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Melanie Cole: Through the hormones it produces, the thyroid gland influences so many of the metabolic processes of your body. As a result, thyroid disorders can be far reaching. Welcome to the GW Medical Faculty Associates Podcast. I'm Melanie Cole. Today's topic is minimally invasive endocrine surgery, what to expect with thyroid and parathyroid surgery. Joining me is Dr. Juliet Lee. She's an Assistant Professor of Surgery at the George Washington University School of Medicine and Health Sciences and the Director of Undergraduate Surgical Education. Dr. Lee is affiliated with the George Washington University Hospital. Dr. Lee, it's a pleasure to have you join us. For the listeners, would you give us a little medical education? Tell us what the thyroid and parathyroid gland even do.

Dr. Lee: The thyroid gland is considered the master gland. It really regulates the function of all the other endocrine organs, which include your adrenal gland, your ovaries, if you're a woman, your testicles, if you're a man, and really controls a lot of the overall metabolism of a patient. The parathyroid glands had a very specific function and they mainly are important in the regulation of calcium. The mineral that is mostly within your bones.

Host: Well, thank you for that physiology lesson. So what are the most common thyroid issues that you see?

Dr. Lee: Most common things that I deal with as a surgeon are either benign or malignant conditions to the thyroid gland. You may have in the past seen pictures of patients who have large masses in the front part of their neck. Those are called goiters. Those are benign conditions. And they come about some gradual increase in the size of the thyroid gland. In the past, when we did not have a good source of iodine in our diets, it was quite common. So in other countries where they do not have iodized salt or other supplements in their nutritional sources or food supplies, it's still a common problem. It's much less common from that standpoint in the US for that reason. But we still do have patients who will have enlarging thyroid glands and enlarging nodules, and most of the time they don't cause any type of malignant problem or functional hyperthyroidism where there's too much production, thyroid gland.

Most of the time as the gland enlarges, it can cause compressive effects where a patient may have swallowing difficulties or breathing problems and even voice changes. On the flip side, I also see patients commonly for thyroid cancer, which has been increasing in its incidents in this country. Although the good news is that the mortality has not changed for over 20 to 30 years. So that's the thyroid side. On the parathyroid side, it's very, very uncommon to have any kind of parathyroid carcinoma or malignancy. And actually in my 25 as a physician, I've only seen one case of parathyroid carcinoma. It's much more common to have what's called hyperparathyroidism, which is an increased function and hormonal secretion from the parathyroid glands and it causes your calcium level to go up.

Host: So then doctor, as a surgeon, tell us when the discussion of surgery for the thyroid or parathyroid even really does come up and tell us a little bit about who might be a candidate for these types of surgeries.

Dr. Lee: Patients who have benign thyroid disease such as a goiter, usually have surgery when they have those compressive effects, either breathing difficulties, difficulty swallowing, difficulty with voice changes, or if they have some transformation of the nodules over time, where they do become functional. For cancer, we usually intervene as soon as there is a diagnosis, and especially if there's a more aggressive type of cancer. Luckily, the majority of thyroid cancers are what we call well differentiated thyroid cancers, so they behave a little bit more favorably. So when a patient has any thyroid cancer, and I'll focus my comments to what are called papillary and follicular carcinomas. There's the well differentiated less aggressive types of cancers. They generally behave well. When we make a diagnosis of any size, we usually recommend some type of surgery. The literature and the science behind how much of the thyroid needs to be removed has been changing over time, but it could mean removing half of diver or sometimes even if the entire thyroid gland. So the parathyroid glands can be a little bit more complex because the metabolism, the calcium can be on a spectrum. You can have very mild symptoms or be essentially asymptomatic to be very symptomatic. So oftentimes we usually wait until a patients has a slightly higher calcium level and we can isolate the enlarged parathyroid gland or the glands, and the surgery is much more straightforward in that situation.

