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/.

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.