Transcription:
The Spectrum of Thyroid Disease

John Leonard, MD (Host):  Welcome to Weill Cornell Medicine CancerCast; Conversations About New Developments in Medicine, Cancer Care and Research. I’m your host, Dr. John Leonard. And today we’ll be talking about thyroid cancer. My guest is Dr. Thomas J. Fahey III, who is Chief of Endocrine Surgery, Director of the Endocrine Oncology Program and Attending Surgeon at New York Presbyterian Hospital and Weill Cornell Medicine. His clinical and research interests lie in the field of endocrine and minimally invasive surgery with a focus on thyroid, parathyroid, adrenal and pancreas surgery. Dr. Fahey also currently serves as President Elect of the American Association of Endocrine Surgeons or AAES, a professional organization dedicated to the advancement of the science and the art of endocrine surgery. So, Tom, it’s great to have you here today. Thanks for joining us. We’ve known each other a long time and it’s nice to have you here and hear some of your insights on this field.

Thomas Fahey III, MD (Guest):  Thank you very much John. Happy to be here.

Host:  So, endocrine surgery is obviously an important area, covers a lot of different topics and organs. How did you end up specializing in this area and maybe tell people a little bit about what endocrine is beyond kind of the organs that you work with.

Dr. Fahey:  So, endocrine surgery I think is unique in that it affords an opportunity to do much in the way of both medicine and surgery. So, much of the care and actually more and more is directed towards medical care as much as it is surgery. So, it has a unique position in surgery and enabling that ability if so choose.

Host:  So, you are dealing obviously with endocrine disorders and have to know things about diabetes, adrenal disease, thyroid disease both a bit from the medical perspective as well as the surgical.

Dr. Fahey:  Yes, and also there are some quite rare endocrine tumors which have very interesting pathophysiology. The combination of that plus much of it being very routine but that gives you the ability to kind of have a spectrum of interests.

Host:  How did you get involved in this area? What got you excited, that feature of it or other aspects?

Dr. Fahey:  I think that in particular. I think that the diseases of the endocrine organs can be both benign and cancerous and the cancers of the endocrine organs span the spectrum from being very curable to those that are very deadly and so there’s a need to be able to traverse the field of both shepherding patients through a fairly easy sometimes course and sometimes extraordinarily difficult.

Host:  So, I noted that you are President Elect of the American Association of Endocrine Surgeons. Tell us just for a minute about that organization and my guess is there aren’t that many or a limited number of endocrine surgeons out there and clearly having somebody with this expertise probably is good for patients for certain conditions especially.

Dr. Fahey:  Yeah, so endocrine surgery is a still growing discipline. In fact, when I was a resident, finishing residency there really were no endocrine surgery fellowships in the United States and I ended up doing my fellowship in Sydney, Australia. Since that time, the American Association of Endocrine Surgeons was just a fledgling organization at that time. But since that time, its membership is now expanded to between 400 and 500 members. So, it is continually growing. There are now fellowships in endocrine surgery in the United States and I think it’s a very exciting and dynamic field.

Host:  And it sounds like having at least for some of these conditions, having somebody who is fellowship trained in this area probably offers some important advantages.

Dr. Fahey:  Absolutely. That is especially true in the fields of thyroid and parathyroid disease as well as pancreas and adrenal.

Host:  When you started here at Weill Cornell, were you the first endocrine surgeon and you’ve grown the division I know to a large number of colleagues that I interact with regularly. So, clearly, it’s become an important area.

Dr. Fahey:  Yes. When I was recruited back, I was the first person here to be an endocrine surgeon, got labeled as an endocrine surgeon and it has grown. We are now three, actually four in total. I think hopefully still we will have room to grow.

Host:  Great. So, our focus today is really on the thyroid and we’ll get to thyroid cancer in a minute. But maybe you could tell the audience a little bit, kind of what does the thyroid gland do, and a lot of people are familiar with having maybe hypothyroidism or other thyroid medical conditions leading to or being associated with nodules and then we’ll get into the cancer part. Because I know there’s a spectrum of people dealing with thyroid issues kind of along that range more or less.

