Thyroid Nodule Management

Transcript

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00:11 --> 00:13Welcome to Yale Cancer
00:13 --> 00:14Answers with your host
00:14 --> 00:16Doctor Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:22latest information on cancer care by
00:22 --> 00:23welcoming oncologists and specialists
00:23 --> 00:26who are on the forefront of the
00:26 --> 00:28battle to fight cancer. This week,
00:28 --> 00:30it's a conversation about thyroid
00:30 --> 00:31cancer and the management of
00:31 --> 00:33thyroid nodules with Doctor Grace Lee.
00:33 --> 00:35Doctor Lee is an assistant professor
00:35 --> 00:38in the section of endocrinology and
00:38 --> 00:40metabolism at the Yale School of
00:40 --> 00:42Medicine where Doctor Schwartz is the
00:42 --> 00:44John Slade Eli Professor of obstetrics,
00:44 --> 00:47gynecology and Reproductive Sciences.
00:47 --> 00:49Doctor Lee, my first question is
00:49 --> 00:52can you tell us a little bit about
00:52 --> 00:54yourself and your area of expertise?
00:54 --> 00:56What cancers do you treat?
00:56 --> 00:58What's your role at the Veterans
00:58 --> 00:58Administration Hospital?
01:00 --> 01:01So as you mentioned,
01:01 --> 01:03I'm assistant professor of Medicine in
01:04 --> 01:06the section of endocrinology at Yale.
01:06 --> 01:08There I teach Endocrinology Fellows,
01:08 --> 01:09medical residents as well
01:09 --> 01:10as medical students.
01:10 --> 01:12I'm also a clinical endocrinologist
01:12 --> 01:14at the Veterans Affairs Connecticut
01:14 --> 01:16healthcare system for the VA.
01:16 --> 01:19I serve veterans at both the West Haven,
01:19 --> 01:20and Newington locations.
01:20 --> 01:22My areas of expertise include
01:22 --> 01:23thyroid nodules, thyroid cancer,
01:25 --> 01:27along with other metabolic bone diseases.
01:27 --> 01:29I also practice general endocrinology.
01:32 --> 01:34How common is thyroid cancer,
01:34 --> 01:35especially in veterans?
01:35 --> 01:37And how is it typically diagnosed?
01:37 --> 01:38Are there any symptoms that
01:38 --> 01:40people should be aware of?
01:40 --> 01:43In general, I can tell you
01:43 --> 01:44about the thyroid itself.
01:44 --> 01:46Not a lot of people know where
01:46 --> 01:48the thyroid is, so let's start
01:48 --> 01:50off by saying where that is.
01:50 --> 01:52It's a gland that's very
01:52 --> 01:54important to the body.
01:54 --> 01:57It's in the front of the neck and
01:57 --> 02:00is right on top of your windpipe.
02:00 --> 02:02You know when you ask about
02:02 --> 02:04how common thyroid cancer is,
02:04 --> 02:07it really depends on the type of
02:07 --> 02:09thyroid cancer that we're talking about.
02:09 --> 02:11And mainly there's about four
02:11 --> 02:13different types of thyroid cancer,
02:13 --> 02:14the most common being
02:14 --> 02:15papillary thyroid cancer,
02:15 --> 02:18and that's about 15 in every 100,000
02:18 --> 02:20people an this being the most common
02:20 --> 02:23type of cancer is actually also the
02:23 --> 02:25most benign type of thyroid cancer.
02:25 --> 02:27I shouldn't say benign,
02:27 --> 02:29the least aggressive of all
02:29 --> 02:31different types of thyroid cancer.
02:31 --> 02:32The more aggressive type would
02:32 --> 02:34be considered something called
02:34 --> 02:35anaplastic thyroid cancer,
02:35 --> 02:36which Fortunately is only less
02:36 --> 02:38than 3% of the different types
02:38 --> 02:40of thyroid cancer that exists.
02:40 --> 02:42You asked about symptoms that people
02:42 --> 02:45should be aware of and how it's diagnosed.
02:45 --> 02:46Typically somebody may notice
02:46 --> 02:48a lump in their neck,
02:48 --> 02:50which can be either from a
02:50 --> 02:52Mass in the thyroid or from an
02:52 --> 02:54abnormal lymph node in the neck,
02:54 --> 02:56or an enlarged lymph node.
02:56 --> 02:58Another way it's typically diagnoses,
02:58 --> 02:59actually, incidentally,
02:59 --> 02:59for example,
02:59 --> 03:01if somebody has a.
03:01 --> 03:02Car accident and has a
03:02 --> 03:04cat scan for their neck.
03:04 --> 03:06They might be surprised to find
03:06 --> 03:08out that they have thyroid nodules,
03:08 --> 03:10but actually they are very common and
03:10 --> 03:12thyroid cancer is actually a very
03:12 --> 03:14small percentage of thyroid nodules.
03:14 --> 03:16But those are the main different
03:16 --> 03:17types of thyroid cancer and chances
03:17 --> 03:19are if you're diagnosed with thyroid
03:19 --> 03:21cancer it is probably going to
03:21 --> 03:22be papillary thyroid cancer.
