention scenario D some of you are probably in this boat people with positive anti fabric lobule and antibodies so these are antibodies made by the immune system present in somewhere between ten and twenty percent of people with differentiated thyroid cancer now normally we use the thyroid globulin that Pro hormone level as a tumor marker however some people have an autoimmune response against thyroid globulin and that makes it so we cannot use that test as a valid marker of the presence of tumor okay let me say that another way so if you if you're like 90 percent of people and you have no antibodies that would interfere with the assay if that fiber globulin level level is zero you have confidence that that is actually that there's accurately measuring that you have little or no tumor in your body however if the antibodies are there they cause some confusion and therefore that thyroid globulin indicator is not as helpful in the real world the way to think of it is we become highly dependent on imaging in this group right so then we only have one of our two tools there is a literature looking at thyroglobulin antibodies levels and measuring those as what we call a surrogate marker of disease so if you can't use the thyroid globulin does the antibody level going down mean a good thing so as a surrogate marker now the literature on this topic goes back and forth and the best I can tell you is if the anti if you have antibodies if you're in that 10 to 15 percent of antibodies and the antibody level is going down that's probably a good sign probably though not as reliable as the thyroglobulin itself and if that level staying the same or going up it may indicate the presence of additional tumor but once again the data is really not that crystal clear okay so this is a question that often get from psych patients thyroid cancer survivor' patient's so I thought we would discuss it what is the path that leads to re operation so some of you may be at home worried that if there's some cyber globulin around does that mean I'm going to need another neck operation so let's talk about that and how you get there a little bit of a complex flowchart but oftentimes the way we start is the first thing we see is the elevated thyroid globulin and the way to remember this is the thyroid globulin is so very sensitive it's like a fire alarm that can pick up a guy smoking a cigarette two doors down it's a very very sensitive assay so once there's a blip or a rise or an unacceptable level in the thyroid globulin that intent of itself won't make us do anything remember we have to have a target all right so we need something structural on it usually on an ultrasound to be visible and then we go through this process that I call we asked the question of identity which means okay you have a thyroid globulin of eight and you have a one centimeter aventure mat structural abnormality on ultrasound do I believe they're one and the same do I believe that area of tumor recurrence explains the thyroid globulin because of the patient if there's another patient in whom I can I can see a little lymph node but the thyroid globulin is 500 it doesn't match does that make sense it doesn't it doesn't match that patients going to have disease outside of that lymph node so we have to ask whether or not and what's our goal we want to take that thing out have the patient be free of disease and have the fiber globulin fall out in our dream scenario that's what we want we don't always achieve that but that's our goal so we think we have identity sometimes we'll do an fna put a needle the needle in that little bit of tumor to prove that it's that we have living tumor cells in there and then there's a discussion between the patient and the surgeon if we're going to do a reoperation in there we don't rush into these operations we have to think about what's the risk and the benefit as surgeons I think maybe that's our most important job is it worth it because if we do an operation there's gonna be risk that's for sure what benefit do we hope you get out of it are we length are we prolong in the patient's life are we improving the quality of life and if and only if we can prove that there's some tangible benefit that's worth worth the risk then and only then can we rewrite so and sometimes we we decide that that's the risk benefit ratio is acceptable and sometimes we decide it's not acceptable and we go back and we resume surveillance and we do have patients in whom we know they have a small amount of cancer it's not hurting them and we continue to watch them you have to hear and it doesn't grow sometimes in these patients if it grows a little bit we'll decide to operate but thankfully most of these sorry cancers are pretty slow growing so we have the luxury to think about this decision and the message I have to you is don't rush don't rush into any reoperation you want to comment I agree completely with that yeah you want to mention the role of PET scanning or anything in there cuz thank a lot of people you know put some questions about PET scanning we don't often use PET scanning it's a functional scan PET scanning looks at the amount of glucose consumption by the tumor and thankfully because most thyroid cancers are slow growing they usually don't take up the pet isotope subsets that do tend to be more metabolically active they're using a lot of energy and so they may be more aggressive but I don't see at most only two or three percent of our patients ever get a PET scan yeah Anna caution of getting a