Dr. Fahey:  So, the thyroid is a small gland in the neck. It’s primary function is to make thyroid hormone which is a general regulator of metabolism. It contributes to how fast your heart beats, how fast your hair grows, how fast things pass through your intestines. So, it has a wide ranging effect throughout the body and disorders of the thyroid are in fact quite common. Thyroid nodules are probably the thing that people are most familiar with, possibly because if you live long enough you will have thyroid nodules. And at times when they get to be large enough, then they become a potential medical issue and have to be addressed.

Host:  So, from the standpoint of people who may have a scan as an example, I take care of lymphoma patients as you know. I was in clinic today and had a few people with a scan, at least one of them had thyroid nodules noted on their scan. I’m sure many in the audience either have patients with those issues or they themselves have those issues. What are the things that would cause someone or prompt a practitioner to say we need to chase after this thyroid nodule versus keep an eye on it? What are the features or how do you guide someone who may be has heard about this either in the course of their medical care or taking care of a patient that would prompt referral for more detailed evaluation?

Dr. Fahey:  So, really two things contribute to whether or not a thyroid nodule needs to have further investigation. The size of the nodule and typically something that is over a centimeter is where we start to be concerned. As well as the makeup of the nodule. So, nodules that are cystic are less concerning. Nodules that are solid are more concerning. So, the threshold for proceeding to doing a needle biopsy which is typically the next investigational step is once centimeter in size for a solid nodule and two centimeters or over for a cystic nodule.

Host:  I know ultrasounds figure into this. Is that something that happens I presume before a biopsy. Are there other tests that people get or kind of what’s the usual pattern before that?

Dr. Fahey:  So, the ultrasound is the most important imaging test and usually is how you will better characterize the nodule as solid or cystic or a combination. But also thyroid function tests. So, how is your thyroid functioning is quite important. One of the sometimes unrecognized features that contribute to perhaps thyroid nodules being termed suspicious is if somebody is hypothyroid. So, it is very important to have it in the background what the thyroid function tests are and hopefully normal.

Host:  So, someone with a nodule or a mass in their thyroid, I mean obviously they want to make sure they don’t have a thyroid cancer. What are the other consequences or concerns that would come around. I mean are there the endocrine issues associated with some nodules, other cancers, what sorts of things beyond thyroid cancer would be something on the radar in that scenario?

Dr. Fahey:  Nodules can be functioning so, like with many endocrine organs, if you have a nodule, one of the first things you have to determine is it producing a hormone in excess and that’s true for thyroid nodules. Really what we want to know is it hyperfunctioning so is it making too much thyroid hormone. And that usually requires some additional blood work, antibodies, or it is not making thyroid hormone is it a so called cold nodule? Although we don’t typically do radioiodine scans as part of the sequence of investigation any longer routinely. If someone looks like they are hyperthyroid; then that would be someone you would consider having a thyroid scan.

Host:  So, someone with a nodule that’s suspicious would end up getting as you said, a needle biopsy? I guess that would be the most common thing. So, what are the possible outcomes and kind of decision paths after that?

Dr. Fahey:  Basically, there are three possible outcomes. The nodule can be deemed to be benign by the pathologist looking at the cells. Which is by far the most common, 70 to 75% of the time. It can be deemed to be malignant which is the least common fortunately and then in the thyroid, there’s approximately a quarter to thirty percent of the time it can be termed indeterminant which means the pathologist sees some cells that are a little atypical but not sufficient to say it looks like cancer. In that situation, there are a couple of options but most commonly, in the United States, a little aliquot of the cells will be sent off for some additional testing termed molecular testing. And that will then better direct the decision to either continue to observe the nodule or potentially remove it if it is found to be cancer.

Host:  Are there particular risk factors for thyroid cancer that people are used to screening for family history or other risk factors for cancers. Is there anything special that would tell someone yeah, I got to really keep a special eye out for this or is it just the presence of a nodule is the most common thing?

Dr. Fahey:  The presence of a nodule is probably by far the most common, but we always will ask the patients whether or not they’ve had exposure to radiation which is typically two sources, one having resided in an area like Chernobyl which had kind of a large population area of radiation exposure or two, medical treatment radiation. Typically in both cases, the exposure has to have been at a young age for that to really increase the risk of cancer.