03:25 --> 03:28I was very interested to see a
03:28 --> 03:30difference between women and men in
03:30 --> 03:33terms of the incidence of thyroid cancer.
03:33 --> 03:35My impression is that women now have
03:35 --> 03:38about 3 times as many cancers as men,
03:38 --> 03:41but it seems to be less deadly in women.
03:41 --> 03:43Can you talk to us a little bit
03:43 --> 03:46about how this phenomenon may occur
03:46 --> 03:48and what should women be aware of,
03:48 --> 03:49particularly during
03:49 --> 03:51reproductive age?
03:51 --> 03:54It's not exactly known why that's true.
03:54 --> 03:56Some people think that women
03:56 --> 03:58come under the care
03:58 --> 04:00of providers more than men do,
04:00 --> 04:03and it's true that in men it seems to be
04:03 --> 04:07more of an aggressive
04:07 --> 04:08cancer, however,
04:08 --> 04:10it's all individual based on
04:10 --> 04:12the patient and that doesn't necessarily
04:12 --> 04:15mean that all men are going to have
04:15 --> 04:17poor prognoses.
04:17 --> 04:20I forgot to mention earlier,
04:20 --> 04:22you mentioned what other
04:22 --> 04:24symptoms that women should watch out
04:24 --> 04:27for and men should watch out for.
04:27 --> 04:29In addition to looking for lumps in the neck,
04:29 --> 04:32which you may just find by feeling your neck
04:32 --> 04:35you can actually, as the disease progresses,
04:35 --> 04:36have compressive symptoms.
04:38 --> 04:40So symptoms where in the neck
04:40 --> 04:42the mass in the thyroid is large,
04:42 --> 04:44it can push on different structures.
04:44 --> 04:46For example, it can make it difficult
04:46 --> 04:48to swallow or breathe.
04:48 --> 04:51It can also actually cause a horse voice.
04:51 --> 04:52There's an important nerve that
04:52 --> 04:54travels near the thyroid called the
04:54 --> 04:56recurrent laryngeal nerve, and if that
04:56 --> 04:58is somehow invaded or pushed upon,
04:58 --> 05:00that can cause a horse voice.
05:00 --> 05:03In addition to that, when it's very large,
05:03 --> 05:04if you're lying flat,
05:04 --> 05:05people actually feel like
05:05 --> 05:07they're choking, but again,
05:07 --> 05:08these are more advanced forms
05:08 --> 05:10of the cancer and
05:10 --> 05:12not typically in the very early stages.
05:13 --> 05:16I noticed that during pregnancy,
05:16 --> 05:18especially thyroid nodules in
05:18 --> 05:20thyroid cancer can present in women
05:22 --> 05:26yet they seem to be very low grade.
05:26 --> 05:28Can you tell us a little bit
05:28 --> 05:30about that phenomenon?
05:30 --> 05:32Thyroid cancer in pregnancy does happen.
05:32 --> 05:35I would say that in most cases when
05:35 --> 05:38this occurs, as long as it's what we
05:38 --> 05:40think is papillary thyroid cancer,
05:40 --> 05:42we typically do not like to
05:42 --> 05:45operate on pregnant women.
05:45 --> 05:47An OB I'm sure would feel the same
05:47 --> 05:50and we will monitor the nodule
05:50 --> 05:51and recommend surgery
05:51 --> 05:54ideally after the birth of the child.
05:54 --> 05:56However, I would say in rare cases if
05:56 --> 05:58something like anaplastic is found,
05:58 --> 06:00which I've never had happened
06:00 --> 06:02to me or my patients,
06:02 --> 06:04but if that were to happen, management,
06:04 --> 06:06I assume would be different,
06:06 --> 06:08but typically because the cancers
06:08 --> 06:09tend to be less aggressive,
06:09 --> 06:12we try to put off surgery for
06:12 --> 06:13the thyroid in someone who's
06:13 --> 06:16pregnant.
06:16 --> 06:18And for veterans in the Vietnam War,
06:18 --> 06:21of course, Agent Orange became an issue
06:21 --> 06:24and I know that there's one recent
06:24 --> 06:26study that suggested that there was
06:26 --> 06:29a 24 % relative risk measure
06:29 --> 06:31or increased risk of thyroid cancers,
06:31 --> 06:34and those exposed to Agent Orange.
06:34 --> 06:36Is this still a problem for our
06:36 --> 06:39Vietnam Veterans today and are
06:39 --> 06:41veterans from the Middle East exposed
06:41 --> 06:44to increased risk for thyroid cancer?
06:44 --> 06:45So those are all
06:45 --> 06:46great questions.
06:46 --> 06:49I can't tell you the exact
06:49 --> 06:51answer to that, although I can say that if
06:51 --> 06:54there's any type of radiation exposure,
06:54 --> 06:56especially at a younger age,
06:56 --> 06:58that does increase
06:58 --> 07:00someone's risk of thyroid cancer,
07:00 --> 07:02and typically we think of incidents
07:02 --> 07:04like Chernobyl or
07:04 --> 07:05nuclear accidents that occur.