PET scan too early from a prior surgery it can be a lot of reactive lymph nodes even an ultrasound also if it's too soon from the time of prior surgery you have a lot of false positive reactive lymph nodes so just a caution there that's a great point yeah so after surgery you know surgery is an injury body has to heal and those tissues are going to consume glucose so you can get a lot of false positive scans so after any operation we wait at least six months to let the neck settle down and heal because before then it's hard to see much of anything it looks like a swirl of healing tissues so a message you're probably getting from my slides is when it comes to fabric cancer surgery that first operation is the best chance for cure every day we're seeing patients who had an incomplete initial operation and then it's hard to play catch-up after that we would rather the patient have an issue operation that was just perfect and we let what we like to tell our residents and students is that this is a pivotal day in the patient's life you know I just confessed as a surgeon we we come into work and it's it's Tuesday you know or was it's a day at work and and it's our job to remember that for the patient who start with cancer operations that day this is the day for them this is the big day and then we have to forget about all those other things that are going on our lives and really dedicate ourselves to make sure that we do the best operation and that could set that person free you could literally cure more than 90% of patients if you just do a great job that day we have to hold ourselves to that standard yeah so we are reliant on excellent preoperative imaging right so we do all the ultrasounds ourselves there are many operations we you know on patients who had failed operations usually elsewhere where the imaging they didn't even have a correct map of what was going on there there were positive lymph nodes that were there that they miss so if you you're the quality of operation is totally contingent upon the quality of your imaging and at UCLA and this is a trend across the country endocrine surgeons are really taking ownership of that imaging doing doing the surgeon doing that ultrasound themselves why don't you want to comment on that I just think that that's so important that's really important because if you have a radiologist who's doing the ultrasound and they may say there's a lymph node and you know left level-3 here and and go after it and you can't do that ultrasound yourself you can't feel that lymph node I just think it's so much harder to really clear that compartment so to be able to see that yourself I think is really critical yeah so we do ultrasound twice on everybody we do it for all of our thyroid cancers on today we meet them and then when they go to sleep for their operation we do it again at least for me it allows me to create a three-dimensional image of fresh in my mind of what what that patient needs what's the roadmap to that patient's operation and for us I really think sometimes I it's hard for me to imagine how I would do that operation well without the Elector sound I feel like I was flying without like flying blind so it's really quite dependent on good ultrasound so we perform methodical surgical clearance of all detectable disease compartment oriented surgery means when we take out a lymph node we don't just take out the node we take out the entire block of tissue so if there's a house on fire we don't just address the house we address the whole city block because if there's one that we saw that was abnormal we had to assume that it's got little buddies there next to it that are also having normal and I want to say this this alone this operation alone without anything else is usually adequate treatment for most patients and even my turtle even though he's not a surgeon he would admit that this is a surgical disease and sometimes when I give lectures to other surgeons about this that we talk about radioactive iodine we talk about all those followed treatments and I tell them hey there's no amount of radioactive iodine that's going to make up for your sloppy operation I hate to say that it just has to be a perfect operation I just wrap up by telling you about a case I know we're running long on time so thanks for sticking with us this is a 55 year old woman I first met in 2009 and she had positive nodes so she came to see me and I saw on my ultrasound and she had positive lymph nodes in the central net here in the middle and also she had positive nodes in the side the lateral neck so she went to another institution for surgery and she got what they called a lymph node mapping so they looked at the lymph nodes there and she had an operation somewhere else had a total thyroidectomy and neck dissection and afterward her thyroid globulin was high okay so she had macroscopically positive lymph nodes and she had a biochemical incomplete response and a couple years later she came back to see me I'll tell you what I found so when I saw her in 2009 here's her thyroid she had it and she had this abnormal lymph node here's the carotid in the lateral neck okay that's a macroscopically positive lymph node so this lady's a high risk for recurrence high risk for reoperation and there you see it again very fat lymph node it's got little chunks of calcium in it is clearly abnormal so she comes back in 2014 and I ultrasound her again and you know what that abnormal lymph node was still there so the the other institution did not remove that