Approximately 12 million Americans are affected by thyroid disease and some of those cases may be cancerous. When a thyroid nodule is discovered, imaging, biopsies and possibly surgery may be recommended.
Jennifer Rosen, MD, Chief of Endocrine Surgery and Vice Chair of Research at MedStar Washington Hospital Center, provides the full picture of what to expect during the process.
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Thyroid Cancer Surgery: Less Invasive, Less Scarring
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Learn more about Jennifer Rosen, MD
Jennifer Rosen, MD
Jennifer Rosen, MD, FACS is Chief of Endocrine Surgery and Vice Chair for Research of the Department of Surgery at Medstar Washington Hospital Center. She serves on the Collaborative Endocrine Surgery Quality Improvement Program Committee of the American Association of Endocrine Surgeons (AAES) and sits as a representative of the College to the Commission on Cancer (COC), a program of the American College of Surgeons (ACS). She has been active on numerous committees of the American Thyroid Association (ATA) and serves as Endocrine Section Editor for the Journal of Surgical Oncology. For more than five years, Dr. Rosen served as The Laszlo N. Tauber Assistant Professor of Surgery and Molecular Medicine at the Boston University School of Medicine.Learn more about Jennifer Rosen, MD
Transcription:
Thyroid Cancer Surgery: Less Invasive, Less Scarring
Melanie Cole (Host): According to the American Cancer Society, approximately 12 million Americans are affected by thyroid disease and some of those affected may become cancerous. My guest today is Dr. Jennifer Rosen. She’s the Chief of Endocrine Surgery and Vice-Chair for Research of the Department of Surgery of MedStar Washington Hospital Center. Welcome to the show, Dr. Rosen. Tell us about the risk factors for thyroid cancer…
Dr. Jennifer Rosen (Guest): So, in fact, there are only a couple of known risk factors for developing thyroid cancer. The first is exposure to radiation and by this I really mean significant levels of radiation such as with radioactive fallout or treatment with radioactive iodine or external beam radiation. The other known risk factor, of course, is a family history of thyroid cancer and this really only explains a very small number of patients with thyroid cancer, in particular, a kind of cancer known as “medullary thyroid cancer”.
Melanie: Is this more common in men or women?
Dr. Rosen: Far more common in women. In fact, I would probably say out of every 10 patients we see, 7 or 8 of them are going to be women.
Melanie: So, how would a woman know? Would she have had to experience thyroid issues earlier on in her life to kind of keep track of her thyroid? How would you know if you had cancer?
Dr. Rosen: So, the answer really is most of my patients who come to see me with thyroid cancer don’t know that they’ve ever had a problem with their thyroid before. Either it’s found through a nodule found by exam by their primary care physician or maybe one of the members of their family was treated for thyroid issues and that’s how they found it o even incidentally where the patient noticed that they were having some changes in their voice or changes in their swallowing. We have a lot of patients who come to see us, in fact, who had a CT scan or an MRI done for an accident or for a neck injury or neck issues and that’s how they find their thyroid nodules. The vast majority of the patients who come to see me with thyroid cancer, in fact, have no symptoms at all and when we check their thyroid function again, the vast majority of patients who come to see me with thyroid cancer, the thyroid is functioning perfectly normally.
Melanie: How is it diagnosed? Can it be caught early?