07:05 --> 07:08So any agents that are used that
07:08 --> 07:10potentially could have radioactivity.
07:10 --> 07:12There are also certain explosive devices
07:12 --> 07:14that may have involved radiation.
07:14 --> 07:15Anything like that.
07:15 --> 07:17If you're in contact with that it
07:17 --> 07:19can certainly increase your
07:19 --> 07:21risk of thyroid cancer, yes.
07:23 --> 07:25And what are the treatment
07:25 --> 07:27options available to patients?
07:28 --> 07:30So in terms of treatment in
07:30 --> 07:32patients who have what's called the
07:32 --> 07:34differentiated thyroid cancers,
07:34 --> 07:36which are the very well developed cancers
07:36 --> 07:38we mentioned, papillary thyroid cancer,
07:38 --> 07:41follicular thyroid cancer is another type.
07:41 --> 07:42The main treatment actually is
07:42 --> 07:44surgery to remove the thyroid
07:44 --> 07:47cancer that's present and luckily
07:47 --> 07:49we have specialist surgeons who
07:49 --> 07:51can provide this kind of surgery.
07:51 --> 07:53People who have high volumes of
07:53 --> 07:56these types of patients to work on,
07:56 --> 07:58they tend to have minimal complications.
07:58 --> 08:01So really surgery is the mainstay
08:01 --> 08:02treatment for thyroid cancer.
08:02 --> 08:05In terms of types of thyroid surgeries,
08:05 --> 08:07you can either do a total thyroidectomy
08:07 --> 08:10which is to take out the entire thyroid
08:10 --> 08:12gland or a thyroidectomy
08:12 --> 08:15to remove just half the gland
08:15 --> 08:17depending on where and how large the
08:17 --> 08:19tumor is will determine the surgeons
08:19 --> 08:21approach in whether they'll take out
08:21 --> 08:23the entire gland or half the gland
08:23 --> 08:26and then in addition to that there can
08:26 --> 08:28be extra surgery called a dissection
08:28 --> 08:30to take out any affected lymph nodes,
08:30 --> 08:33typically in the neck area
08:33 --> 08:35in the middle of the neck
08:35 --> 08:36where the thyroid is,
08:36 --> 08:38but then also on the sides of the neck.
08:39 --> 08:41So actually one of the things that's
08:41 --> 08:42really important before somebody
08:42 --> 08:44has surgery for thyroid cancer is to
08:44 --> 08:46have a neck ultrasound looking at
08:46 --> 08:47all the lymph nodes including the
08:47 --> 08:49sides of the neck so that the surgeon
08:49 --> 08:51can plan the appropriate operation
08:51 --> 08:54and really have the best outcome and
08:54 --> 08:55not have to go again
08:55 --> 08:56for surgery.
08:56 --> 08:58I understand that there is some
08:58 --> 09:00controversy about how extensive
09:00 --> 09:01the surgery should be.
09:01 --> 09:03What would be the difference between
09:03 --> 09:05a partial thyroidectomy versus the
09:05 --> 09:07complete removal of a gland in terms
09:07 --> 09:09of the patient and her side affects?
09:09 --> 09:11So that's a good question. In
09:11 --> 09:13terms of total thyroidectomy which
09:13 --> 09:15is taking up the entire gland,
09:15 --> 09:17actually in both cases I should probably
09:17 --> 09:19talk about what the risks are in
09:19 --> 09:22both and then kind of separate them.
09:22 --> 09:24So a risk of course in any procedure
09:24 --> 09:26would be infection or bleeding,
09:26 --> 09:29but in particular to thyroid surgery is that
09:29 --> 09:31there could be damage to that
09:31 --> 09:33nerve that we mentioned earlier,
09:33 --> 09:36the recurrent laryngeal nerve which could
09:36 --> 09:38actually cause a permanent or temporary
09:38 --> 09:40hoarse voice for someone.
09:40 --> 09:43Actually, that can be a big change
09:43 --> 09:45in their life, especially someone
09:45 --> 09:47who's a singer or their vocation
09:47 --> 09:49includes speaking and giving lectures,
09:49 --> 09:51for example.
09:51 --> 09:53In terms of other side effects,
09:53 --> 09:55right behind the thyroid gland
09:55 --> 09:57are tiny little rice grain sized
09:57 --> 09:58glands called parathyroid glands.
09:58 --> 09:59And
09:59 --> 10:01even though they're very small,
10:01 --> 10:03they are very important in
10:03 --> 10:04controlling the body's calcium level,
10:04 --> 10:06and as you know,
10:06 --> 10:08things like really like the heart,
10:08 --> 10:08for example,
10:08 --> 10:10rely on important calcium
10:10 --> 10:11concentration so you know those
10:11 --> 10:13glands are essential to the body.
10:13 --> 10:15And it takes a very skilled surgeon
10:15 --> 10:18to make sure that those are not
10:18 --> 10:20harmed or the blood supply to those
10:20 --> 10:22glands are not harmed as well.
10:22 --> 10:24So one of the complications can
10:24 --> 10:25be an under active parathyroid
10:25 --> 10:27gland or parathyroid glands
10:27 --> 10:29that aren't functioning properly.
