Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Currently, a third to a half of the population have some form of thyroid nodules. And up to 90% of present thyroid nodules are benign, but detection and monitoring is imperative to keep track of size and placement. Welcome to UAB MedCast. I'm Melanie Cole. And we have three UAB Medicine practitioners here today to discuss thyroid nodules and cancer detection.

Joining me in this thought leader panel is Dr. Andrea Gillis, she's an endocrine surgeon and an Assistant Professor; Dr. Sophie Dream, she's an endocrine surgeon and an Associate Professor; and Kelly Lovell, she's a certified registered nurse practitioner in Endocrine Surgery. Thank you all for joining us today. And Dr. Gillis, I'd like to start with you. Speak a little bit about the prevalence of thyroid nodules and how common thyroid cancer is. From that, is there a connection between them? Give us a little overview and background for us.

Dr. Andrea Gillis: Yeah. So, thank you. Thyroid nodules are really quite common. As many as half of the patients or half of the people walking around have some type of thyroid nodule. And most people don't know it, they're usually asymptomatic. The good part is most of these nodules are totally benign. They are not a cancer, they won't turn into a cancer. Only about 5-6% of all thyroid nodules are a cancer. So, a lot of our job as endocrine surgeons, endocrinologists, primary care doctors, people who find patients with thyroid nodules is figuring out which of these nodules are a cancer and which of these nodules need something done about them.

Melanie Cole, MS: Well, that certainly is interesting. So then, Dr. Dream, along those lines, latest advancements in diagnostic tools for detecting nodules in the first place. And then, as Dr. Gillis was pointing out, distinguishing between benign and malignant cases. So, tell us a little bit about the imaging that you might use in the decisions you might make to decide whether or not you're going to go forward with more diagnostics to detect whether it's malignant or not.

Dr. Sophie Dream: Yeah. So usually, the best imaging for thyroid nodule is an ultrasound. And we don't recommend that everybody get a screening ultrasound, because again, as we kind of established that thyroid nodules are very common. About a third to half of the population will have a thyroid nodule. Most of those are benign. So, we don't want to be overdiagnosing and overtreating disease. So if someone has something that's a change in their neck where they feel a palpable nodule in their neck, or they notice changes in their swallowing or things are getting stuck, those are times where we'd say you should get a screening ultrasound to see if there's something there.

The other times we would do an ultrasound is if someone has a really high risk of family history of thyroid cancer or if they have an exposure, like radiation exposure to their head or neck, sometimes those patients will get an ultrasound, or it'll be found incidentally. Once something's been found and we usually take a really close look at those nodules and categorize how worrisome those nodules look based on the TIRADS classification. So, the features of those nodules on the ultrasound. And then, based on that TIRADS classification and the size of the nodule, then we decide whether or not to biopsy it. Again, we try not to overdiagnose and overtreat thyroid nodules. So, things that are less than a centimeter generally don't get biopsied, because oftentimes thyroid cancers don't necessarily need to come out. So, we try not to do too much. It is a fine balance.

Melanie Cole, MS: Well, it certainly is. So, Kelly, how do you stratify the risk among patients with these nodules? Can you speak to the factors that contribute to a higher risk of malignancy as you're counseling patients and helping them to not be so worried all the time? How does this impact the treatment decisions? And help us understand the risk.

Kelly Lovell: So if a patient's TIRADS criteria meets requirements for biopsy, then we would send them to either Radiology, Endocrinology or our office, to do a biopsy, which is done just under local numbing medication. And then, there are multiple passes with a needle to try to get some cells and give us some clue into what's going on inside the nodule.

And then, there are multiple results that can come. So, I think it's important to counsel the patient on what those results could mean for them. So, Bethesda is the criteria that they use. There's non-diagnostic, so they don't get enough cells to tell us anything. It can come back benign, definitely malignant, more suspicious for malignancy or this indeterminate category. And the indeterminate category, it's kind of provider-dependent on doing extra genetic testing or just recommending removal for the patient.

Melanie Cole, MS: Kelly, sticking with you for a second. Are there genetic risks? Are there familial risks in families? Tell us a little bit about thyroid cancer and nodules, but is this something that we look at genetic markers for?

Kelly Lovell: Yes. So, there are some genetic conditions, and maybe Dr. Dream or Dr. Gillis can speak more to those, that predispose people for higher risk of cancer. But then, there's also the genetic testing of the actual tumor or thyroid nodule that lets us know if it's more suspicious for cancer or not.