Dr. Rosen: So, yes. The patient who comes to see me who noticed a thyroid nodule or the thyroid nodule was found, the first thing that we do is we do an ultrasound. This is a non-invasive test. If you’ve ever had it before, it’s very simple. You use an ultrasound probe and rub it on the skin with a little bit of cold jelly and it takes a picture image of the thyroid and the surrounding tissue. That’s the most important diagnostic step for anybody noticed to have a thyroid nodule. The next thing that we do is for patients that meet criteria and we do follow the American Thyroid Association guidelines and recommendations for when we do or do not biopsy thyroid nodules. For the most part, patients who have nodules over 1 cm or with any of the worrisome appearance of these nodules, we’re going to do an ultrasound guided needle biopsy. It’s a very straightforward process and should be done with someone that has a lot of experience in doing those. It’s a day procedure. You come and go during the same procedure. The skin sometimes is numbed up and then a series of small needles is passed into the thyroid nodule using the guidance of the ultrasound probe. Some people tell me that this didn’t cause any pain or discomfort at all. Sometimes patients have a little bit of pressure sensation during this procedure and we collect all of that needle specimen is collected into either a vial, a jar or a slide. Sometimes we put a specimen aside for genetic testing and it really has to be collected at the time of your needle biopsy. Those specimens go off to the pathologist who looks at them under a microscope and then comes back and tells us whether that patient either has a completely benign growth, an obviously cancerous growth or this middle category called “indeterminate”. In twenty percent of needle biopsies, the biopsy results alone are not enough to tell us whether they have cancer of the thyroid gland or not. So, those patients often have surgery for the purpose of diagnosis. So, patients really come to us through those two main ways. Every so often, a patient will come to us because they already have spread of the disease to other parts of their body and that’s how we make the diagnosis for thyroid cancer.
Melanie: So, if you’ve determined that it is cancer, what is the first line of defense as far as treatment goes? And, speak about reducing scarring if they do have to have surgery.
Dr. Rosen: Sure. So, the patients who come to me with a diagnosis of thyroid cancer, very often they’ve already read on the web, maybe they have a family member or somebody who has been through this process before. The first thing and the most important thing is for me to sit down and tell them it’s not a one-size fits all operation. It’s a conversation that we’re going to have about how we’re going to approach this. So, if a patient has a significant thyroid cancer, meaning something that’s over 1 cm, their options really are thyroid surgery and it comes really in two different approaches. The first approach is lobectomy—removal of half of the thyroid that contains that thyroid cancer alone; or a total thyroidectomy—removal of the entire thyroid gland and examination of the lymph nodes in the center of the neck at the time of surgery. Any patient with a diagnosis of thyroid cancer needs to have a neck ultrasound looking at the lateral lymph nodes to see if there are any worrisome lymph nodes. Almost 1 out of 5 patients have spread to the lymph nodes elsewhere in the neck at the time that they come to see me. So, that’s an important thing to find out before surgery because that’s going to change the scope of my operation and, of course, the size of the incision. So, if a patient comes to see me and they have opted for having a total thyroidectomy—removal of all of the thyroid gland—then, I’m going to examine the lymph nodes in the center of the neck at the time of surgery. We often remove the lymph nodes at the center of the neck at the time of surgery. We can do that all through the same small incision. Our incisions typically are low in the neck. They go across the neck. They’re about a fingerbreadth above the collar bone. There are also a couple of other approaches to thyroid surgery but this is our preferred method and my 3 partners and I do quite a fair number of these. The most important first thing that a patient can do to help the operation go well is avoid significant sun exposure just before surgery. Men should not shave and women should not put any makeup or perfume in the area. No special lotions or creams—just cleanse the area as instructed by whatever hospital they’re going to. Then, the things that I do in the operating room are really important for minimizing scarring. The first, of course, is surgeons who do a lot of this operation are more comfortable with managing the operation making for a small incision, delicate handling the skin of the skin in the operation. I use the same closure with every patient every time. It’s a very non-reactive suture. None of the stitches that I put in the incision have to be removed. They all are going to melt away on their own and then we use a little bit of glue on top of that—a special kind of skin glue that is very protective of the skin lining. Then, I tell patients, “Don’t do anything for the incision until I see you in the office 2 weeks after. No creams or lotions. Try to avoid a lot of sun exposure.” You don’t have to go out of your way to cover the incision or do anything special for it and you can shower the day after surgery as long as you don’t rub at the incision or take the glue off. By the time they come back to see me in the office, many patients have either had the glue come off from that incision or the glue is still there and we’ll peel it off at the time that we see them in the office. If the incision is soft and flat and looks as though it’s going to go on the path towards healing without any intervention, that’s exactly what I do. I leave the incision alone. Any patients have a concern for family history of keloid scarring or hypercellular scars or hypertrophic scars, I’ll advise them to either use a small amount of vitamin E cream or sometimes some of the silicone gel strips or lotion that they can apply to it but, really, the less is better. Part of the most important part of managing that incision is going to be careful skin handling in the operating room.
