Thyroid Disease and Thyroid Cancer

Additional Info

• Audio File:uab/ua052.mp3
• Doctors:Greene, Benjamin;Hughley, Brian;Buczek, Erin
• Featured Speaker:Dr. Benjamin Greene, | Dr. Brian Hughley, | Dr. Erin Buczek
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=2053
• Guest Bio:Dr. Benjamin Greene is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University at Buffalo, School of Medicine and Biomedical Sciences and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
  
  Learn more about Dr. Benjamin Greene
  
  Dr. Brian Hughley is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University of Virginia School of Medicine and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
  
  Learn more about Dr. Brian Hughley
  
  Dr. Erin Buczek is an otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ears, nose, throat, the respiratory and upper alimentary systems and related structures of the head and neck.
  
  Learn more about Dr. Erin Buczek 
  
  Release Date: December 6, 2017
  Reissue Date: December 4, 2020
  Expiration Date: December 4, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Brian B. Hughley, MD
  Assistant Professor in Otolaryngology,
  
  Erin Buczek, MD
  Assistant Professor in Otolaryngology,
  
  Benjamin J. Greene, MD
  Assistant Professor in Otolaryngology,
  
  Drs. Buczek, Greene and Hughley have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• 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 and can range from nodules to hypothyroidism, to life-threatening cancer. Here today, in a panel discussion regarding thyroid cancer and thyroid disease are Dr. Benjamin Greene, Dr. Brian Hughley, and Dr. Erin Buczek. They are Head and Neck Surgeons at UAB Medicine. Welcome to the show, Doctors. Dr. Buczek, I’d like to start with you. Please explain a little bit about thyroid disease. How common is it, and what are the different types that you see?
  
  Dr. Erin Buczek (Guest 1): Excellent question. There are several different types of thyroid disease. There are metabolic thyroid diseases such as Grave’s Disease or hyperthyroidism. Also, commonly, there is something called hypothyroidism, where the thyroid is less active and producing less thyroid hormone. There are also autoimmune diseases of the thyroid, such as Hashimoto’s Thyroiditis, which usually results in hypothyroidism long-term. Additionally, we see anatomic problems with the thyroid. Most commonly we see thyroid nodules, and you can also see thyroid cancers as well that start in the thyroid gland and can go elsewhere in the body.
  
  Melanie: So, Dr. Greene, patients with abnormalities of the thyroid gland, function, or structure come to medical attention for several reasons. Give us some of those reasons.
  
  Dr. Benjamin Greene (Guest 2): So, most of the time, to be honest, it’s found on routine labs because people don’t feel well for some reason. What they feel as – if people have an overactive thyroid gland, people tend not to be able to sleep, they’re losing weight; they’re always hungry, they have a tremor, they feel like they can never – they are restless, and things like that.
  
  And people that have a low thyroid, kind of have the opposite. They’re having fatigue, weight gain – despite eating the same amount of food – their hair is falling out, their nails are becoming brittle. Those are things for metabolic thyroid problems that people usually complain about. And usually, they’re seeing their – they’re usually not coming to a head and neck surgeon for those kinds of complaints. They’re usually seeing their primary doctor and saying, “You know, Doc, I really just feel terrible, and I don’t know why,” and they ask a couple of questions, get some lab work, and find out that the thyroid is not functioning the way it’s supposed to.
  
  Melanie: Dr. Hughley, what might some of those reasons be? Are we looking at lack of Iodine? You certainly have to have an understanding of thyroid disease and the interpretation of this function to get that basic understanding. What are you looking at?
  
  Dr. Brian Hughley (Guest 3): Well, that is true. The lack of Iodine worldwide – worldwide, excuse me – is a very big cause of thyroid disease. However, we don’t see that much in the United States. There are certainly familial inherited thyroid diseases that run in certain families that can cause both cancers as well as benign, physiologic dysfunction.
  
  Melanie: So, let’s talk about treatments now, and Dr. Greene, back to you for a minute. When we’re talking about clinical tests and diagnosis, then what would be the first line of treatment – because it’s not really always going to be surgical in nature – speak about some of the medicational intervention that you might encounter.
  
  Dr. Greene: Well, mostly what you’ll see is people having low thyroid – having not enough thyroid hormone. That can be due to a number of reasons like Dr. Hughley said, or it can be – most commonly, in this country, it’s due to something called Hashimoto’s Thyroiditis, where people have an autoimmune reaction to the thyroid gland that causes it to produce not enough thyroid hormone. The treatment of that is just replacing the thyroid hormone. That’s one of the safest medications that you can give because it’s literally just the exact same hormone and replacing it. And so that’s usually done under the care of a family medicine, or an internal medicine doctor or an endocrinologist to make sure that they are giving enough but not too much thyroid hormone replacement therapy.
  
