This year, nearly 40,000 Americans will discover that they have thyroid cancer. Most will be women. In fact, thyroid cancer case numbers in American women are going up faster than than breast or lung cancer figures. The good news is that with appropriate first line surgical therapy and follow-up radioiodine treatment, most thyroid cancer can be controlled or cured.
The main obstacle that Americans with thyroid cancer face is getting a proper pre-operative evaluation and finding the right thyroid cancer surgeon. In 2010, the pre-operative evaluation for thyroid cancer requires considerable technical and intellective expertise on the part of the managing endocrinologist. Ideally, the endocrinologist should personally perform pre-operative neck ultrasonography to evaluate the anatomy of the thyroid cancer mass in the central neck and to assess whether lymph nodes in the central or lateral neck are involved. Without such an assessment, it is common for cancerous nodes to be missed by even the best surgeons, particularly in the lateral neck, outside the carotid arteries. Leaving enlarged and cancerous lymph nodes in the neck is a serious problem because post-operative radioiodine therapy is only effective against very small cancer deposits, not large deposits hiding inside enlarged lymph nodes. The surgeon needs to have an accurate ultrasonographic map of neck lymph node architecture prior to making a surgical plan for removing the cancer. While it is true that such a map can be constructed by a radiologist or a radiology technician, in the United States, only a few technicians are up to this challenge and most radiologists do not actually perform ultrasonography anymore. From a practical standpoint, patients should seek out endocrinologic thyroid cancer specialists who are expert in neck and thyroid ultrasonography and who personally perform the ultrasonographic evaluations in their offices. Such endocrinologists are certified by the American Association of Endocrinologists and carry the ECNU designation (Endocrine Certification in Neck Ultrasound).
But the pre-operative evaluation should consist of more than a neck anatomy assessment. The endocrinologist must determine the patient's vitamin D status. Fully 60% of adult females in this country do not have adequate vitamin D stores. Remember that near total thyroidectomy with lymph node removal is very stressful to the body's calcium control systems and vitamin D insufficiency increases the likelihood of transiently low blood calcium levels. Such blood calcium drops often necessitate intravenous calcium infusions and longer hospital stays after thyroid surgery.
The final and most important component of 21st century thyroid cancer care is the surgeon. Ideally, your surgeon should be specifically trained in thyroid cancer removal and lymph node dissection. The American College of Surgeons suggests that your surgeon should perform at least 100 neck surgeries per year to hone his or her skills in this area. Sadly, more than 50% of the thyroid cancer surgeries in this country are performed by general surgeons who do less than 50 neck surgeries per year. The central neck is loaded with vital structures like the parathyroid glands that control blood calcium levels, and the voice box nerves that control speech. Careful and competent neck surgeons have the experience to recognize these vital structures and stay from them with scalpels and cautery devices. The simple question that you must ask your neck surgeon prior to thyroid cancer surgery is: "How many neck surgeries did you perform last year?"
Once you have selected your surgeon and had your pre-operative evaluation, you can rest assured that the likelihood of a good outcome with your cancer is very high. Most patients do not die from thyroid cancer, they live with it. Lymph node recurrence of the cancer locally is our largest obstacle, and recurrence is minimized with a proper initial evaluation and a carefully planned first surgery.
Sunday, June 27, 2010
Friday, December 11, 2009
Minimally Invasive Parathyroid Surgery and Local Anaesthesia
At Fort Lauderdale Endocrine Surgery, we are often asked if minimally invasive parathyroid surgery can be performed without the use of inhalational agents (general anaesthetic agents) and endotracheal tubes for breathing. The answer is a qualified "yes" depending on several factors.