Melanie: What is life like, Dr. Rosen, for those patients after this type of surgery? Do they have, sometimes, temporary loss of voice? Do they have to take daily thyroid pills? How is life changed for them?
Dr. Rosen: So, there are a number of ways this can change. The first, of course, is getting used to the fact that you’re going to have to take a lifelong medication and that medication is Levothyroxine. That’s the generic form of that. We make our best guesstimate about what the dose is going to be for that patient after surgery and then we often adjust it a number of times very gently a couple of times after surgery. In our hands, we find that most patients don’t need more than one or two dose changes to find the right level for them. Now, you have to remember that for patients with thyroid cancer, replacement therapy is, they’re actually going to get thyroid hormone suppressive therapy. They’re not just going to get enough thyroid hormone to replace the thyroid but often they’re going to be given a little extra to keep the brain signal to the thyroid called the “TSH” level a little bit lower than most patients. So, we need to really find the right dose for them. That medication needs to be taken first thing in the morning, separated from food or drink, and so we’ll work on adjusting that and getting patients used to the fact that they can’t just get out of bed and have their cup of coffee or breakfast right away. They need to take their pill and then they can go on with the rest of their day. Most of my patients will not experience the signs and symptoms of low thyroid function. So, when they go on the web and read about this, they’ll hear about loss of energy, loss of hair, gaining weight and so forth. Our patients shouldn’t change their weight more than about 3-5 lbs. after surgery. They ought to feel normal after surgery. Now, there are risks and complications to this operation. The first is that right in the few weeks after surgery, you can have some swelling in the neck. That should go away over time and that can give people a pressure or a discomfort feeling that there is something in their throat when they swallows and that should go away with time. If there is any injury to the nerves that go into the voice box, most commonly the recurrent laryngeal or the external branch of the superior laryngeal, you can either have hoarseness or you can have difficulty in sustaining the upper part of your voice—sort of the issue with yelling at your kids or raising your voice or finding that your voice fatigues by the end of the day. For most patients, that should go away within a few weeks after surgery. If there truly is a nerve injury, we recommend that patients, six weeks after surgery, get evaluated with the video stroboscopy. That’s a special technique where they look in the back of your throat to see if the vocal cords are moving. Less than 1 out 100 patients should have a permanent change in their voice after this operation. The other thing or symptom that patients often experience is a low calcium level from injury to or removal of one of their parathyroid glands. Those are little glands the size of a grain of rice. They’re attached to the thyroid gland and they help regulate the calcium level in your blood. A number of patients—anywhere from 3-6% if you look at the American literature—can have low function of those parathyroid glands after surgery and then they can have numbness and tingling in the fingers, hands or around the mouth and maybe 1 out 100 patients permanently will have low function and will have permanent low calcium levels where they have to take multiple pills during the day. The vast majority of my patients, within 3 months after surgery, tell me that they feel normal and are back to their usual activity level.
Melanie: In just the last few minutes, Dr. Rose, what a fascinating topic and you’re so well spoken. Please wrap it up and tell the listeners what you really want them to know about thyroid cancer, if it can be prevented, and any lifestyle modifications you’d like to tell them about.
Dr. Rosen: So, the first and most important thing is, come to see a doctor and don’t be afraid. Surgeons don’t bite. We’re there to take good care of you. The vast majority of surgeons in the United States do endocrine surgery. A lot of them do a lot of this kind of surgery. Ask questions. Feel comfortable with the person who’s going to take care of you. Thyroid cancer is very treatable. Even patients with metastatic disease, meaning spread of the thyroid cancer to other parts of the body or lymph nodes can be safely treated and live a long, happy, healthy and productive life. So, don’t feel that this is a death sentence or something that’s going to be a significant change in your life. That may be true for some patients but don’t let it keep you from getting your treatment and going forward. The other thing is, you really need to see either your endocrinologist or your endocrine surgeon as a partner in going forward and making sure that you have the best possible outcome. We monitor our patients for life. I would say that the happy, healthy patient I see before surgery should be happy and healthy afterwards, back to their usual level of energy, exercise and activity and I’m very pleased to be able to take care of patients at this important and critical point in time because I know the vast majority of patients are going to go on to lead a productive life and be better, if not improved, after their operation.
Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That’s www.medstartwashington.org. This is Melanie Cole. Thanks so much for listening.
Thyroid Cancer Surgery: Less Invasive, Less Scarring
Melanie Cole (Host): According to the American Cancer Society, approximately 12 million Americans are affected by thyroid disease and some of those affected may become cancerous. My guest today is Dr. Jennifer Rosen. She’s the Chief of Endocrine Surgery and Vice-Chair for Research of the Department of Surgery of MedStar Washington Hospital Center. Welcome to the show, Dr. Rosen. Tell us about the risk factors for thyroid cancer…
Dr. Jennifer Rosen (Guest): So, in fact, there are only a couple of known risk factors for developing thyroid cancer. The first is exposure to radiation and by this I really mean significant levels of radiation such as with radioactive fallout or treatment with radioactive iodine or external beam radiation. The other known risk factor, of course, is a family history of thyroid cancer and this really only explains a very small number of patients with thyroid cancer, in particular, a kind of cancer known as “medullary thyroid cancer”.
Melanie: Is this more common in men or women?
Dr. Rosen: Far more common in women. In fact, I would probably say out of every 10 patients we see, 7 or 8 of them are going to be women.
Melanie: So, how would a woman know? Would she have had to experience thyroid issues earlier on in her life to kind of keep track of her thyroid? How would you know if you had cancer?
Dr. Rosen: So, the answer really is most of my patients who come to see me with thyroid cancer don’t know that they’ve ever had a problem with their thyroid before. Either it’s found through a nodule found by exam by their primary care physician or maybe one of the members of their family was treated for thyroid issues and that’s how they found it o even incidentally where the patient noticed that they were having some changes in their voice or changes in their swallowing. We have a lot of patients who come to see us, in fact, who had a CT scan or an MRI done for an accident or for a neck injury or neck issues and that’s how they find their thyroid nodules. The vast majority of the patients who come to see me with thyroid cancer, in fact, have no symptoms at all and when we check their thyroid function again, the vast majority of patients who come to see me with thyroid cancer, the thyroid is functioning perfectly normally.
Melanie: How is it diagnosed? Can it be caught early?
Dr. Rosen: So, yes. The patient who comes to see me who noticed a thyroid nodule or the thyroid nodule was found, the first thing that we do is we do an ultrasound. This is a non-invasive test. If you’ve ever had it before, it’s very simple. You use an ultrasound probe and rub it on the skin with a little bit of cold jelly and it takes a picture image of the thyroid and the surrounding tissue. That’s the most important diagnostic step for anybody noticed to have a thyroid nodule. The next thing that we do is for patients that meet criteria and we do follow the American Thyroid Association guidelines and recommendations for when we do or do not biopsy thyroid nodules. For the most part, patients who have nodules over 1 cm or with any of the worrisome appearance of these nodules, we’re going to do an ultrasound guided needle biopsy. It’s a very straightforward process and should be done with someone that has a lot of experience in doing those. It’s a day procedure. You come and go during the same procedure. The skin sometimes is numbed up and then a series of small needles is passed into the thyroid nodule using the guidance of the ultrasound probe. Some people tell me that this didn’t cause any pain or discomfort at all. Sometimes patients have a little bit of pressure sensation during this procedure and we collect all of that needle specimen is collected into either a vial, a jar or a slide. Sometimes we put a specimen aside for genetic testing and it really has to be collected at the time of your needle biopsy. Those specimens go off to the pathologist who looks at them under a microscope and then comes back and tells us whether that patient either has a completely benign growth, an obviously cancerous growth or this middle category called “indeterminate”. In twenty percent of needle biopsies, the biopsy results alone are not enough to tell us whether they have cancer of the thyroid gland or not. So, those patients often have surgery for the purpose of diagnosis. So, patients really come to us through those two main ways. Every so often, a patient will come to us because they already have spread of the disease to other parts of their body and that’s how we make the diagnosis for thyroid cancer.