  Now, there are some intricacies that come into it when people are producing too much thyroid hormone. There are medications that we usually start with, such a propylthiouracil to stop the thyroid from producing so much hormone and help with some of the feedback mechanisms that cause it to keep producing the hormone. Those are a little bit more tricky to give and are usually given under the direction of an endocrinologist to make sure that people are getting the correct amount, getting treated well, and also, it’s very difficult to treat patients with these medications if they’re planning on getting pregnant or things like that, so usually, those are directed by an endocrinologist for people who have Grave’s Disease or hyperactive thyroid hormone.
  
  Melanie: Important points, all. Let’s veer off for a minute. Dr. Buczek, what about nodules – thyroid nodules? How are they treated? Specifically, when is a needle biopsy needed? When is observation indicated and when might surgery be indicated?
  
  Dr. Buczek: That’s an excellent question. To start off with, thyroid nodules are extremely common. Among mixed studies, they are palpable in somewhere between 2 to 6% of the population, and thyroid nodules can be found on autopsy studies in up to half of the population, so they are extremely common. And most importantly, most thyroid nodules – up to 90 to 95% of them – end up being benign. The question as clinicians that we have been working on sorting out is exactly which nodules do we determine to be benign, and how do we figure that out and trying to avoid surgery? Surgery is the most definitive way to figure that out since we can send the entire nodule to the pathologist to look at, but the goal for us is to figure out who is safe to watch and who do we need to take to surgery?
  
  One of the most important tools that we have is the ultrasound. Ultrasound is a noninvasive technique. It doesn’t involve any external radiation, and it allows us to evaluate the structure of the thyroid gland and the surrounding lymph nodes. There are a lot of characteristics on ultrasound as well as on palpation that can lend you to think that a nodule might be more concerning. Size is one of them. Traditionally, it used to be anything greater than a centimeter, but depending on the appearance of the nodule, we now say a centimeter and a half to two centimeters. Is the nodule cystic or is it solid? Does it have well-defined edges? Is it particularly vascular?
  
  We use all of these different data points to grade these nodules, and depending on whether a nodule is concerning enough or not to meet what we call biopsy criteria. And so, if it meets criteria, we do a fine needle aspiration. Nodules that don’t meet that criterion, we consider to be very low-risk for malignancy, and those are considered safe for observation. Observation usually means an ultrasound within about a year, potentially less if they change.
  
  The nodules that are deemed biopsy-worthy, we’ll do a needle biopsy. We send that off to the pathologist to look at and grade and tell us whether or not they are either benign, whether they are suspicious for malignancy, whether they are malignant, or whether they are uncertain. Now, we actually have some genetics testing tools to look at that uncertain category to tell us whether they have concerning molecular features that would make us think that they were more likely to be malignant or not. Based on the results of the biopsy determines whether or not we recommend further observation or whether or not we recommend surgical removal of the nodule.
  
  Dr. Hughley: The one thing I would add is that occasionally, in the workup of a nodule, it’s actually too large to recommend a biopsy. If they are four centimeters or larger is the typical cutoff. Occasionally, the – or, not occasionally – we will recommend actually taking that side of the gland out -- assuming all other things are normal – to get a more accurate diagnosis rather than a needle biopsy.
  
  Dr. Greene: And if I can add something, that makes a lot of sense because if something is larger than four centimeters and you’re just taking one, small, tiny needle sample of it the question is, is cancer hiding in there and you just didn’t hit it with this very small needle? It’s called a fine needle aspiration biopsy, and it is a very, very fine needle. But also, there’s something new in the line of ultrasound reporting that came in part out of UAB, and it’s based on the breast data. If you’ve heard any podcasts or talked to any people who have had breast biopsies done, there is something called BI-RADS, which stands for Breast Imaging Reporting and Data System. UAB was very influential – the Radiology Department – in developing something called TIRADS, which is Thyroid Imaging Reporting and Data System. TIRADS is based on ultrasonic features – and they have this huge grading system about how to grade thyroid nodules and whether or not to biopsy them, and not only whether or not they need a biopsy, but also if you can follow them up and when they should have follow-up. It’s a very helpful thing, and this is brand new. It came out -- I think the paper on this came out in April of 2017 or somewhere around that time. It’s very, very new.
  
  Melanie: That’s fascinating. Dr. Hughley, thyroid cancer, is there a screening recommendation? Is this controversial? Tell us about it.
  