First, the enlarged parathyroid(s) must be localizable by high resolution ultrasonography and visible relatively close to the skin surface. In shallow necks, local injection of anaesthetic agents (like lidocaine or Marcaine) can control intra-operative pain very nicely when given in combination with an intravenous twilight sleep agent (like propofol, also known as Diprivan). In addition, oral opiates should be given pre-operatively, so that the doctor has a "headstart" on controlling post-operative pain when the patient abruptly awakens as the propofol is discontinued. In general, the parathyroid glands most amenable to this kind of Minimal Anaesthesia Care (MAC) are lower pole glands in patients with thin necks. Lower pole glands are often found just below the thyroid gland and right under the skin surface in such patients, and can be removed with 15-30 minutes of gentle surgical manipulation. Occasionally, upper glands in thin necks can be removed just as easily.
Second, the patient needs to have a good airway prior to considering anaesthesia without a breathing tube (endotracheal tube). If there has been damage to the trachea from surgery, radiation or previous intubation, it is wiser to insert a breathing tube under controlled conditions before the surgery, rather than risking an emergent intubation during surgery should the patient's breathing pattern deterioriate.
Finally, MAC with local anaesthesia cannot be used if the patient is allergic to "caines" or propofol. Because propofol produces only twilight sleep, some patients have vague dream-like recollections of their surgical experience. Occasional patients dread the idea of any memory of the surgical experience and may prefer general anesthesia for this reason.
Our experience with Minimally Invasive Radioguided Parathyroid Surgery (MIRP) under MAC anesthesia has been very favorable. Appropriately selected patients avoid the potential trauma of a breathing tube (endotracheal tube) insertion and the post-operative headache and nausea that plague up to 30% of patients who elect to have general anaesthesia. Time spent in the recovery room is shorter with this technique and overall hospital time is minimized. For more information on MAC anaesthesia with MIRP, please don't hesitate to contact us at 954-267-8883.
First, the enlarged parathyroid(s) must be localizable by high resolution ultrasonography and visible relatively close to the skin surface. In shallow necks, local injection of anaesthetic agents (like lidocaine or Marcaine) can control intra-operative pain very nicely when given in combination with an intravenous twilight sleep agent (like propofol, also known as Diprivan). In addition, oral opiates should be given pre-operatively, so that the doctor has a "headstart" on controlling post-operative pain when the patient abruptly awakens as the propofol is discontinued. In general, the parathyroid glands most amenable to this kind of Minimal Anaesthesia Care (MAC) are lower pole glands in patients with thin necks. Lower pole glands are often found just below the thyroid gland and right under the skin surface in such patients, and can be removed with 15-30 minutes of gentle surgical manipulation. Occasionally, upper glands in thin necks can be removed just as easily.
Second, the patient needs to have a good airway prior to considering anaesthesia without a breathing tube (endotracheal tube). If there has been damage to the trachea from surgery, radiation or previous intubation, it is wiser to insert a breathing tube under controlled conditions before the surgery, rather than risking an emergent intubation during surgery should the patient's breathing pattern deterioriate.
Finally, MAC with local anaesthesia cannot be used if the patient is allergic to "caines" or propofol. Because propofol produces only twilight sleep, some patients have vague dream-like recollections of their surgical experience. Occasional patients dread the idea of any memory of the surgical experience and may prefer general anesthesia for this reason.
Our experience with Minimally Invasive Radioguided Parathyroid Surgery (MIRP) under MAC anesthesia has been very favorable. Appropriately selected patients avoid the potential trauma of a breathing tube (endotracheal tube) insertion and the post-operative headache and nausea that plague up to 30% of patients who elect to have general anaesthesia. Time spent in the recovery room is shorter with this technique and overall hospital time is minimized. For more information on MAC anaesthesia with MIRP, please don't hesitate to contact us at 954-267-8883.
Sunday, June 14, 2009
Do I Really Need a Neck Ultrasound Prior to Parathyroid Surgery?
At Fort Lauderdale Endocrine Surgery (FTLES), we frequently are asked to perform surgery on patients with clearcut high serum calcium levels due to overactive parathyroids (hyperparathyroidism) who have not undergone adequate neck ultrasonography. There are several reasons for this sad state of affairs.