Dr. Andrea Gillis: Yeah. So, there are different types of thyroid cancer. And within those different types of thyroid cancer, there are certain that run in families. So, medullary is one of the more rare types of thyroid cancer that is associated with a type of genetic syndrome called multiple endocrine neoplasm. So, those medullary thyroid cancers tend to run in families. So if one person in a family has been diagnosed with that, we would test that person for this genetic syndrome. And then, for the differentiated thyroid cancers, those are papillary and follicular. There's a whole host of other genetic syndromes that predispose someone to having those. But the vast majority of people with thyroid cancer is not going to be genetically mediated. It just pops up sporadically.

Melanie Cole, MS: Well, thank you for that. So, Dr. Dream, tell us about how UAB has a non-invasive ultrasound-guided procedure that shrinks benign nodules that may be bothersome or impacting hormone production. Tell us a little bit about what you're doing there at UAB Medicine.

Dr. Sophie Dream: So, we have a radiofrequency ablation program, where nodules that are causing compressive symptoms or cosmetic symptoms, or that are producing too much thyroid hormone. We can address those with a needle probe that creates heat, that in turn causes necrosis of the cells of these thyroid nodules and eventually causes those nodules to scar in and shrink over time. It's a really great procedure for nodules that are less than four centimeters and that have been biopsy-proven benign, because we don't want to change the way a nodule looks on ultrasound if we aren't certain about its malignancy risk. So, we want to make sure those nodules are benign before we're treating it with radiofrequency ablation.

And larger nodules that might be causing a little bit more compressive systems, like five, six centimeter nodules. There's a procedure called microwave ablation that's a little bit more effective that we're starting to bring to UAB hopefully in the upcoming months. But Dr. Gillis and I have been exploring that option, and it seems like a really promising technology that we're hoping to bring here.

Dr. Andrea Gillis: Yeah. Endocrine surgery and the field of Endocrine Surgery is really interesting and we do a lot of shared decision-making with our patients. There's not always a clear cut, right or wrong answer. So, we spend a lot of time with our patients making sure they understand the risks and the benefits. Because unfortunately, we don't always have a test that is a hundred percent accurate for, yes, there's a cancer or, no, there's not a cancer in the nodule.

Just like Kelly mentioned, biopsies can return with a variety of results. So, that's why we have a wide variety of procedures we can offer. So yes, we can do a surgery to definitively diagnose, or we can surveil and get serial ultrasounds if the nodule does not look like it's a high risk for cancer, or we can try one of these thermal ablation techniques, which have the potential to allow patient to avoid a surgery if that's something they're really interested in, especially if we have a low concern for a cancer.

Dr. Sophie Dream: I think the biggest benefit of the ablative techniques is there are patients who have been told that they either have surgery and take care of their nodule by having it removed, or they just continue to watch it and they don't want to do something, what do they feel so, so extreme like surgery or something so passive as doing nothing. I think for some of those patients where we are not saying, "Yes, it's absolutely has to come out," it's a nice intermediary. It doesn't burn the bridge to surgery. And it still allows the patients some control over having some treatment option.

The other biggest benefit I think of ablative techniques is the risk of hypothyroidism. So, the risk of hypothyroidism with a thyroid lobectomy is upwards of 20%. So with thyroid ablation, that risk of hypothyroidism in an otherwise normal thyroid that's been functioning normally is less than 1%. So, it allows preservation of thyroid function.

Melanie Cole, MS: This is really an exciting time in your field. There's so much going on. and Dr. Gillis, are there new surgical techniques or technologies you'd like to speak about that have improved outcomes for thyroid cancer patients that do undergo surgery? How do you approach minimally invasive versus traditional surgery in this context? Speak about what's exciting in your field for thyroid cancer right now.

Dr. Andrea Gillis: So, some of the newer technologies that we offer starts as early as the diagnosis phase. So, Kelly mentioned that the fine-needle aspiration can result in a variety of findings. So, one of those indeterminate findings can then be further evaluated with certain genetic or genomic tests. So, looking for any molecular deviations within the nodule that, over years of prior testing, we've been able to classify as either high risk for malignancy or low risk for malignancy. So now in addition to just the pathologist looking at the aspirate, we can send those cells for genetic testing and that gives us even more information to make an educated decision about if a patient needs surgery or not, because if we can avoid taking out thyroid nodules unnecessarily. If we can tell there's not a cancer in there, then that's absolutely what we want to try to offer the patient. So, these newer tests are giving us more and more information to be able to do that.

Dr. Sophie Dream: I think the other newer treatment that's kind of come out that has some promise is immunotherapies for advanced thyroid cancers. Oftentimes, patients will have really bulky advanced thyroid cancers that are invading either the trachea of the larynx. And they were often getting palliative surgeries or treatments like tyrosine kinase inhibitors that were not great treatment options, because they didn't really affect the long-term prognosis or shrink those tumors down very well.