Melanie: So, if you’ve determined that it is cancer, what is the first line of defense as far as treatment goes? And, speak about reducing scarring if they do have to have surgery.
Dr. Rosen: Sure. So, the patients who come to me with a diagnosis of thyroid cancer, very often they’ve already read on the web, maybe they have a family member or somebody who has been through this process before. The first thing and the most important thing is for me to sit down and tell them it’s not a one-size fits all operation. It’s a conversation that we’re going to have about how we’re going to approach this. So, if a patient has a significant thyroid cancer, meaning something that’s over 1 cm, their options really are thyroid surgery and it comes really in two different approaches. The first approach is lobectomy—removal of half of the thyroid that contains that thyroid cancer alone; or a total thyroidectomy—removal of the entire thyroid gland and examination of the lymph nodes in the center of the neck at the time of surgery. Any patient with a diagnosis of thyroid cancer needs to have a neck ultrasound looking at the lateral lymph nodes to see if there are any worrisome lymph nodes. Almost 1 out of 5 patients have spread to the lymph nodes elsewhere in the neck at the time that they come to see me. So, that’s an important thing to find out before surgery because that’s going to change the scope of my operation and, of course, the size of the incision. So, if a patient comes to see me and they have opted for having a total thyroidectomy—removal of all of the thyroid gland—then, I’m going to examine the lymph nodes in the center of the neck at the time of surgery. We often remove the lymph nodes at the center of the neck at the time of surgery. We can do that all through the same small incision. Our incisions typically are low in the neck. They go across the neck. They’re about a fingerbreadth above the collar bone. There are also a couple of other approaches to thyroid surgery but this is our preferred method and my 3 partners and I do quite a fair number of these. The most important first thing that a patient can do to help the operation go well is avoid significant sun exposure just before surgery. Men should not shave and women should not put any makeup or perfume in the area. No special lotions or creams—just cleanse the area as instructed by whatever hospital they’re going to. Then, the things that I do in the operating room are really important for minimizing scarring. The first, of course, is surgeons who do a lot of this operation are more comfortable with managing the operation making for a small incision, delicate handling the skin of the skin in the operation. I use the same closure with every patient every time. It’s a very non-reactive suture. None of the stitches that I put in the incision have to be removed. They all are going to melt away on their own and then we use a little bit of glue on top of that—a special kind of skin glue that is very protective of the skin lining. Then, I tell patients, “Don’t do anything for the incision until I see you in the office 2 weeks after. No creams or lotions. Try to avoid a lot of sun exposure.” You don’t have to go out of your way to cover the incision or do anything special for it and you can shower the day after surgery as long as you don’t rub at the incision or take the glue off. By the time they come back to see me in the office, many patients have either had the glue come off from that incision or the glue is still there and we’ll peel it off at the time that we see them in the office. If the incision is soft and flat and looks as though it’s going to go on the path towards healing without any intervention, that’s exactly what I do. I leave the incision alone. Any patients have a concern for family history of keloid scarring or hypercellular scars or hypertrophic scars, I’ll advise them to either use a small amount of vitamin E cream or sometimes some of the silicone gel strips or lotion that they can apply to it but, really, the less is better. Part of the most important part of managing that incision is going to be careful skin handling in the operating room.
Melanie: What is life like, Dr. Rosen, for those patients after this type of surgery? Do they have, sometimes, temporary loss of voice? Do they have to take daily thyroid pills? How is life changed for them?