lymph node they did an incomplete operation and this thing continued to grow and continue to make thyroid globulin and then when it you know it actually grows kind of slowly right for years it's only like I don't know 50 percent bigger but this just goes to show that if your imaging is not good if the surge is not like that doesn't have the mindset that they're going to own that imaging you're going to leave disease behind you know this was a clear example of disease left behind anyway so we went back and we cleared that and now she's disease-free uh and this just goes to show that I I think we're privileged as surgeons you know we get to do an ultrasound and then unwrap this mystery box and then see if we were right you know and then the next time we do an ultrasound we could be better because we learn from the last case and so we do this thousands and thousands of times and it makes us better at doing the scan yeah that immediate feedback is really helpful in that process yeah so we're just like you guys what we're developing ourselves we want to be better every day this is one of our quality dashboards and what this means is a very small font but every quarter we get a printout from our information technology medical informatics service about all the thyroid cancer patients we operated on how often did they get the radioactive iodine how often did we check a thyroglobulin on them how often were we doing it by the book and we also show our results here and this was a about a year's worth of data from 2013 to 2014 showing that of all the patients we operated on with thyroid cancer in that one-year period only 1.9 percent of them needed another operation within a year and that's you know you've got to measure your quality if you're going to really be serious about it and so we're proud to offer this level of care we're always scrutinizing our own outcomes and and you know when we say we're going to offer a certain level of quality we want to back it up with the numbers to show it okay just to summarize most papillary thyroid cancer patients live long healthy lives thankfully and I know I haven't addressed the other cancer sometimes we might reserve that for another day many of these patients have detectable thyroglobulin levels please don't let that keep you up at night it's important to have good surveillance to catch those recurrences early and deal with them early the pathway to reoperation there are a lot of hurdles you got to get through okay you have to have an elevated thyroid globulin you have to have a target and then to be worth it in terms of the risk benefit discussion you're having with the surgeon good initial surgery for thyroid cancer is the best chance for cure that really important day in the patient's life and it's worth being fussy about ultrasound exams because everybody doesn't know differently and a lot of places you can't you can't always have a doctor to your real interest and some places there are technicians to do them we have a lot of very good technicians but I just think so when it comes to thyroid cancer so much is riding on the quality of the ultrasound that I I just feel like I need to do it myself I just can't accept yeah so that's what we have please feel free to tweet in your questions to UCLA MD chat and I think we do have some more questions so maybe we'll take a couple more thanks so much for paying attention to our broadcast okay let's see what are the biggest risk factors for developing thyroid cancer so I'd say a couple would be radiation exposure I'm especially childhood radiation exposure like having a childhood cancer that required head and neck radiation and then a family history family history of either well differentiated thyroid cancer or you know an m en history that might predispose you to medullary thyroid cancer I agree so the thyroid you know in children under the age of 15 the thyroid is susceptible to certain genetic changes brought about by radiation so we do see survivors of the Chernobyl nuclear disaster here we have yet to see anybody from Fukushima that the Japanese nuclear power plant released much less radiation than Chernobyl thankfully and then here at UCLA we have a large group of children who were treated for lymphoma as kids and the radiation was part of their treatment and they sometimes develop thyroid cancer as a secondary effect is because they were treated in the treatment caused a new cancer so I think radiation and family history then we do have some people who grew up in iodine deficient areas who migrated to Los Angeles so here in Los Angeles we have large groups of Iranian and Armenian immigrants and those parts of the world are deficient in iodine so if you have iodine deficiency in childhood it can predispose to thyroid cancer it this interesting question how easy is it to tell apart a parathyroid tumor from a thyroid tumor based on imaging so that's a great question so I would say if you are and we have another webinar about parathyroid disorders that would also refer you to but the first step in diagnosing a parathyroid disorder is the laboratory test so high calcium hyper thyroid hormone level if you don't have biochemical evidence of hyperparathyroidism or parathyroid adenoma then I would not be looking for anything on imaging because that imaging is very likely to be false positive in that case so don't worry too much about that unless you actually have the laboratory test the next step in terms of the imaging is that usually parathyroid adenoma is adjacent to the