The first is that many physicians and patients have the mistaken impression that gamma camera sestamibi parathyroid scanning is the "gold standard" radiologic procedure for parathyroid localization. Unfortunately, gamma camera scanning frequently misses upper pole parathyroids (remember that there are typically 2 upper pole glands deep in the neck below the thyroid, one on the left and one on the right) and parathyroid glands that are close to pulsatile vascular structures. Also, sestamibi does not discriminate the multi-gland parathyroid disease that is present in up to 15% of patients. In fact, out-patient sestamibi scanning may miss up to 40% of "surgical" parathyroid enlargement and occasionally incorrectly identifies thyroid nodules or lymph nodes as "parathyroids."
The second reason for ultrasound mis-utilization is that parathyroid ultrasonography is becoming a "lost" art. As a result of declining reimbursement, most hospital and out-patient radiologic facilities have handed over thyroid and parathyroid ultrasound responsibilities to radiology technicians who are not formally trained in parathyroid localization. Sure, a radiology physician eventually reviews the pictures that the technician takes, but the radiologist is only as good as the technologist. At Fort Lauderdale Endocrine Surgery (FTLES), I personally perform ALL parathyroid ultrasonography without a "middle man." In my office ultrasound suite, I find that many parathyroid adenomas require "real time" visualization. In other words, the glands are easier to "see" in real time as I actually move the ultrasound probe over them, rather than in the static pictures that I snap and review later. Patients also appreciate the fact that we take an ultrasonographic tour of the neck together, by virtue of the LG flat screen LCD panel that I have suspended over the examining table (for patient convenience and education).
Finally, when we contemplate minimally invasive parathyroid surgery at FTLES, we must be absolutely certain that there are no anatomic thyroid, parathyroid or vascular problems that will make our surgery incomplete or unsuccessful. In this regard, ultrasound is the best technology for finding small, unsuspected thyroid cancers that need to be removed along with enlarged parathyroids. The saddest outcome for a minimally invasive neck surgery occurs when an unsuspected parathyroid adenoma or a thyroid cancer is mistakenly left in the neck due to inadequate pre-operative ultrasound localization. For these reasons, we at Fort Lauderdale Endocrine Surgery require competent neck ultrasonography prior to any neck surgery. To make sure that the procedure is adequate, we do it ourselves using a state-of the art Siemens Acuson X-150 office ultrasound device.
The first is that many physicians and patients have the mistaken impression that gamma camera sestamibi parathyroid scanning is the "gold standard" radiologic procedure for parathyroid localization. Unfortunately, gamma camera scanning frequently misses upper pole parathyroids (remember that there are typically 2 upper pole glands deep in the neck below the thyroid, one on the left and one on the right) and parathyroid glands that are close to pulsatile vascular structures. Also, sestamibi does not discriminate the multi-gland parathyroid disease that is present in up to 15% of patients. In fact, out-patient sestamibi scanning may miss up to 40% of "surgical" parathyroid enlargement and occasionally incorrectly identifies thyroid nodules or lymph nodes as "parathyroids."
The second reason for ultrasound mis-utilization is that parathyroid ultrasonography is becoming a "lost" art. As a result of declining reimbursement, most hospital and out-patient radiologic facilities have handed over thyroid and parathyroid ultrasound responsibilities to radiology technicians who are not formally trained in parathyroid localization. Sure, a radiology physician eventually reviews the pictures that the technician takes, but the radiologist is only as good as the technologist. At Fort Lauderdale Endocrine Surgery (FTLES), I personally perform ALL parathyroid ultrasonography without a "middle man." In my office ultrasound suite, I find that many parathyroid adenomas require "real time" visualization. In other words, the glands are easier to "see" in real time as I actually move the ultrasound probe over them, rather than in the static pictures that I snap and review later. Patients also appreciate the fact that we take an ultrasonographic tour of the neck together, by virtue of the LG flat screen LCD panel that I have suspended over the examining table (for patient convenience and education).