Host:  How frequently does thyroid cancer present with advanced disease or metastatic disease? Are there people diagnosed where it’s in multiple places outside of the thyroid or in the lymph nodes or is it typically confined to the thyroid at diagnosis?

Dr. Fahey:  It’s not uncommon for there to be presentation with a lymph node in the neck that is the first recognition of thyroid cancer or how the diagnosis is made. The most common way is for there to be a nodule that is then discovered to be cancer in the thyroid. Metastases to lymph nodes around the thyroid and in the lateral neck are not uncommon in thyroid cancer but fortunately, can be controlled typically by neck surgery with some additional adjuvant treatment.

Host:  So, the typical patient diagnosed with thyroid cancer would have a nodule, have a biopsy, and get a pathologic diagnosis and then is the typical next step you evaluating them for the nature of the surgery they would need since surgery is typically the primary management of this?

Dr. Fahey:  That would be most common. Again, the size of the nodule becomes important so, nodules that are less than a centimeter and not in a kind of critical area of the thyroid can be – there is now abundant data that these nodules can be safely observed which requires ultrasound follow up. Those nodules greater than a centimeter in size typically the recommendation is for removal. And then the decision usually has to be made as to whether or not a portion of the thyroid, typically a hemithyroidectomy which is half or total thyroidectomy should be done.

Host:  So, from the standpoint of the patient, what is the typical kind of patient experience. I presume they have surgical issues locally in the neck. Is it inpatient, outpatient? What’s the typical kind of issues that patients have with the surgery?

Dr. Fahey:  The day of surgery, for a hemithyroidectomy oftentimes these can be done as outpatients. It does require being here at the hospital for pretty much the entire day. Mainly because of the postoperative observation period. Typically total thyroidectomies sometimes patients will stay, sometimes they will leave.

The surgery itself can take anywhere from an hour to two hours to three hours and is typically very well tolerated. It’s not something that there’s a lot of difficult recovery for. Patients typically do very, very well.

Host:  Once a patient has had surgery, is the follow up typically just seeing you or an endocrine surgeon periodically? Do patients get scans? Do they get additional treatment afterwards? What’s the usual approach, I’m sure it depends on the characteristics but what are some of the key features that define that?

Dr. Fahey:  So, typically, the follow up will include obvious postop visits but those are usually just one or at most two and then routine follow up for the first two years is an ultrasound and bloodwork every six months and then yearly after that. The ultrasound is a very again, very easily tolerated non-radiation associated test so it’s a relatively straightforward follow up.

Host:  So, what patients go on to get additional treatment? Are there any? And what happens if it comes back either locally or somewhere else?

Dr. Fahey:  The first line of additional treatment is radioactive iodine therapy. This is treatment that requires a total thyroidectomy so for tumors that are deemed to be more aggressive, radioactive iodine therapy would be indicated. That is a treatment which occurs usually approximately six to eight weeks after the surgery. It requires a single capsule. Typically there is a follow up scan a week later. Following that, the observation occurs where again, back to every six months and then yearly as long as there is no evidence of disease.

Host:  So, the concept of radioactive iodine treatment as I understand it is that basically it’s ingested, it’s taken up wherever there is thyroid tissue and therefore delivers radiation to that area and that kills the tumor cells wherever they might be. Is that the gist of it?

Dr. Fahey:  Yes. I mean in some ways; radioactive iodine treatment is probably one of the earliest if not the earliest form of targeted therapy. It takes advantage of the fact that the iodine is a fundamental component of thyroid hormone and so thyroid cells are naturally designed to take up iodine and that feature is taken advantage of with the administration of radioactive iodine.

Host:  So, I presume there are relatively few but obviously an important number of patients that the disease comes back after that? Just at a high level, some of the approaches to those patients?

Dr. Fahey:  The most common location for recurrence is in the neck, typically lymph nodes in the neck. Usually that would lead to additional surgery. Additional radioactive iodine is usually not indicated just because the feeling is that those cells are already resistant to radioactive iodine. If it occurs in a field that is already gone through surgery, other options may include ablation of the lymph node by either ethanol or radiofrequency ablation.