  Dr. Hughley: Not – there’s not screening for the general public that everyone can just have. It’s based on – basically, risk factors. We mentioned earlier thyroid nodules being concerning, and once a nodule is discovered whether a patient feels that, or much more commonly it’s being found incidentally on scans that are done for other reasons. As Dr. Buczek mentioned, if it’s not an ultrasound that it’s found on, often times we will then get an ultrasound to look for any of those concerning characteristics that she mentioned to determine if that nodule that was found incidentally needs to be biopsied, or, as we were discussing, removed surgically.
  
  The amount of imaging that’s being done in the head and neck for other reasons -- whether it’s head and neck cancer, or neck pain, or before spine surgery – is much higher than it’s ever been, so a lot of these nodules – excuse me, PET scans, also are showing incidental thyroid nodules. A lot are being found without the patient even knowing that there is a nodule present. And it’s important to know that not all of those – just because they’re present – actually need to be biopsied. Even when nodules are found on other imaging, just like Dr. Buczek mentioned before, there’s a criterion to go on to determine if that needs to be worked up any farther, or can be observed.
  
  Melanie: And Dr. Buczek, so let’s start with some treatments if thyroid cancer is detected -- so medicational or nonsurgical to begin -- whether you’re talking radioactive iodine therapy, or chemo, targeted, medicational – give us a little bit of that adjuvant therapy.
  
  Dr. Buczek: Generally speaking, the treatment for thyroid cancer is going to be surgical in nature as a frontline therapy. Exceptions to that may include particularly advanced thyroid cancer if it’s involving the larynx or the airway, or a particularly aggressive – like a variant called anaplastic thyroid cancer – in which case the prognosis is extremely poor. It’s a very rare cancer, but we generally don’t operate on that. But generally speaking, for the more common thyroid cancers like papillary thyroid cancer, follicular thyroid cancer, and medullary thyroid cancer, the treatment modality is going to be, for the most part, total thyroidectomy with some exceptions. For instance, if the thyroid cancer is extremely small, like less than a centimeter, you do not necessarily have to remove the other half to the gland. You at least just have to remove the side of the gland that the cancer is involved with. But for most cancers, it's going to be a complete thyroidectomy, potentially removing some lymph nodes that could be at risk if they’re either clinically evident to have cancer in them or if the cancer itself in the thyroid is large enough, we often will recommend getting some of the lymph nodes taken out as well.
  
  And then, adjuvant therapy for papillary and follicular thyroid cancer, it’s going to be radioactive iodine, and we usually recommend those for cancers that are at high risk. High risk means any cancer that’s grossly invaded outside of the thyroid gland into the surrounding structures, if it has metastasized to lymph nodes – either in the central neck around the thyroid or into the lateral neck nodes – we often recommend radioactive iodine, and then for any metastatic disease. Occasionally, we have used external beam radiation, but generally speaking, we don’t use that for thyroid cancer. Radioactive Iodine is the mainstay of adjuvant treatment.
  
  Melanie: Dr. Greene – as Dr. Buczek got to my next question in that whether it’s metastatic or it’s become systemic, tell us a little bit about the support that’s available for those with thyroid cancer should they have to have a full-on total thyroidectomy.
  
  Dr. Greene: Well, thyroid cancer is interesting to me in that it can be a very nonaggressive cancer, like a very small papillary thyroid cancer where the – in a young person, a very small papillary thyroid cancer, the five-year survival rate is almost 99 to 100%. I have even read studies that show that in young women, people who have thyroid cancer live longer than those who don’t because they see a doctor more commonly and things like that. It can be a very, very nonaggressive cancer, but then like Dr. Buczek said, anaplastic thyroid cancer is one of the most aggressive human malignancies there is and kills people faster than virtually any other type of cancer.
  
  Thyroid cancer runs the whole spectrum of nonaggressive to extremely aggressive, so the support can vary significantly. A lot of the support needed for thyroid cancer is just understanding the risks that go with surgery. The risks that go with thyroid cancer surgery can be significant. There can be risks to the recurrent laryngeal nerve, which controls the voice. There’s risk to the parathyroid glands, which are near the thyroid gland and control calcium homeostasis in the body. There are bleeding risks; there’s risk to the tone of your voice. We see a lot of singers that have nodules, and any type of change in their voice has profound implications to their job and their lifestyle. There are support groups for that, but most of the support is done through our other head and neck cancer supports, and it’s for people who have had big neck dissections for cancer, and tracheal resection, or laryngectomies for cancer. People who have thyroid cancer and undergo thyroidectomy generally do really, really, really well for the most part.
  
  Melanie: Dr. Hughley, what about things like targeted therapy? Give us your blueprint for what you see as the future for thyroid cancer, and treatments, and also, that support.
  