Finally, when we contemplate minimally invasive parathyroid surgery at FTLES, we must be absolutely certain that there are no anatomic thyroid, parathyroid or vascular problems that will make our surgery incomplete or unsuccessful. In this regard, ultrasound is the best technology for finding small, unsuspected thyroid cancers that need to be removed along with enlarged parathyroids. The saddest outcome for a minimally invasive neck surgery occurs when an unsuspected parathyroid adenoma or a thyroid cancer is mistakenly left in the neck due to inadequate pre-operative ultrasound localization. For these reasons, we at Fort Lauderdale Endocrine Surgery require competent neck ultrasonography prior to any neck surgery. To make sure that the procedure is adequate, we do it ourselves using a state-of the art Siemens Acuson X-150 office ultrasound device.
Monday, February 16, 2009
The Plain Truth About Parathyroid Surgery
Every year 100,000 Americans discover that they have high blood calcium levels caused by overactive parathyroid glands in the neck. Surgery is necessary to cure the hypercalcemia if the blood calcium exceeds 11.0 mg/dl or if the parathyroid hormone excess is causing kidney stones, ulcer disease, pancreatitis (severe pancreatic inflammation and belly pain) or bone loss. 85-90% of the time, the enlargement involves only one out of the four parathyroids and minimally invasive removal of the enlarged gland will result in a persistent normalization of the serum calcium and clinical cure. Finding the enlarged parathyroid gland (adenoma) or glands (adenomas) can require considerable expertise from the surgeon during the surgery and from the doctor who images the parathyroids prior to the surgery. Our recent paper in the November 2008 Endocrine Practice journal suggests that pre-operative high resolution neck ultrasound performed by an ultrasound-certified endocrinologist is the best imaging technique for locating an enlarged parathyroid (adenoma). In addition, we have found that close collaboration between an ultrasound-savy endocrinologist and a minimally invasive parathyroid surgeon is the key to cure. Two intra-operative procedures turn out to be very important in maximizing surgical success. The first is the use of intra-operative sestamibi scanning using a thin surgical probe. Technetium sestamibi is given intravenously 2 hours prior to surgery and during surgery the patient's neck is scanned carefully with the probe applied directly to skin and inserted in the surgical incision. In conjunction with the pre-operative ultrasound, the sestamibi scanning locates most enlarged parathyroids (~90%). However in some cases, the enlarged glands are too deep in the chest or neck for either technology to be effective. In these cases, the patient depends on the surgeon's skill in locating deep or hidden parathyroids. In order for the surgeon to recognize the existence of unimaged enlarged glands, he must first recognize that abnormal parathyroids are still present in the neck. This final realization is achieved by the utilization of the intra-operative parathyroid hormone blood test. After the removal of an enlarged parthyroid gland and before we declare any patient cured, we test the parathyroid hormone level in blood to make sure that it has fallen at least 50% from the pre-removal level. If such a fall has not occurred, we continue to look for other enlarged glands. Without the use of PTH testing in the operating room, we estimate that as many as 10-15% of patients could undergo removal of one enlarged parathyroid adenoma without being cured. Unfortunately, the lack of cure may take 3-6 months to be recognized, as the initial post-operative blood calcium levels may drop into the normal range, only to rise again later.
Our practical advice to patients can be summed up as follows:
(1) Make sure that you get your parathyroid adenoma(s) localized by a physician with special training in parathyroid localization (many radiology ultrasound technicians do not have this training).
(2) Make sure that your surgeon does at least 50 minimally invasive parathyroidectomies a year and that he or she works closely with an endocrinologist specializing in parathyroid problems. If the endocrinologist actually does parathyroid imaging with high resolution ultrasound this will save you the trouble of finding an experienced ultrasonographer elsewhere.
(3) Demand that your parathyroid surgeon use intra-operative sestamibi scanning as well as the blood parathyroid hormone assay to make sure that you are cured while you are on the operating table.