Host:  I know a lot of what your focus is in research to improve outcomes for patients and different aspects of patient care. Tell us a little bit about some of the things that you’ve been working on here at Weill Cornell and New York Presbyterian to try to improve upon care for patients with thyroid cancer.  

Dr. Fahey:  There’s a couple of areas that we focused on. One is trying to identify ways to reactivate the ability for thyroid cancer cells to take up iodine. It is quite common that thyroid cancer cells themselves lose that ability to take up iodine. That mechanism is done through a receptor on the thyroid cells called the sodium iodine symporter and so the goal of the treatment is to reactivate that. With the introduction of tyrosine kinase inhibitors which is a targeted therapy for thyroid cancers; one of the findings is that these may be able to turn on the sodium iodine symporter and allow the thyroid cancer cells then to once again take up iodine and then be potentially eliminated by radioactive iodine.

So, one of the areas that we’ve been researching is what combination of tyrosine kinase inhibitors might actually best be utilized to reactivate the sodium iodine symporter.

Host:  So a big buzzword in cancer treatment is the whole precision medicine or precision therapy thing. Has that made it’s way into thyroid cancer? Are there patients who should have their tumors undergo or even nodules undergo some sort of sophisticated testing to sort out what’s going on or is it really just focused on the standard pathology?

Dr. Fahey:  Molecular diagnostics I think has been a big part of the diagnosis of thyroid nodules and in fact, we were one of the leading institutions in that push to develop that field now 17 years ago. We were the first to introduce a gene test for differentiating benign and malignant thyroid nodules. So, it’s definitely a part of the diagnosis of thyroid nodules and in trying to discriminate between benign and malignant thyroid nodules.

It's also very important in the treatment of thyroid cancers and here at Weill Cornell, we are very fortunate to have the routine molecular testing or molecular characterization of thyroid cancer. So, all thyroid cancers are submitted for mutation analysis and that is very important in terms of ultimately directing further therapy. Particularly in those cases where the thyroid cancer isn’t well behaved one and has recurred and requires additional treatment.

Host:  So, you’ve covered some of these topics in the big picture, what are you most excited about going forward? How will the treatment of thyroid cancer potentially change in the next five years? are there new drugs? Are there new diagnostic techniques, new surgical procedures? What are some of the things out there on the horizon that you’re enthusiastic about?

Dr. Fahey:  I think for the standard everyday thyroid cancer, it will still be treated and cured with surgery and if needed, radioactive iodine. For those that have recurred and the more difficult thyroid cancers; that ultimately lead to both morbidity and death; there are definitely bright spots on the horizon. The development of new tyrosine kinase inhibitors that are very specifically targeting the mutations found in thyroid cancer are going to bring a greater ability to at least stabilize disease in thyroid cancer in the recurrent thyroid cancers going forward.

Host:  So, before we wrap up, I know having shared many patients with you, you are very much of a patient centered physician. Are there a message or two that you have for patients, perhaps newly diagnosed or dealing with thyroid cancer that you would want to kind of share with them or something that you currently tell patients. Because obviously any cancer diagnosis is concerning. Any main messages for patients to think about as they are working through this?

Dr. Fahey:  I think the most important message is that thyroid cancer is generally very treatable, curable. At the current time, if it’s not, there are certainly therapies available to overcome the problems that we’ve had in the past with treating thyroid cancer. So, I think it’s overall a very optimistic outlook for the treatment and management of patients with thyroid cancer.

Host:  Great and I know it’s also very important for patients to seek a physician or surgeon that’s an expert in this area and does this as part of their day to day activities, not just kind of here and there.

Dr. Fahey:  That is absolutely the case. Because on the surgical side of things, but also in terms of the follow up in medical oncology and endocrinology, it is important to have physicians who are – an oncologists who are focused in the management of thyroid cancer.

Host:  Well thank you Tom for being here today. It’s really been a great discussion. I’ve learned a lot and appreciate you taking the time to share your thoughts with our audience. I want to encourage our listeners to download, subscribe, rate and review CancerCast on Apple podcasts, Google Play Music or online at www.weillconell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments and topics you’d like to see us cover more in depth in the future. That’s it for CancerCast; Conversations About New Developments in Medicine, Cancer Care and Research. I’m Dr. John Leonard. Thanks for tuning in.