  Dr. Hughley: There are specific drugs that are being used occasionally. It’s not standard treatment -- Tyrosine Kinase Inhibitors are one example that comes up. Our medical oncology friends are the experts with those and indications for when to use them, but one thing that almost all patients who will need that type of adjuvant therapy also need is multidisciplinary care. Just like with our other head and neck cancers, we’re fortunate at UAB, to participate in our multidisciplinary tumor board for head and neck tumors that includes endocrine tumors as well as the others. That’s meeting with the surgeons that take care of the head and neck tumors, as well as radiation when that’s indicated, and adjuvant chemotherapy -- including all of the newer, directed therapies, which are occasionally given as part of clinical trials and occasionally given as adjuvant treatment in very rare settings for the more aggressive types of diseases -- or sometimes, not necessarily invasive and aggressive, but if there is an indication of a small recurrence, but it’s in a very sensitive region, or in a patient who may not otherwise qualify or be a good candidate for surgery, that’s when those agents are being used for thyroid cancer more frequently.
  
  Melanie: Dr. Greene, do you have anything to add to that?
  
  Dr. Greene: No, I think Dr. Hughley hit it right on the head. It’s a very sensitive area, and recurrences or metastatic disease, we do rely heavily on our medical oncology colleagues and our nuclear medicine colleagues to help with delivering adjuvant therapies. Mostly, our adjuvant therapy for thyroid cancer is Radioactive Iodine. That is tagged Iodine that – with radioactive entities that goes to the thyroid tissue wherever it is in the body and kills it with the radiation because as we know, the thyroid uptakes Iodine. The Iodine will be drawn into the thyroid cells, whether it’s in the neck in the thyroid bed or even in the lungs, and in small amounts, the radioactive agents that are tagged with Iodine can kill it. We rely on our nuclear medicine, endocrinology, and medical oncology colleagues to totally help us out with treating that.
  
  Dr. Buczek: Sorry, one thing that I just wanted to add on a little different tangent as far as new technology and moving to the forefront. On the front end, and detecting cancers, I think one of the exciting things that’s being currently developed right now, and a lot of new changes are in the genetic profiling of thyroid nodules. The testing there, that’s really giving us a lot better data preoperatively about whether or not these nodules are cancerous or not. They can take some of the tissue from the fine needle aspiration, send that off and run it for like 130 or 167 different transcription abnormalities, and basically, spit out the report that says whether or not the lesion is suspicious or not for cancer. Every year or two, they’re really improving that technology and making it a lot more specific, which I think helps everybody out in targeting who really needs surgery and who doesn’t.
  
  Melanie: Dr. Buczek, tell other physicians what you’d like them to know about thyroid disease, thyroid cancer, and when to refer to a specialist.
  
  Dr. Buczek: That’s a great question. I think thyroid nodules are extremely common and picked up by a lot of folks – family medicine practitioners. One thing I would say if a nodule or a thyroid mass seems symptomatic, which is something we haven’t talked a whole lot about, but if someone is complaining that they’re having a hard time swallowing, if they’re having hoarseness, if there’s a lot of pain in their neck and they have a big nodule, these are reasons to suspect that something potentially more aggressive is going on or potentially that they have a large, benign goiter that may need surgery. Those would be instances where I would recommend referring to an ENT Surgeon who does thyroid surgery.
  
  On the other forefront, things I’d want people to know is making sure when they do thyroid ultrasounds, doing needle biopsies, that their institution is utilizing some of those tools for genetic testing – which is often a send-out test. Here at UAB, we end up sending it out to – actually, Texas, to get it tested, but it can be really valuable and helpful to know who needs surgery and who we can simply observe.
  
  Melanie: Dr. Hughley, what do you like best about working with UAB and your team?
  
  Dr. Hughley: Well, our team, as Dr. Greene mentioned earlier, we have a great time working with each other. The three of us here today all work great together, but we also, as we’ve said many times today already, really enjoy working with our colleagues in radiation oncology, medical oncology, endocrinology, nuclear medicine, radiology, pathology. It’s just really easy to pick up the phone and get in touch with somebody if there’s a specific question about an image or about the treatment plan. We have our head and neck multidisciplinary tumor boards that meet regularly, and we actually talk with our colleagues about the cases that are not straight-forward. There are a lot of experts around who – for lack of a better term, you can just either pick their brains or actually have them formally consult on patients. There are a lot of people around that do the same things that I do, and also very complimentary things to what I do that I can bounce ideas off of, learn things from, and share new ideas with.
  
  Melanie: Thank you all, so much, for being with us today. It’s really great information. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks so much for listening.
  
  
  
• Hosts:Melanie Cole, MS