Host: Before we get into the difference between minimally invasive and open thyroidectomies and the type of surgeries you're discussing, what's life like for the patient once you've had to perform one of these surgeries as they are involved, as you said, in calcium and in so many metabolic processes? Tell us a little bit about life after.

Dr. Lee: I can say it's both in situations that thyroid and the parathyroid that essentially 98 to 99% of patients are cured of their disease process and especially, in the setting of a parathyroid patient, there is very little follow-up or need for additional medications. And in fact the patient's calcium levels will normalize very quickly after surgery, so they actually live completely normal lives without any need for medication. In terms of thyroid patients, they certainly have a very good recovery, especially in the setting of the well differentiated thyroid cancers and goiters. In the past because the sourcing of thyroid hormone was from natural products. The stability of the medication was very inconsistent, so over 40 years ago, it was very challenging for those patients to have normal metabolism. That is not the case in today's modern medication and thyroid hormone replacement, the synthetic thyroid hormone is very well tolerated, has a long half life. It has a half life of 20 to 21 days, so you can miss a dose and not feel many of the affects at all, and it's very easily taken once a day. So these patients actually function very, very well.

Host: That's so encouraging, you know, to hear from a surgeon. So tell us about the benefits of the minimally invasive versus an open surgery and what you want patients to know when you're helping them make these decisions.

Dr. Lee: When you talk about minimally invasive endocrine surgery, in terms of thyroid versus parathyroid, we've focused really more on the parathyroid gland versus the thyroid gland. Many times the thyroid gland surgery has not changed significantly in terms of an open approach or a minimally invasive approach. The reasons that the parathyroid gland has been able to be approached from a minimally invasive standpoint is taking advantage of its actual function and the very short half life of a parathyroid hormone. So the first thing to do is to localize the abnormality in the parathyroid. And this is where we utilize our radiology colleagues to help us to localize whether someone has one large dominant parathyroid gland that's hyper functioning or is it multiple glands that are hyper functioning. In the majority of cases it is usually just one single enlarged gland that is hyper functioning. So we use a combination of ultrasound and nuclear medicine and CT scan to localize. That way we can identify is the gland on the right side of the body, is it on the left side and even more specifically as in the upper part of the neck or the lower part of the neck, and even at topic or unusual positions of the parathyroid can be picked up with these localization methods. Once we can do that, we can take out a parathyroid gland with an incision that may be no larger than two centimeters or less than an inch long.

Host: That's amazing. It's really fascinating what was going on 40 years ago versus what you can do now. As we wrap up, Dr. Lee, give your best advice on the multidisciplinary approach and when you feel it's important that patients come to see you at the George Washington Medical Faculty Associates.

Dr. Lee: Well, the first thing is if you suspect that you have any problem with your thyroid or parathyroid glands and you may have symptoms of fatigue, changes in hair and nails, you may have heat or cold intolerance. Those could be clues that your thyroid is not functioning properly. And in terms of the parathyroid glands, you can have symptoms of kidney stones, abdominal pain, joint pain, hand pain, see your primary care physician, they can run tests that are very easily detected with a blood test that can help to determine if you have any problems with your thyroid or parathyroid gland. So it is important to have a team to work with. So your primary care physician is going to start that workup process. So many patients may never come to see me because that original screening is enough to rule out any kind of problem. Once you come to have a problem with your thyroid and parathyroid, it's really important to make sure that you have an endocrinologist who can follow you long-term. And a surgeon who is well experienced. And it is scary to think that you might need an incision in the neck itself and you have complications related to some of the vessels and nerves. But a well placed incision is very faint and fades over time. And a well-experienced thyroid and parathyroid surgeon minimizes the chance of complications.

Host: It's great advice and thank you so much. That was a great summary. Dr. Lee, thank you for joining us. And that concludes this episode of the GW Medical Faculty Associates Podcast. Please visit our website at gwdocs.com for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other GW Medical Faculty Associates podcasts. I'm Melanie Cole.