Dr. Rosen: So, there are a number of ways this can change. The first, of course, is getting used to the fact that you’re going to have to take a lifelong medication and that medication is Levothyroxine. That’s the generic form of that. We make our best guesstimate about what the dose is going to be for that patient after surgery and then we often adjust it a number of times very gently a couple of times after surgery. In our hands, we find that most patients don’t need more than one or two dose changes to find the right level for them. Now, you have to remember that for patients with thyroid cancer, replacement therapy is, they’re actually going to get thyroid hormone suppressive therapy. They’re not just going to get enough thyroid hormone to replace the thyroid but often they’re going to be given a little extra to keep the brain signal to the thyroid called the “TSH” level a little bit lower than most patients. So, we need to really find the right dose for them. That medication needs to be taken first thing in the morning, separated from food or drink, and so we’ll work on adjusting that and getting patients used to the fact that they can’t just get out of bed and have their cup of coffee or breakfast right away. They need to take their pill and then they can go on with the rest of their day. Most of my patients will not experience the signs and symptoms of low thyroid function. So, when they go on the web and read about this, they’ll hear about loss of energy, loss of hair, gaining weight and so forth. Our patients shouldn’t change their weight more than about 3-5 lbs. after surgery. They ought to feel normal after surgery. Now, there are risks and complications to this operation. The first is that right in the few weeks after surgery, you can have some swelling in the neck. That should go away over time and that can give people a pressure or a discomfort feeling that there is something in their throat when they swallows and that should go away with time. If there is any injury to the nerves that go into the voice box, most commonly the recurrent laryngeal or the external branch of the superior laryngeal, you can either have hoarseness or you can have difficulty in sustaining the upper part of your voice—sort of the issue with yelling at your kids or raising your voice or finding that your voice fatigues by the end of the day. For most patients, that should go away within a few weeks after surgery. If there truly is a nerve injury, we recommend that patients, six weeks after surgery, get evaluated with the video stroboscopy. That’s a special technique where they look in the back of your throat to see if the vocal cords are moving. Less than 1 out 100 patients should have a permanent change in their voice after this operation. The other thing or symptom that patients often experience is a low calcium level from injury to or removal of one of their parathyroid glands. Those are little glands the size of a grain of rice. They’re attached to the thyroid gland and they help regulate the calcium level in your blood. A number of patients—anywhere from 3-6% if you look at the American literature—can have low function of those parathyroid glands after surgery and then they can have numbness and tingling in the fingers, hands or around the mouth and maybe 1 out 100 patients permanently will have low function and will have permanent low calcium levels where they have to take multiple pills during the day. The vast majority of my patients, within 3 months after surgery, tell me that they feel normal and are back to their usual activity level.
Melanie: In just the last few minutes, Dr. Rose, what a fascinating topic and you’re so well spoken. Please wrap it up and tell the listeners what you really want them to know about thyroid cancer, if it can be prevented, and any lifestyle modifications you’d like to tell them about.
Dr. Rosen: So, the first and most important thing is, come to see a doctor and don’t be afraid. Surgeons don’t bite. We’re there to take good care of you. The vast majority of surgeons in the United States do endocrine surgery. A lot of them do a lot of this kind of surgery. Ask questions. Feel comfortable with the person who’s going to take care of you. Thyroid cancer is very treatable. Even patients with metastatic disease, meaning spread of the thyroid cancer to other parts of the body or lymph nodes can be safely treated and live a long, happy, healthy and productive life. So, don’t feel that this is a death sentence or something that’s going to be a significant change in your life. That may be true for some patients but don’t let it keep you from getting your treatment and going forward. The other thing is, you really need to see either your endocrinologist or your endocrine surgeon as a partner in going forward and making sure that you have the best possible outcome. We monitor our patients for life. I would say that the happy, healthy patient I see before surgery should be happy and healthy afterwards, back to their usual level of energy, exercise and activity and I’m very pleased to be able to take care of patients at this important and critical point in time because I know the vast majority of patients are going to go on to lead a productive life and be better, if not improved, after their operation.
Melanie: Thank you so much for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That’s www.medstartwashington.org. This is Melanie Cole. Thanks so much for listening.