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Thyroid Nodule Management
Transcript
- 00:00 --> 00:02Support for Yale Cancer Answers
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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.
- 14:42 --> 14:44Support for Yale Cancer Answers
- 14:44 --> 14:47comes from AstraZeneca providing
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- 14:49 --> 14:52various types and stages of cancer.
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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.
Information
Thyroid Nodule Management with guest Dr. Grace Lee
August 9, 2020
Yale Cancer Center
visit: http://www.yalecancercenter.org
email: canceranswers@yale.edu
call: 203-785-4095
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