10:29 --> 10:30So I would say that
10:30 --> 10:31in particular,
10:31 --> 10:33that parathyroid effect would be
10:33 --> 10:35a higher risk in patients with a
10:35 --> 10:36total thyroidectomy versus only
10:36 --> 10:39half of the thyroid being removed.
10:39 --> 10:41But even then the risk is actually very
10:41 --> 10:45quite low in patients who have both
10:45 --> 10:46these procedures in experienced hands.
10:46 --> 10:48So I really don't worry
10:48 --> 10:50about that for my patients.
10:50 --> 10:52It sounds like experience is
10:52 --> 10:55a major issue and you really want
10:55 --> 10:57to be sure to have a surgeon who
10:57 --> 11:00does a lot of these surgeries on a
11:00 --> 11:03routine basis
11:03 --> 11:06if a total thyroidectomy is
11:06 --> 11:08performed. What additional
11:08 --> 11:09replacement therapies are necessary
11:09 --> 11:11for the patient versus the
11:11 --> 11:12partial thyroidectomy.
11:12 --> 11:14Good question, in
11:14 --> 11:15patients who have only part
11:15 --> 11:17of their thyroid removed,
11:17 --> 11:18which is usually going to
11:18 --> 11:20be half of the thyroid,
11:20 --> 11:22they actually have a chance of not
11:22 --> 11:23needing thyroid hormone after surgery.
11:23 --> 11:25It's interesting the other half of
11:25 --> 11:27the thyroid gland can build enough
11:27 --> 11:29response that they can make extra
11:29 --> 11:31thyroid hormone so you don't have
11:31 --> 11:33to take the pills after the surgery,
11:33 --> 11:35but that's not always the case and
11:35 --> 11:37so I would say if you're going in
11:37 --> 11:39and you know that you're going to
11:39 --> 11:41have half your thyroid removed,
11:41 --> 11:43I would expect that you may need
11:43 --> 11:45to take a pill afterwards with
11:45 --> 11:47the whole thyroid being removed.
11:47 --> 11:49You'll definitely need to have
11:49 --> 11:50thyroid hormone therapy afterwards,
11:50 --> 11:53and that's usually in the form of
11:53 --> 11:54something called Levothyroxine.
11:54 --> 11:55This thyroid hormone would be
11:55 --> 11:57a life long treatment because,
11:57 --> 11:59as we mentioned earlier,
11:59 --> 12:01the thyroid has lots of effects
12:01 --> 12:03in the body and you really can't
12:03 --> 12:04live without thyroid hormone.
12:04 --> 12:06Well, you mentioned earlier also that
12:06 --> 12:08most of the thyroid cancers that
12:08 --> 12:10we're seeing are low grade cancers.
12:10 --> 12:12Are additional treatments necessary
12:12 --> 12:14for high grade cancers or for
12:14 --> 12:16cancers that have spread to
12:16 --> 12:18local lymph nodes or beyond
12:18 --> 12:20that?
12:20 --> 12:23Yes, for those types of cancers we also offer
12:23 --> 12:25something called radioactive iodine
12:25 --> 12:28therapy and I think that this is
12:28 --> 12:31very what we would call a
12:31 --> 12:33targeted therapy because a thyroid
12:33 --> 12:35gland is really good at absorbing
12:35 --> 12:38iodine and we take advantage of that.
12:38 --> 12:39That's
12:39 --> 12:42radioactive and what can happen is
12:42 --> 12:44the patient when they take radioactive
12:44 --> 12:46iodine that iodine can go to
12:46 --> 12:48all parts of the body that
12:48 --> 12:49have thyroid tissue,
12:49 --> 12:52whether it be in your lungs or other parts,
12:52 --> 12:54where it may have spread all
12:54 --> 12:56they have to do is take the pill
12:56 --> 12:58and it will go to both the neck
12:58 --> 13:00area where there is probably little
13:00 --> 13:02bits of thyroid cells left behind
13:02 --> 13:04and then also to the lungs
13:04 --> 13:05if there is spread
13:05 --> 13:07of the cancer to the lungs,
13:07 --> 13:09so instead of
13:09 --> 13:10a general chemotherapy,
13:10 --> 13:12it's really a targeted therapy
13:12 --> 13:14to that thyroid tissue and that
13:14 --> 13:15is sort of the beauty of
13:15 --> 13:16the treatment.
13:16 --> 13:17Are there any additional side
13:17 --> 13:19effects that would be expected with
13:19 --> 13:20radioactive iodine being
13:20 --> 13:22injected?
13:22 --> 13:24We think at low doses,
13:24 --> 13:27really patients tolerate it very well
13:27 --> 13:29an the biggest complaint that I usually get
13:29 --> 13:32about it is fatigue or the fact that
13:32 --> 13:34they have to actually be on something
13:34 --> 13:37called a low iodine diet beforehand and
13:37 --> 13:39the reasoning for the low iodine diet
13:39 --> 13:41is to make your body hungry for iodine,
13:41 --> 13:44so that will take up the
13:44 --> 13:47iodine to the thyroid
13:47 --> 13:49tissue where it's widespread
13:49 --> 13:51in terms of side effects.