(4) Beware of any parathyroid surgeon who demands money up front for a telephone consultation. You have a right to meet your surgeon face-to-face before any money changes hands. You should not feel locked into using a surgeon because of a telephone consultation charge. Remember, there is a reason that no insuror will pay for up front telephone consultation,
(5) Beware of any surgeon who claims more than a 99% success rate, no matter how many patients he/she claims to cure every year. It is easy to claim that a patient is cured if you never see them again after the day of surgery. Many patients with 2 gland disease will initially show normalization of calcium levels after removal of one enlarged gland, only to have hypercalcemia recur 6-12 months later.
(6) If the claims you see on a parathyroid surgical website seem like hype, they probably are. Beware of unsubstantiated internet claims.
Please feel free to navigate to our website at http://www.ftles.com/ and review all our content critically. Good luck with your parathyroid surgery!!!
Our practical advice to patients can be summed up as follows:
(1) Make sure that you get your parathyroid adenoma(s) localized by a physician with special training in parathyroid localization (many radiology ultrasound technicians do not have this training).
(2) Make sure that your surgeon does at least 50 minimally invasive parathyroidectomies a year and that he or she works closely with an endocrinologist specializing in parathyroid problems. If the endocrinologist actually does parathyroid imaging with high resolution ultrasound this will save you the trouble of finding an experienced ultrasonographer elsewhere.
(3) Demand that your parathyroid surgeon use intra-operative sestamibi scanning as well as the blood parathyroid hormone assay to make sure that you are cured while you are on the operating table.
(4) Beware of any parathyroid surgeon who demands money up front for a telephone consultation. You have a right to meet your surgeon face-to-face before any money changes hands. You should not feel locked into using a surgeon because of a telephone consultation charge. Remember, there is a reason that no insuror will pay for up front telephone consultation,
(5) Beware of any surgeon who claims more than a 99% success rate, no matter how many patients he/she claims to cure every year. It is easy to claim that a patient is cured if you never see them again after the day of surgery. Many patients with 2 gland disease will initially show normalization of calcium levels after removal of one enlarged gland, only to have hypercalcemia recur 6-12 months later.
(6) If the claims you see on a parathyroid surgical website seem like hype, they probably are. Beware of unsubstantiated internet claims.
Please feel free to navigate to our website at http://www.ftles.com/ and review all our content critically. Good luck with your parathyroid surgery!!!
Tuesday, October 14, 2008
Curing Sestamibi Negative Hyperparathyroidism
At Fort Lauderdale Endocrine Surgery (www.ftles.com), we specialize in minimally invasive parathyroid resection (MIRP) through a tiny 2 centimeter incision (less than 1 inch). Unfortunately many patients have been denied access to this 21st century surgical technique because their sestamibi parathyroid scans performed in hospitals or free-standing out-patient nuclear scanning facilities do not locate the diseased and enlarged parathyroid(s). In the November 2008 edition of the peer-reviewed journal Endocrine Practice, Dr. David Bimston and myself report that the pre-operative use of endocrinologist-performed high-resolution parathyroid ultrasound locates enlarged parathyroids in nearly 2/3's of sestamibi scan negative patients. This is great news for hyperparathyroid patients because more people now qualify for a curative out-patient minimally-invasive procedure. The advantages of this approach are a tiny cosmetic scar and avoidance of hospitalization with its attendant risks (infection with antibiotic resistant bacteria).At our surgical facility, the Imperial Point Minimally Invasive Surgical Center (MIESC), we are also able to document surgical cure of hyperparathyroidism while the patient is on the operating table with our use of intra-operative parathyroid hormone testing. This technology allows for rapid measurement of the expected drop in parathyroid hormone blood levels after successful minimally invasive removal of parathyroid tumors. In 8-15% of patients, hyperparathyroidism is not cured with the removal of one gland; in fact, some patients have 2, 3 or even 4 enlarged and hyper-functional parathyroid glands. Because sestamibi and ultrasound occasionally do not detect these multi-gland patients, we use intra-operative parathyroid hormone testing as a fail-safe procedure, to make sure that cure has been achieved. Should you wish to read the full text article from Endocrine Practice, please visit our website at www.ftles.com. For a consultation appointment, please call 954-267-8883. You may also email us at info@ftles.com, if you desire further information regarding MIRP.
