Transcription:

Melanie Cole (Host):  Through the hormones it produces, the thyroid gland influences almost all of the metabolic processes in your body. As a result, thyroid disorders can be far reaching. My guest today is Dr. Reese Randle. He is a Board Certified General Surgeon with additional fellowship training in endocrine surgery at UK Healthcare. Welcome to the show Dr. Randle. And as we are talking about thyroid nodules today, I’d like you to start with a little bit of an overview, a physiology lesson as it were, of what the thyroid does.

Dr. Reese Randle, MD (Guest):  Thanks Melanie, for having me. The thyroid is a small butterfly shaped gland that lives in the center of your neck and it primarily functions as a kind of guide for metabolism in your body. It produces a hormone that is referred to as thyroid hormone that like you said, influences many of the different metabolic processes in your body and so abnormalities in its function can certainly be quite impactful for a patient’s everyday life, how they feel, their energy levels, their ability to concentrate and just do normal day to day activities.

Melanie:  So, who gets thyroid nodules? Do we know what causes them? What are some common conditions and factors that would lead to them?

Dr. Randle:  By and large, thyroid nodules are very common, and we actually don’t have a good grasp of what causes them or who is more prone to get them. By the time we are about 50 years old, almost half of us will have thyroid nodules. And they are so common in fact, that we don’t actually go looking for them. The way we find them most often is you know for a couple of reasons; one, either a patient or their provider will feel a lump in their neck and that will lead to a workup for a possible thyroid nodule. Alternatively, we do see sometimes thyroid nodules are discovered incidentally when imaging studies are performed for reasons completely unrelated to the thyroid. There are a few conditions that will make people more prone to develop thyroid cancers in these nodules. One is a strong family history of thyroid cancer. The other is a previous exposure to radiation. But most people with thyroid nodules do not have any known risk factors. It is just a very common condition.

Melanie:  So, once you have detected them, then what? What’s the first line of defense and are nodules associated with thyroid function as it were?

Dr. Randle:  That’s a great question, one that we commonly address. By and large, nodules are completely separate from thyroid function. That being said, occasionally thyroid nodules will make too much thyroid hormone and cause what we call hyperthyroidism, where the body’s metabolism is actually revved up which can lead to rapid heart rate, a lot of anxiety, just feeling like you need to be on the go. So, the first way that you workup a thyroid nodule when it’s identified is by checking the thyroid function with a simple lab that you can get at any lab, it is very common. The result of that lab will guide further therapy or further workup, but commonly patients will need to receive an ultrasound of their neck to look at the thyroid, look at the lymph nodes around the thyroid and then really get at some of the characteristics of the nodule itself. If the nodule is concerning for cancer, the next step would be a biopsy depending on its size and again imaging characteristics.

Melanie:  Dr. Randle, as long as you mentioned the word cancer; while nodular disease of the thyroid might be a little bit more common, does it necessarily follow that you will see a malignancy as well and if someone has nodules, how do you reassure them?

Dr. Randle:  Right, so another great question, Melanie. The vast majority of thyroid nodules are benign. Only about five percent of nodules will end up being cancer. That being said, it is important to work them up once you find them to make sure that that risk of cancer is low. The best way to stratify that is with a biopsy and once a nodule gets to the size that we can and should biopsy it; the vast majority of those even are benign. And so, when I see a patient for the first time, you know that concern seems to be there regardless of what they know about thyroid nodules. So, usually with the ultrasound and the biopsy we can offer a lot of reassurance to people about the true risk of their actually being cancer in their thyroid. Overall, it is quite low.

Melanie:  So, when do nodules become surgical and do you do observation, kind of watch and wait, see if it changes in size? When is surgery indicated?

Dr. Randle:  Right, that’s a great question and one that is often individualized to the patient. There are two primary reasons to take out a thyroid nodule. One is if the nodule becomes large enough to cause symptoms. Some of those symptoms just simply from pressing on surrounding structures are swallowing, or voice problems. Some people perceive a shortness of air or feel like a choking sensation if they are to turn their neck in certain positions. So, symptoms is one of the reasons we will take out thyroid nodules. The other is if there is a concern for cancer. And again, that’s often guided by the ultrasound characteristics and the biopsy results.

Melanie:  So, then what is it like for a patient, if you decide to remove them? Is this something then that will affect the rest of their life and as it is not necessarily related to thyroid function; is there a medicational intervention for thyroid that needs to be then managed if you have to take them off?

Dr. Randle:  Right, so if the entire thyroid is removed; patients will need a supplement of thyroid hormone. And while the nodule might not necessarily affect function; not having a thyroid means that you will need to have its function replaced. So, that medication is a once daily medication that patients would take for the rest of their life. It’s actually the most commonly prescribed medication in the United States so, it’s widely available in many different forms, generic and otherwise. As far as the surgery itself, again, it’s often tailored to the individual patient whether part of the thyroid needs to be removed or the whole thyroid, with or without lymph nodes and each scenario requires a detailed discussion about the risks, benefits, expectations and really the goals of care for each patient.

Melanie:  So, to summarize and I’d like you in this summary to discuss the thyroid medications that you are discussing as it is so widely prescribed. What is it intended to do, so that people who have to go on to Thyroxin or whatever, they understand why that they are on this and what it’s meant to do and then summarize for us what you would like people to know about the thyroid itself and thyroid nodules.

Dr. Randle:  Great, so, the medication we take, the generic form is simply referred to as levothyroxine. It is what the thyroid makes. That is later converted into an active form in the tissues of your body and, so we aim to replace exactly what the thyroid makes, and we guide how much hormone we need to replace by the feedback that that hormone gives on the pituitary. And so, by measuring the thyroid stimulating hormone, which is the hormone that the pituitary secretes to regulate the thyroid; we can attempt to dose patients exactly what their body needs. Thyroid hormone has been used in the past for a variety of different indications and one of them is weight loss, however, they found that that is not a healthy way to lose weight because it would – taking too much thyroid hormone is very hard on your heart and causes too much heart disease to actually have any benefit from weight loss. So, it’s really important to keep that dosing regulated to keep you in the right position. If you don’t have enough thyroid hormone, then over time, it can be very debilitating with just overwhelming lethargy or fatigue and even to the point where people can become demented from not having enough thyroid hormone. So, again, very important to keep things in the right range there.

In summary, as far as thyroid nodules go, the take home points really are that they are very common. When we do find them, we do like to evaluate them primarily with labwork and an ultrasound are the usual places to start. Nodules that are concerning for cancer on ultrasound should be biopsied to further help us guide therapy.

Melanie:  Thank you so much Dr. Randle, for being with us today. This is UK Health Cast with the University of Kentucky Healthcare. For more information you can go to www.ukhealthcare.uky.edu that’s www.ukhealthcare.uky.edu. I’m Melanie Cole. Thanks so much for listening.