13:51 --> 13:53Some people do get dry mouth,
13:53 --> 13:55you can get watery eyes.
13:55 --> 13:57Some people get sort of this
13:57 --> 13:59inflammation of the stomach and these
13:59 --> 14:01can be either temporary or permanent,
14:01 --> 14:04but typically the stomach effect
14:04 --> 14:07is very limited and goes away.
14:07 --> 14:09And in rare cases, at higher doses,
14:09 --> 14:11there is a concern for other
14:11 --> 14:13malignancies occurring such as leukemia.
14:13 --> 14:13But again,
14:13 --> 14:15those risks are minimal and typically
14:15 --> 14:18with higher doses of radioactive iodine.
14:18 --> 14:19So all in all,
14:19 --> 14:20patients really usually tolerate
14:20 --> 14:22radioactive iodine rather well,
14:22 --> 14:23and if patients are complaining
14:23 --> 14:25most about the low iodine diet,
14:25 --> 14:28it tells you that the effects
14:28 --> 14:29usually are not that bad.
14:30 --> 14:32We're going to take a
14:32 --> 14:34short break for a medical minute.
14:34 --> 14:36Please stay tuned to learn
14:36 --> 14:37more about thyroid cancer
14:37 --> 14:39and the management of thyroid
14:39 --> 14:41nodules with Doctor Grace Lee.
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15:35 --> 15:38You're listening to Connecticut public radio.
15:39 --> 15:42Welcome back to Yale Cancer Answers.
15:42 --> 15:43This is doctor Peter Schwartz
15:43 --> 15:46and I'm joined tonight by
15:46 --> 15:48my guest Doctor Grace Lee
15:48 --> 15:51and we are discussing thyroid
15:51 --> 15:53cancer and the management of thyroid nodules.
15:53 --> 15:56So doctor Lee, what are thyroid nodules?
15:56 --> 15:57How are they managed?
15:57 --> 15:59Can they be cancerous?
15:59 --> 16:01What causes them?
16:01 --> 16:03Thyroid nodules are actually nodularity of
16:03 --> 16:05the thyroid tissue so I describe it
16:07 --> 16:08as little balls within your thyroid.
16:08 --> 16:11They're very common and actually can
16:11 --> 16:13be president in up to 68% of
16:13 --> 16:16adults, if you look at adults with ultrasound
16:16 --> 16:18and they actually increase with age,
16:18 --> 16:19they are often found
16:19 --> 16:21incidentally most of the time.
16:21 --> 16:24How I see patients as referrals is that
16:24 --> 16:26they were found for another reason.
16:26 --> 16:26For example,
16:26 --> 16:28they had a carotid ultrasound to
16:28 --> 16:30look at their arteries and
16:30 --> 16:32happen to find a thyroid nodule,
16:32 --> 16:35and then I end up seeing those patients.
16:35 --> 16:37And we mentioned earlier another
16:37 --> 16:39time is when people have CAT scans
16:39 --> 16:41for other reasons of their neck
16:41 --> 16:44and they find the thyroid nodules.
16:44 --> 16:44And typically,
16:44 --> 16:47the way to best evaluate them is
16:47 --> 16:49actually a thyroid ultrasound.
16:49 --> 16:52Most of these nodules are benign and
16:52 --> 16:54I think that's the biggest message I
16:54 --> 16:57want to say is that if somebody tells
16:57 --> 16:59you that you have a thyroid nodule,
16:59 --> 17:02the first thing is not to panic.
17:02 --> 17:04There actually very common and only
17:04 --> 17:07about four to 6 1/2% of these thyroid
17:07 --> 17:09nodules are cancerous in terms of who
17:09 --> 17:12is at risk for these thyroid
17:12 --> 17:14cancers they are usually people who have had
17:14 --> 17:16radiation to the head or neck area,
17:16 --> 17:18especially as a child,
17:18 --> 17:20or have had radiation exposure.
17:20 --> 17:22And who another risk factor would be
17:22 --> 17:24having a family history of thyroid
17:24 --> 17:26cancer in a first degree relative.
17:29 --> 17:31So I guess the next
17:31 --> 17:32question that people ask me,
17:32 --> 17:35what do I do when I find a thyroid nodule?
17:35 --> 17:37What does the doctor do or what
17:37 --> 17:39should they do?
17:39 --> 17:41The first thing to do is a blood test,
17:41 --> 17:43and in addition to the thyroid
17:43 --> 17:45ultrasound that I mentioned and the
17:45 --> 17:47blood test is really to see whether
17:47 --> 17:49you have a normal amount of thyroid
17:49 --> 17:50hormone in your body and that's
17:50 --> 17:52done through a test called thyroid
17:52 --> 17:53stimulating hormone called TSH.
17:53 --> 17:55And so the reason we do that
17:55 --> 17:56is that thyroid nodules,
17:56 --> 17:58actually some of them can make
17:58 --> 18:00thyroid hormone and those
18:00 --> 18:01are called hot nodules.