thyroid so you see sort of a separation between the thyroid itself and the parathyroid you see a little plane in between there and we do have some additional imaging for parathyroid disorders sestamibi scan 4d parathyroid CT scan that can be helpful yeah I agree so um just to read our ear a with that dr. Lovett said if you're looking for an abnormal Perth already a it's less about the imaging and more about what's your calcium high on the blood test before okay so I hope that helps so in endocrine surgery we tend not to jump to imaging we tend to really scrutinize the history of the patient what's going on with the blood test and then we sort of proceed methodically down this path instead of jumping right into looking for structures and things like that dr. Clark my teacher always said remember Michael we don't treat x-rays we treat patients so we rarely respond to an image alone all right so you want to try this one okay oh that's a good one yeah if thyroid nodules have such a low mortality rate why should I pay to remove them ah that's a good question so we would agree that we want to try not to operate whenever we can you know in medicine sounds like a maybe an engineer or a businessman emailing us but in medicine we don't deal with tests that give us a certain answer we we deal with probabilities and we have to make decisions based on imperfect information and what that means is in a way we're kind of gambling right so if we do a biopsy and it shows it's suspicious for cancer we could not do anything and gamble that it's benign but if we're wrong maybe it's a pretty high-stakes gamble right so a lot of times we take the safe gamble we do we do an operation that we know we can do safely and sometimes it ends up being benign or as that as the participant says um you know maybe it was so low mortality that we didn't need to do it maybe however what about that small chance that it isn't one of those low mortality rate cancers it's really hard sometimes to predict which cancer is going to be the but the the slow growing one and which one's going to be the real monster sometimes it's hard to know until you have that one year of information to see how they responded to initial therapy so it's a great question I'm not sure we'd have too many people volunteer to just do nothing about their thyroid cancer so this has been attempted in Japan there was a sighting in Japan where they had some older people with known thyroid cancers and they just watched them and if some of these patients like 70 or 80 unit they got uh something else they died of something other than thyroid cancer but it turns out in younger people they tended to progress and give up mitat give off metastasis and start to act in a dangerous fashion so we tend to be aggressive particularly in patients who are otherwise young and healthy sorry for long answer go ahead I'm curious what you want to say yeah philosophically it really is yeah you know I think there's a risk-benefit ratio for every patient and I would agree that if you have an eighty-year-old patient with some heart disease who has a lesson 1 centimeter thyroid cancer and you want to get another ultrasound in 6 months rather than operating on that patient I think that there that that's a very valid you know point to bring up and something that as a patient you could really consider but more of our patients are young healthy patients so the question is if you were to leave even that small little thyroid cancer that we are telling you is not and you know not going to kill you let's say if you leave it for a year and then you come back for your ultrasound and now you have you know multiple positive lymph nodes and then you have to have a little more surgery you have a higher risk of recurrence you know we don't want that to happen I think we're still as a community doing a lot of studies to see how far we can push this towards being less aggressive with the treatment but overall we're really concerned about your safety first our individual patient that's in our clinic and we don't want it gamble and potentially have the patient you know risk having a worse prognosis by not having the treatment and so that's that's me there's definitely a sweet spot here I mean we don't want to do too much surgery we don't want to do little surgery we just want to do the right amount of surgery for the people who need it there is a sweet spot there that we're after yeah yeah that's a good question it really is yeah let's see oh okay so the higher the thyroid makes hormones that regulate metabolism how can one live once the gland is removed yeah go for it yeah so the great the great thing is that we are have gotten really good at replacing thyroid hormone with thyroid medication called synthroid now most patients once you remove the thyroid and are placed on thyroid hormone really do very well they have a normal quality of life you know they don't have problems with their way with getting pregnant with all kinds of things they really are just like any other normal patient most patients I am aware that there are some patients who don't feel well on the Styron hormone medication I don't want to discount that because there are some patients even if the thyroid function is normal in the laboratory tests still don't feel well and then there's some room to play around with different forms t3 versus t4 replacement I would say the most important point there is to have a really good relationship with your endocrinologist you need an endocrinologist who will