We now have a lot of immunotherapies that target like a BRAF mutation or a RET mutation, which we commonly see in thyroid cancers. We can give to patients and they can shrink those tumors down to get to a place where they're either resectable or can prolong patient longevity of life, and help them just with the overall long-term survival. It's a very promising technique and I anticipate to see how some of those pan out.

Melanie Cole, MS: Dr. Dream, I'd like you to speak about the multidisciplinary team approach. We've got three of you on here today. And I know there are more practitioners involved when patients are going through your clinic and learning that they have thyroid nodules and/or cancer. Speak about who's all involved and who's typically the different specialties that are involved.

Dr. Sophie Dream: Thyroid nodules, they come from oftentimes either the patient or their primary care doctor is discovering them first, or they're coming in through the ER, they've had some incidental imaging where they've gotten a car accident, they had a head or neck image, and now they have a thyroid nodule that's getting worked up.

So, we work with all of those people too. So, I think that multidisciplinary team extends out to absolutely everyone. But then, when we dive deeper into working up the nodule, we have endocrinologists that will help us with ultrasound, FNA. Oftentimes, radiologists will also help us with FNAs.

And then, we will talk to the patients as well as our Endocrinology team, with whether or not the patient needs thyroid surgery, observation, or some other intervention. And that's a process we encourage patients to have lots of conversations with lots of different people, so that they get a really good sense of what life looks like with any given treatment. Just because any treatment can affect their hormone levels or affects how they live their day-to-day life. So, we want them to have a really good experience and a really educated decision in what they're choosing for themselves, for their treatment.

Melanie Cole, MS: It's so important. And I'd love to give you each a chance for a final thought here. So Kelly, I'd like you to speak about key considerations when you are counseling patients about thyroid nodule findings, particularly in terms of potential malignancy, these treatment options that we've discussed here today, and certainly watching and waiting. That can always be a little tense for the patient. So, how does the nurse practitioner contribute to the care team in managing these patients? And tell us about your specific responsibilities and expertise.

Kelly Lovell: So, I think, like Dr. Gillis had mentioned earlier, shared decision-making is really important. So, the first thing is just making sure that the patient gets all the information upfront and that they understand what we're saying to them. And I think, as a nurse practitioner, it kind of plays in that they're not always telling the doctor what they do or do not understand.

So, my role kind of coming in behind and making sure that they understand what we're telling them, what their options are because there are multiple; the half, the whole thyroid, watching, waiting and those kinds of things there. And then, ultimately, I think sometimes they need a little bit of extra time to make the decision and think about it and not having to do it right there. So, just following up with them.

Melanie Cole, MS: Such an important part of your job. And Dr. Gillis, how do you address patient concerns and ensure informed decision-making? And certainly, as we were saying with Kelly, when you're doing surveillance, how do you help them throughout the diagnostic and treatment process?

Dr. Andrea Gillis: Yeah. I think it's all about shared decision-making and the patient should feel like they are a part of that and they're driving the ship. So if there's ever a treatment option that they're not comfortable with, there's never any point of no return. So if they initially select surveillance, but it's causing them a lot of anxiety or something in their personal situation has changed, we can always revisit the topic, and discuss more definitive management like a surgery or thermal ablation.

But I think it's key that we're on the same page, and that the patient understands the risks and the benefits of all their options in front of them. And so, I really try to spend the time to have those discussions upfront, really set expectations. And just like Kelly mentioned, they may not make that decision during the initial visit. So, we're always available for followup visits. We have telehealth opportunities. If patients live further away and they don't want to have to make a long trip back to see us in person. We can always talk virtually as well. So, I think open communication, and sharing that decision, because ultimately it's the patient's body and we want them to be comfortable with what they decide and lead a good quality of life afterwards.

Melanie Cole, MS: It's a comprehensive approach for sure. With that shared decision-making, which you've all reiterated, and that's so important. And Dr. Dream, last word to you, key takeaways for other providers, what you would like them to know about thyroid nodules, thyroid cancer, and the work that you're doing there at UAB Medicine.

Dr. Sophie Dream: As a surgeon, I always want everyone to know that we are happy to see and talk to patients, even if they don't want surgery, if they just want to talk to a surgeon, just get a sense of what we do and what we can offer them. We don't expect that every single patient that comes into our office is ready for surgery or needs surgery or wanting it right away. Sometimes it's just to have a conversation and just give them a sense of treatment options. So, we are more than happy to talk to people. I think we're positioned in a very unique place where we understand that some patients need surveillance and they need to be followed in the long term. We know some patients might benefit better from surgery and that some patients might need a different sort of treatment option. And I think we're very poised to be able to have those conversations about what long-term those look like.

Melanie Cole, MS: Thank you all so much for joining us today. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.