18:01 --> 18:02On the other hand,
18:02 --> 18:04there are thyroid nodules that
18:04 --> 18:06don't make extra thyroid hormone,
18:06 --> 18:08and those are the ones that
18:08 --> 18:10typically need to be more evaluated
18:10 --> 18:12for whether they are cancerous or not.
18:12 --> 18:14So if somebody has a test that
18:14 --> 18:16shows that their thyroid
18:16 --> 18:18hormone levels are very high,
18:18 --> 18:20then it's very unlikely for that
18:20 --> 18:22thyroid nodule to be cancer,
18:22 --> 18:23and in that case
18:23 --> 18:25it's not something that's biopsied.
18:25 --> 18:27However, if you find a cold nodule,
18:27 --> 18:30what we do is a thyroid ultrasound.
18:30 --> 18:32We look at the ultrasound to see
18:32 --> 18:34what does this nodule look like.
18:34 --> 18:36Are there things in the nodule
18:36 --> 18:37that are more concerning?
18:37 --> 18:37For example,
18:37 --> 18:39sometimes tiny bits of calcium can
18:39 --> 18:42be seen in the nodule and that can be
18:42 --> 18:44very classic for papillary thyroid cancer.
18:44 --> 18:46So in those cases we're more
18:46 --> 18:48concerned will offer the patient a
18:48 --> 18:50biopsy which is done with a very
18:50 --> 18:52fine needle where only cells are
18:52 --> 18:54removed from the thyroid nodule and
18:54 --> 18:55then looked at under the microscope.
18:57 --> 19:00You mentioned some of the risk factors
19:01 --> 19:03are radiation,
19:03 --> 19:05especially and
19:05 --> 19:06other inherited susceptibilities.
19:06 --> 19:08I guess what I'm really asking
19:08 --> 19:10is who should be screened?
19:10 --> 19:13Or should screening be done on a
19:13 --> 19:15routine basis for thyroid nodules?
19:15 --> 19:16So I would
19:16 --> 19:18say that screening just doing ultrasounds
19:18 --> 19:21on everybody should not be done.
19:21 --> 19:24I believe that if that's done there would
19:24 --> 19:27be a lot of patients who would have
19:27 --> 19:28unnecessary biopsies
19:28 --> 19:29potentially and tiny tiny
19:29 --> 19:32thyroid cancers being found that really
19:32 --> 19:35may not have caused the patient any trouble.
19:35 --> 19:36So generally speaking,
19:36 --> 19:38if a nodule is palpated on exam,
19:38 --> 19:40so having good physical exams at
19:40 --> 19:42your annual physical is important.
19:42 --> 19:44If something is found there, then yes,
19:44 --> 19:46thyroid ultrasound should be performed.
19:46 --> 19:49Or if one of the thyroid cancers that we
19:49 --> 19:52didn't really talk about much today but
19:52 --> 19:54is called medullary thyroid cancer,
19:54 --> 19:56and that one can run in families,
19:56 --> 19:58meaning that it can be passed
19:58 --> 20:00on from parent to child.
20:00 --> 20:01And
20:01 --> 20:03is often due to a genetic mutation
20:03 --> 20:05that can be checked for in
20:05 --> 20:07those types of families, yes,
20:07 --> 20:08thyroid ultrasound would be indicated,
20:08 --> 20:10but in the general public,
20:10 --> 20:12I wouldn't say at a specific age
20:12 --> 20:14that people should
20:14 --> 20:15just generally be screened.
20:15 --> 20:18I think that would be finding too many
20:18 --> 20:20and there would be too many
20:20 --> 20:20unnecessary procedures.
20:20 --> 20:21I'm aware
20:21 --> 20:22of a Korean study,
20:22 --> 20:23and apparently the conclusion
20:23 --> 20:26was they went through the roof with
20:26 --> 20:27finding so many thyroid nodules,
20:27 --> 20:29so we don't need to do that.
20:29 --> 20:31I think that's a
20:31 --> 20:33perfect example of what you just said.
20:33 --> 20:36Another controversy seems to be
20:36 --> 20:37regarding these indeterminant fine
20:37 --> 20:39needle aspiration biopsies. Can you
20:39 --> 20:41discuss that for us? It seems like
20:41 --> 20:44it's around 25% or so of biopsy is
20:44 --> 20:46a significant number of patients so
20:46 --> 20:49so let me walk you through a biopsy.
20:49 --> 20:52If I send you for a biopsy and you
20:52 --> 20:54had this aspiration biopsy
20:54 --> 20:57the results can be one of the following
20:57 --> 21:00so they can come back and say
21:00 --> 21:03this is most likely benign.
21:03 --> 21:05Two, they can come back and
21:05 --> 21:07say, this is most likely cancer.
21:07 --> 21:09And then there's this whole gray
21:09 --> 21:10area in between of what you've
21:10 --> 21:12described called indeterminate.
21:12 --> 21:13It's very frustrating both
21:13 --> 21:15for patients and providers.
21:15 --> 21:16What does that mean?
21:16 --> 21:18How much percentage risk of cancer is that?
21:18 --> 21:20It's a large range and so
21:20 --> 21:22management can be difficult if you
21:22 --> 21:24just get this intermediate result.