listen to how you're feeling I'm taking to account your symptoms as well as the objective data from the laboratory tests to make decisions with you on how to adjust the dosing and there's some room for adjustment in those patients and I recognize that that can be a little bit of a struggle for some patients but most patients do very well and just have a normal quality of life with replacing thyroid hormone and there's really not any side effects as long as the dosage is the right dose for you yeah so I would go that comment it's good to have help good to have professional help now the endocrinologist who have a long term relationship with and and most people so that word form on the nice thing about thyroid hormone is it's one of these very slow acting hormone so it's a nice easy ride maybe you have a friend who's on insulin insulin the opposite where it has to be regulated minute to minute it's very very fussy but you take a tablet of fiber home and it lasts for a month so it's almost like flying a hot air balloon we make you know small adjustments and then we wait a month to see where the level reaches a steady state and again 90 percent of people have a normal quality of life a normal metabolism we ask patients that they're feeling tired gaining or losing weight a lot of people worry about gaining weight if they're on thyroid hormone usually that's not a problem we tell most people is weight gain really has more to do with diet and exercise behaviors in most people so people are good about taking their thyroid hormone regularly at the same time of day I have a routine for doing this they do fine I want to advise the audience that thyroid hormone is a second most commonly described prescribed drug in the country there are millions of Americans on thyroid hormone out there living their lives paying their taxes and both some do fine and there are a small percentage that need a little bit more attention this is probably five to ten percent out there overall population you want to take one more let's see okay so how often should you follow up a nodule with ultrasound to make sure that it's not malignant so I'm going to sort of transform this question just a little bit to make it a little more generalizable to the population so let's say you have a thyroid nodule that's been biopsied that doesn't require any surgery when should you get the next ultrasound to make sure that it's not cancerous I would say traditionally it's about once a year if you have a benign biopsy about once a year sometimes if it really looks pretty suspicious or something that that's the first time we're seeing it we may want to get a six-month ultrasound but you know it's very rare for an ultra for a nodule to change within six months usually one year's time is actually very safe and the new guidelines even suggest every couple of years depending on what exactly the nodule looks like so I'd say roughly once a year yeah so yeah again in medicine we don't have any tests that are 100% accurate right so benign biopsy is one of the best tests we have in medicine it's highly reassuring it's a 95 96 percent chance that that nodule is going to be truly benign that said there is that four percent now four percent false negative rate so that's why we do you know want to follow at least with one more ultrasound in a year to make sure that we don't miss anything and certainly if you're one of those people and you feel that your nozzle is enlarging or something that's new or it's bothering you or sometimes your voices voices change come back in what we want to we want to be sensitive to the changing landscape of a patient's symptoms of anything changes go back in to see your doctor you know the Internet is great I love you think about this all the time Internet's great for these things and of course we want to help you but you're out there we have met you we we haven't felt your neck and so that's why you're always going to need a doctor you're always going to need a doctor who knows you and and if there's any advice ever to have for you is know the limitations of internet-based medical information and there's no substitute for a good doctor you trust any closing points no I mean I am I hope that what we said is helpful we really enjoy discussing the subject and seeing patients I think one of the reasons that I really enjoy endocrine surgery and and thyroid is that most patients really do very well and it really is very rewarding to be able to remove a thyroid tumor and to have patients just live the rest of their life with a really good quality of life and that's really personally rewarding great part of the job I agree so we're going to wrap up we welcome your feedback please write in comments and questions and we'll use that to design the next webinar if you can come up with your top questions so thank you again for your attention thank you

Channel: UCLA Health

Views: 217,341

Rating: 4.7717276 out of 5

Keywords: endocrinology, thyroid nodules, thyroid cancer, how to treat thyroid cancer, thyroid cancer treatment, thyroid cancer surgery, thyroid surgery, los angeles thyroid treatment, los angeles thyroid cancer, los angeles endocrinologist

Id: zLmZj1e1ojg

Length: 61min 49sec (3709 seconds)

Published: Tue Jan 26 2016

Reddit Comments

[u/Rude-Biscotti4508]

Omg Dr. Yeh did my surgery!!

[u/aknat5]

Really good! Very helpful to share! Thank you!

[u/Wishlist2222]

Esp the part about how rare it is to die, the treatment options and why having some detectable Tg is ok.

[u/[deleted]]

🙏 🙏