Sunday, November 11, 2007
Thyroid Cancer in America
Thyroid cancer is the most rapidly expanding female cancer category in the United States. Over 30,000 new cases are diagnosed yearly and most of these can be completely cured with appropriate surgical therapy and subsequent treatment with radioactive iodine and thyroid hormone.
Thyroid cancer is usually painless and typically cannot be diagnosed by a blood test. Most patients present with a painless lump in the front of the neck. They may also notice swallowing difficulty and/or hoarseness.
Risk factors for the development of thyroid cancer include exposure to neck X-rays and proximity to nuclear accidents like Chernobyl and Three Mile Island. Thyroid lumps and thyroid cancers may develop years after these exposures. In addition, the propensity for the development of thyroid cancer seems to run in some families, particularly if the cancer is an unusual one called medullary carcinoma of the thyroid.
Thyroid malignancies are generally discovered with a thorough physical examination and careful palpation of the neck. Once a thyroid lump (nodule) has been recognized, the next step is to perform high resolution ultrasonography of the neck. Ideally, this test should be performed in your thyroid doctor's office with attention directed toward the assessment of all thyroid nodules, parathyroid nodules (4 small glands behind the thyroid) and lymph nodes in the neck. At Fort Lauderdale Endocrine Surgery, we perform all neck ultrasonography ourselves because we believe that this testing is too important to farm out to radiology para-professionals.
Once the neck has been mapped with high resolution ultrasound, we make a decision regarding biopsy of thyroid nodules or unusual lymph nodes. If the thyroid nodule is large or possesses worrisome characteristics, we puncture it several times with tiny 25 gauge needles to try to retrieve cells for pathologic evaluation. This process is called fine needle aspiration (FNA) biopsy of the thyroid and is accomplished in our office in about 15 minutes. No anaesthesia is required and results take about 7-10 days to return.
If cancer is discovered, then we plan a surgical removal of the thyroid and the cancerous nodule(s) contained therein. The skill of the surgeon is the most important factor in determination of surgical outcome and cancer cure. The thyroid surgeon must be capable of removing the thyroid safely while avoiding damage to the recurrent laryngeal nerves under the gland (these nerves control the vocal chords and allow you to speak normally) and the parathyroid glands (these glands control the blood calcium levels). In addition, the surgeon must be capable of assessing the lymph nodes that lie around the thyroid in the front of the neck and removing those that contain visible evidence of thyroid cancer. In order to perform these tasks with skill your surgeon needs years of focused training and lots of practical experience with neck endocrine surgery. In our center at Imperial Point Medical Center, Dr. David Bimston has years of training in endocrine oncology surgery and performs over 100 neck procedures annually.
Thyroidectomy patients usually stay overnight and leave the hospital the next day. If radioiodine therapy is needed to clean up any residual cancer cells in the neck, we typically administer this 2-3 weeks after the thyroid is removed and once the patient's blood TSH level exceeds 30 (a high TSH level is necessary to drive radioactive iodine into thyroid cancer cells). During this 2-3 week hiatus, the patient is placed on a low iodine diet to maximize the absorption of radioiodine when the time comes.
Once the blood TSH test exceeds 30, radioiodine treatment is accomplished in the hospital to minimize family member radiation exposure, and patients typically go home after 48 hours of radioactive isolation with a prescription to start thyroid hormone therapy.
Thyroid hormone treatment is easy and economical. We tell our patients to think of their thyroid hormone pill as an anti-cancer treatment that minimizes the chance that thyroid cancer will ever return. Thyroid hormone must be taken every day and at least 4 hours away from calcium pills, iron supplements, vitamins, nutritional supplements and soy products. Patients who take their thyroid hormones religiously usually have very consistent blood levels and great outcomes. Occasionally, changes in other medications like female hormones, birth control pills and male hormone supplements can throw the thyroid levels off.