21:24 --> 21:26So over the past couple of years,
21:26 --> 21:28what's been developed is called
21:28 --> 21:29molecular testing,
21:29 --> 21:31where they take the RNA or the ribo
21:31 --> 21:33nucleic acid from these cells that
21:33 --> 21:35you have taken from the biopsy.
21:35 --> 21:37And actually test that for different
21:37 --> 21:39mutations or changes that
21:39 --> 21:41are typically seen in thyroid cancer.
21:41 --> 21:44If those are seen than the results
21:44 --> 21:46can come back and say,
21:46 --> 21:48you actually have, for example,
21:48 --> 21:49of 40% risk of cancer,
21:49 --> 21:52not a 15% risk of cancer in
21:52 --> 21:53that indeterminate category,
21:53 --> 21:55and that can sway you and say,
21:55 --> 21:56you know what?
21:56 --> 21:59This makes more sense to take the patient
21:59 --> 22:02to surgery or offer them a thyroid surgery,
22:02 --> 22:05at least for that side of the thyroid
22:05 --> 22:07as opposed to watching that nodule, so
22:07 --> 22:09this molecular testing has been
22:09 --> 22:11very helpful in guiding us in
22:11 --> 22:12managing these patients,
22:12 --> 22:13but yes,
22:13 --> 22:14a very frustrating result
22:14 --> 22:16when you get that gray,
22:16 --> 22:17area result.
22:18 --> 22:20Do you find the patients tend to
22:20 --> 22:21lean more towards surgery
22:21 --> 22:24then follow up because of this
22:24 --> 22:26uncertainty about the
22:26 --> 22:28nature of the nodules.
22:28 --> 22:31It varies. I've had both ends of the
22:31 --> 22:33spectrum more so I would say more of
22:33 --> 22:36my patients would be more
22:36 --> 22:38proactive.
22:38 --> 22:40I don't want to categorize people,
22:40 --> 22:42but there are patients also who are
22:42 --> 22:44very conservative and maybe with more
22:44 --> 22:47advanced age with other risk factors for
22:47 --> 22:49surgery they may want to just watch it
22:49 --> 22:51and I think that makes sense
22:51 --> 22:53if you have other reasons,
22:53 --> 22:55severe heart disease or heart failure.
22:55 --> 22:57Other things that may increase your
22:57 --> 22:59risk of complications post operatively,
22:59 --> 23:01then it would make sense to watch them,
23:01 --> 23:03especially if your risk
23:03 --> 23:05ends up being low.
23:05 --> 23:08Let's move on and let me ask
23:08 --> 23:10you this, what is endocrinology?
23:10 --> 23:13What is the role that hormones play and
23:13 --> 23:16how is that managed and what does the
23:16 --> 23:18thyroid do?
23:18 --> 23:21You're an endocrinologist.
23:21 --> 23:23What exactly do you do?
23:23 --> 23:26Endocrinology is a study of the body's
23:26 --> 23:28endocrine system, which is basically
23:28 --> 23:30the system that controls your hormones,
23:30 --> 23:32and this includes the pancreas,
23:32 --> 23:33the thyroid, parathyroid,
23:33 --> 23:36the parathyroid and thyroid in your neck.
23:36 --> 23:38The hypothalamus and pituitary which are
23:38 --> 23:41in your brain and adrenal glands
23:41 --> 23:44I like to say sit on top of the
23:44 --> 23:47kidneys are like little hats on the kidneys.
23:47 --> 23:49In addition to that, sex hormones
23:49 --> 23:52are made by the testes and ovaries.
23:52 --> 23:54So as an endocrinologist I manage diseases
23:54 --> 23:56that involve the endocrine system,
23:56 --> 23:57including thyroid disorders,
23:57 --> 23:59osteoporosis and bone diseases,
23:59 --> 24:00diabetes, pituitary disease,
24:00 --> 24:01and even transgender medicine.
24:03 --> 24:05You mentioned a lot of
24:05 --> 24:07organs that are now sometimes
24:07 --> 24:09affected by our newer medications.
24:09 --> 24:12We have targeted therapy and a lot
24:12 --> 24:14of the new checkpoint inhibitors,
24:14 --> 24:16for instance, affect these organs.
24:16 --> 24:20Can you talk a little bit about that?
24:20 --> 24:20Definitely,
24:20 --> 24:23so we've had a lot of rules over
24:23 --> 24:25the last few years as those
24:25 --> 24:28immunotherapy's have been used and these
24:28 --> 24:30immunotherapies are basically tricking
24:30 --> 24:32your body's immune system to attacking
24:32 --> 24:35the cancer and it works really well.
24:35 --> 24:37But actually also tends to attack
24:37 --> 24:39these glands that I treat so quite
24:39 --> 24:42often I will see patients who are
24:42 --> 24:44getting these treatments and will have
24:44 --> 24:47what we call thyrotoxicosis or too
24:47 --> 24:49much thyroid hormone because the
24:49 --> 24:51thyroid gland is being attacked by
24:51 --> 24:53the agents. In addition to that,
24:53 --> 24:55you can actually see also
24:55 --> 24:56inflammation of your pituitary gland,
24:56 --> 24:59which is the gland which is a tiny
24:59 --> 25:01gland in the middle of your brain
25:01 --> 25:03and we call it actually the master
25:03 --> 25:05gland because it sends out
25:05 --> 25:08hormones to other parts of your
25:08 --> 25:10body and glands to control those.