Follow-up of thyroid cancer patients for recurrence is fairly straightforward. We perform thyroid ultrasound evaluations in the office every 1-3 years. In addition, we document biochemical cure using injections of human TSH (Thyrogen) every 1-5 years depending on the clinical context. After two injections of Thyrogen on consecutive days, patients who are completely cured will exhibit serum thyroglubulin (TG) levels of less than 2 (thyroglobulin is a thyroid cancer marker- people without thyroid tissue left in their necks should NOT be able to elevate their TG levels above 2 with Thyrogen shots). Thyrogen is easily administered in the out-patient setting and thyroglobulin levels just require a blood draw 3 days after the shots.
In summary, thyroid cancer is increasing in prevalence in the United States, particularly in women. Fortunately, thyoid cancer outcomes are usually quite good if the management team includes an endocrinologist with a special interest in thyroid cancer and a well-trained thyroid surgeon who performs more than 100 neck procedures a year. For more information on minimally invasive endocrine surgery and the surgical treatment of thyroid cancer please visit the Fort Lauderdale Endocrine Surgery website at http://www.ftles.com/.
Thyroid cancer is usually painless and typically cannot be diagnosed by a blood test. Most patients present with a painless lump in the front of the neck. They may also notice swallowing difficulty and/or hoarseness.
Risk factors for the development of thyroid cancer include exposure to neck X-rays and proximity to nuclear accidents like Chernobyl and Three Mile Island. Thyroid lumps and thyroid cancers may develop years after these exposures. In addition, the propensity for the development of thyroid cancer seems to run in some families, particularly if the cancer is an unusual one called medullary carcinoma of the thyroid.
Thyroid malignancies are generally discovered with a thorough physical examination and careful palpation of the neck. Once a thyroid lump (nodule) has been recognized, the next step is to perform high resolution ultrasonography of the neck. Ideally, this test should be performed in your thyroid doctor's office with attention directed toward the assessment of all thyroid nodules, parathyroid nodules (4 small glands behind the thyroid) and lymph nodes in the neck. At Fort Lauderdale Endocrine Surgery, we perform all neck ultrasonography ourselves because we believe that this testing is too important to farm out to radiology para-professionals.
Once the neck has been mapped with high resolution ultrasound, we make a decision regarding biopsy of thyroid nodules or unusual lymph nodes. If the thyroid nodule is large or possesses worrisome characteristics, we puncture it several times with tiny 25 gauge needles to try to retrieve cells for pathologic evaluation. This process is called fine needle aspiration (FNA) biopsy of the thyroid and is accomplished in our office in about 15 minutes. No anaesthesia is required and results take about 7-10 days to return.
If cancer is discovered, then we plan a surgical removal of the thyroid and the cancerous nodule(s) contained therein. The skill of the surgeon is the most important factor in determination of surgical outcome and cancer cure. The thyroid surgeon must be capable of removing the thyroid safely while avoiding damage to the recurrent laryngeal nerves under the gland (these nerves control the vocal chords and allow you to speak normally) and the parathyroid glands (these glands control the blood calcium levels). In addition, the surgeon must be capable of assessing the lymph nodes that lie around the thyroid in the front of the neck and removing those that contain visible evidence of thyroid cancer. In order to perform these tasks with skill your surgeon needs years of focused training and lots of practical experience with neck endocrine surgery. In our center at Imperial Point Medical Center, Dr. David Bimston has years of training in endocrine oncology surgery and performs over 100 neck procedures annually.
Thyroidectomy patients usually stay overnight and leave the hospital the next day. If radioiodine therapy is needed to clean up any residual cancer cells in the neck, we typically administer this 2-3 weeks after the thyroid is removed and once the patient's blood TSH level exceeds 30 (a high TSH level is necessary to drive radioactive iodine into thyroid cancer cells). During this 2-3 week hiatus, the patient is placed on a low iodine diet to maximize the absorption of radioiodine when the time comes.