25:10 --> 25:13The beauty though is that we never tell
25:13 --> 25:14oncologists
25:14 --> 25:16to stop their treatment.
25:16 --> 25:18The beauty of it is that we
25:18 --> 25:20have all the hormones to replace
25:20 --> 25:22that in terms of treatment.
25:22 --> 25:24So whatever needs to be done
25:24 --> 25:25for their primary cancer,
25:25 --> 25:27we say go on and do what you need
25:27 --> 25:30to do and we will take care
25:30 --> 25:32of this equality that happens with
25:32 --> 25:34the hormones and we will replace
25:34 --> 25:35whatever hormones needed to
25:35 --> 25:37be replaced so the thyroid,
25:37 --> 25:39in my experience, can be both
25:39 --> 25:40overactive as you just mentioned,
25:40 --> 25:42but also under active.
25:42 --> 25:44So you need to be able to evaluate that.
25:47 --> 25:50One of the reasons I love endocrinology
25:50 --> 25:52is that we can check blood work
25:52 --> 25:55and blood work can be very helpful
25:55 --> 25:57in telling you what is going on.
25:57 --> 25:59So one of the things
25:59 --> 26:01that can happen is inflammation,
26:01 --> 26:03or thyroiditis of the
26:03 --> 26:05thyroid gland can happen with
26:05 --> 26:06these immune checkpoint inhibitors.
26:06 --> 26:08So initially what happens with them
26:08 --> 26:11is inflammation of the gland and there
26:11 --> 26:13is actually a thyroid hormone
26:13 --> 26:16within the gland that as it's attacked is
26:16 --> 26:18released and so because that happens,
26:18 --> 26:20there's a lot of extra thyroid hormone
26:20 --> 26:22in the body and patients can feel
26:22 --> 26:25symptoms of too much thyroid hormone.
26:25 --> 26:27What would those be?
26:27 --> 26:30Feeling hot when no one else is hot.
26:30 --> 26:32Almost like a hot flash feeling
26:32 --> 26:35very hungry and actually having weight loss.
26:35 --> 26:37You can have weight gain, just an
26:37 --> 26:39imbalance in your thyroid
26:39 --> 26:41hormone after that happens because
26:41 --> 26:44the thyroid gland has been inflamed.
26:44 --> 26:46It also can no longer make
26:46 --> 26:47thyroid hormone,
26:47 --> 26:50so a lot of
26:50 --> 26:52thyroid hormone patients go through
26:52 --> 26:56a state of
26:56 --> 26:57very low thyroid hormone and so
26:57 --> 27:00at that point the thyroid hormone
27:00 --> 27:01needs to be replaced,
27:01 --> 27:04and so that's a very typical
27:04 --> 27:05picture that we see.
27:05 --> 27:07We call immunotherapy related.
27:07 --> 27:09It's like a thyroiditis and the
27:09 --> 27:11symptoms of low thyroid.
27:11 --> 27:14And you can see the opposite
27:14 --> 27:16so you can feel very tired.
27:16 --> 27:19Feel cold when no one else is cold,
27:19 --> 27:21constipated. And you can
27:21 --> 27:23also have a low heart rate.
27:23 --> 27:24We're just about ready
27:24 --> 27:28to finish. But let me ask you are there any
27:28 --> 27:29recent advances that have been made or
27:29 --> 27:31exciting research in the pipeline?
27:31 --> 27:33You alluded to some of that.
27:33 --> 27:35Actually, immunotherapy is being used now
27:35 --> 27:38in trials to see whether that can help
27:38 --> 27:39patients with advanced thyroid cancer.
27:39 --> 27:41And at Yale, there is a trial
27:41 --> 27:43now ongoing with cabozantinib,
27:43 --> 27:45which is a tyrosine kinase inhibitor in
27:45 --> 27:48patients who have failed another type of
27:48 --> 27:50tyrosine kinase inhibitor called Lynn VAT,
27:50 --> 27:52and if so, a lot of interesting
27:52 --> 27:54research is going on in advanced
27:54 --> 27:55thyroid cancer these days.
27:56 --> 27:58Doctor Grace Lee is an assistant
27:58 --> 28:00professor in the section of
28:00 --> 28:01endocrinology and metabolism at
28:01 --> 28:03the Yale School of Medicine.
28:03 --> 28:05If you have questions,
28:05 --> 28:06the address is canceranswers@yale.edu
28:06 --> 28:08and past editions of the program
28:08 --> 28:10are available in audio and written
28:10 --> 28:12form at Yalecancercenter.org.
28:12 --> 28:14We hope you'll join us next week to
28:14 --> 28:16learn more about the fight against
28:16 --> 28:19cancer here on Connecticut public radio.

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August 9, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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