Once the blood TSH test exceeds 30, radioiodine treatment is accomplished in the hospital to minimize family member radiation exposure, and patients typically go home after 48 hours of radioactive isolation with a prescription to start thyroid hormone therapy.
Thyroid hormone treatment is easy and economical. We tell our patients to think of their thyroid hormone pill as an anti-cancer treatment that minimizes the chance that thyroid cancer will ever return. Thyroid hormone must be taken every day and at least 4 hours away from calcium pills, iron supplements, vitamins, nutritional supplements and soy products. Patients who take their thyroid hormones religiously usually have very consistent blood levels and great outcomes. Occasionally, changes in other medications like female hormones, birth control pills and male hormone supplements can throw the thyroid levels off.
Follow-up of thyroid cancer patients for recurrence is fairly straightforward. We perform thyroid ultrasound evaluations in the office every 1-3 years. In addition, we document biochemical cure using injections of human TSH (Thyrogen) every 1-5 years depending on the clinical context. After two injections of Thyrogen on consecutive days, patients who are completely cured will exhibit serum thyroglubulin (TG) levels of less than 2 (thyroglobulin is a thyroid cancer marker- people without thyroid tissue left in their necks should NOT be able to elevate their TG levels above 2 with Thyrogen shots). Thyrogen is easily administered in the out-patient setting and thyroglobulin levels just require a blood draw 3 days after the shots.
In summary, thyroid cancer is increasing in prevalence in the United States, particularly in women. Fortunately, thyoid cancer outcomes are usually quite good if the management team includes an endocrinologist with a special interest in thyroid cancer and a well-trained thyroid surgeon who performs more than 100 neck procedures a year. For more information on minimally invasive endocrine surgery and the surgical treatment of thyroid cancer please visit the Fort Lauderdale Endocrine Surgery website at http://www.ftles.com/.
Monday, October 15, 2007
Vitamin D Deficiency and Hyperparathyroidism
A new hot topic in Endocrinology relates to the high incidence of unsuspected Vitamin D deficiency in patients with high blood calcium and hyperparathyroidism. Traditionally, patients with blood calcium levels in excess of 11.0 or long term complications of hyperparathyroidism including kidney stones, advancing osteoporosis or stomach ulcers are sent directly to surgery for removal of enlarged parathyroid glands (there are 4 parathyroid glands located low in the neck, just behind the thyroid gland, usually one gland is overactive and enlarged with hyperparathyroidism). At Fort Lauderdale Endocrine Surgery, more than 30% of patients referred to us for minimally invasive parathyroid surgery turn out to have unexpected Vitamin D deficiency!!! Given the directness of the sun's rays and the year-round exposure in Florida, we had been perplexed by this finding until we came to realize that the dermatologists have done such a good job of promoting sunscreen use that many Floridians do not get enough unscreened sun exposure to manufacture Vitamin D in their skin. In any event, recognition of Vitamin D defiency is important for the patient with hyperparathyroidism because some patients will normalize their parathyroid hormone levels and improve their blood calciums simply with a vitamin D supplement. We offer a course of Vitamin D3 replacement prior to scheduling the patient for minimally invasive surgery in hopes that we can prevent an unnecessary procedure. The only contraindications to Vitamin D3 supplementation are a blood calcium in excess of 11.5 or active kidney stone formation. We typically treat for 3-4 months with a proprietary Vitamin D3 preparation (not all vitamin D3's are equally potent as the FDA does not regulate nutritionals) and then re-assess to see if surgery is still necessary.
For more information on hyperparathyroidism and minimally invasive radioguided parathyroid surgery (MIRP) visit http://www.ftles.com/ and peruse our text and video content.
For more information on hyperparathyroidism and minimally invasive radioguided parathyroid surgery (MIRP) visit http://www.ftles.com/ and peruse our text and video content.
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