ENDOCRINE SURGERY

Special Attention to the Thyroid

ENDOCRINE SURGERY

Special Attention to the Thyroid

Thyroid Disease

Overview of the Thyroid Gland and Nodules

The thyroid gland is located in the lower neck in front of the trachea. It is butterfly shaped with a right and left lobe. Four parathyroid glands, which regulate calcium metabolism, sit behind the gland.  Other structures near the gland are the esophagus, the voice box, and the nerves to the voice box.

The function of the thyroid gland is to secrete hormones which regulate metabolism.  Thyroid stimulating hormone (TSH) is secreted by the pituitary gland to regulate the thyroid gland. Thyroxine (T4) and Triiodothyronine (T3) are secreted by the thyroid gland which controls the body’s metabolism. It has direct effects on the brain, heart, protein synthesis, and cholesterol, among many other functions.

The thyroid can develop nodules or masses. The majority of thyroid nodules are benign, but some can be cancers. Risk factors for developing thyroid nodules include older age, female gender, radiation exposure, family history, and iodine deficiency, among others.

Overview of Thyroid Cancer

Thyroid cancer has been on the rise with improved technology for detection of and monitoring the thyroid gland. There are different types of thyroid cancer.

Papillary thyroid carcinoma is the most common type of thyroid cancer, which also has the best prognosis. There are different variants within this type of thyroid cancer such as tall cell, columnar cell or hobnail variants.  The other more common types of thyroid cancers include follicular carcinoma, Hürthle cell carcinoma.

Medullary thyroid carcinoma is a less common type of thyroid cancer that arises in a different cell type of the thyroid gland, the parafollicular or C cells. This form commonly can be inherited thus can prompt genetic testing.

Anaplastic thyroid carcinoma is the most rare type of thyroid cancer. This type of cancer is automotically designated as Stage IV because the prognosis can be very poor.

Overview of Goiter

Goiter refers to an enlargement of the thyroid gland that is abnormal. The presence of a goiter does not mean you have thyroid cancer. In fact, most of these are benign causing no symptoms.

Goiter can cause symptoms related to the size. Functions related to swallowing, voice and breathing may be affected. Some patients can experience discomfort in the lower neck as well.

Signs and Symptoms of Thyroid Cancer

The most common sign of a thyroid mass is a lump in the mid-lower neck. In many cases, thyroid masses are found incidentally, meaning they were discovered inadvertently. A patient may have an imaging study such as a CT scan of his or her neck. While evaluating the spine, the thyroid gland is picked up by the scan revealing abnormalities in the thyroid gland.

Symptoms often differ between patients. The following is a list of common signs and symptoms that can warrant an evaluation by a thyroid specialist.

  • Neck mass
  • Swallowing difficulty
  • Change in voice
  • Discomfort in neck
  • Breathing difficulty
Diagnosis and Staging of Thyroid Cancer

To thoroughly evaluate the thyroid gland and the lymph nodes associated, an imaging study is performed. In the case for the thyroid gland, an ultrasound is the best choice. In thyroid ultrasound, an experienced thyroid surgeon has an advantage by knowing the intimate gross anatomy of the thyroid gland. We perform thyroid ultrasounds, being able to monitor thyroid masses as well as being able to perform thyroidectomy surgery.

Other imaging studies may be used depending on the type of thyroid problem.

  • CT (Computed tomography) scan
  • MRI (magnetic resonance imaging) scan
  • PET (positron emission tomography) scan

In addition to monitoring the thyroid gland with ultrasound, our surgeons perform in-clinic fine-needle aspiration (FNA) or needle biopsies leading to more definite diagnoses. Our surgeons will have a thorough discussion with patients before planning any invasive procedures to decrease the number of procedures as well as maximizing education for patients with thyroid problems.

Radioactive iodine update scans may be ordered if the function of the thyroid gland or a particular nodule is in question. These types of scans may also be ordered after surgery to plan for radioactive iodine treatment to help eradicate microscopic cancer cells in the body.

We will order labs including thyroid hormone levels and other related tests based on the type of thyroid problem encountered. Other laboratory tests may also be ordered depending on the medical status of patients. We will also obtain all medical records pertaining to your diagnosis.

After obtaining all tests, we follow the most up to date AJCC (American Joint Committee on Cancer) Cancer Staging System to stage your cancer. We will stay up to date on the most modern philosophies in treating thyroid cancer. The American Thyroid Association (ATA) has guidelines for the treatment of thyroid cancers which we adhere to as well.

Treatment of Thyroid Caner

Regardless of the type of cancer, thyroid cancers are treated with surgery. This can include hemithyroidectomy, total thyroidectomy and different lymph node surgeries depending on the stage of the cancer. Radioactive iodine treatment can be used as an adjuvant or additional therapy after surgery if different criteria are met. Rarely, in the case of very advanced thyroid cancers, radiation therapy and/or chemotherapy can be prescribed.

The recurrent laryngeal nerves are intimately related to the thyroid gland. These nerves provide the larynx or “voice box” with movement of the muscles that create our voice. As a thyroid surgery specialist, Dr. Son ensures proper identification and preservation to these nerves in order to preserve the voice. He uses NIM Nerve Monitoring during all thyroid surgeries to increase the safety of patients.

The parathyroid glands are 4 glands that sit behind the thyroid gland. These glands are responsible for the body’s calcium regulation. Without functioning parathyroid glands, the body is unable to regulate the calcium often leading to chronic issues with hypocalcemia or low calcium levels. Dr. Son ensures proper handling of these glands during thyroid surgery. If any blood flow to a parathyroid gland is compromised, he will re-implant these to ensure proper function.

Thyroid Hormone Replacement and Calcium Supplements

After thyroid surgery, most patients will need to rely on lifelong thyroid replacement therapy. After hemithyroidectomy, most patients will NOT need thyroid hormone supplementation, but 30-40% of patients will require some form of supplementation sometime in his or her life.

In regards to thyroid supplementation after thyroid cancer surgery, different suppressive levels may need to be maintained to prevent any recurrence of cancerous thyroid cells that hide in the body.

After total thyroidectomy, some patients may have temporary low calcium levels with the need to take calcium supplementation and/or calcitriol. We will work close with you to optimize levels before weaning you off of these calcium related medications.

Parathyroid Disease

Overview of Parathyroid Disease

Parathyroid glands are 4 small glands located behind the thyroid gland in the lower neck. Although they are the size of a grain of rice, these 4 glands control the calcium regulation for the entire body. Parathyroid hormone is secreted and acts on the kidneys, bones and intestines to conserve the calcium in the bloodstream.

Hyperparathyroidism, overactivity of one or more parathyroid glands, results in increased calcium in the blood, increased calcium in the urine and decreased levels in bones. A gland that is overactive and enlarged is called a parathyroid adenoma.  Patients with chronic kidney problems can develop secondary or tertiary hyperparathyroidism.

Signs and Symptoms of Parathyroid Disease

Most patients found with hyperparathyroidism do not have any symptoms, but many patients can be symptomatic because of the dysregulation of calcium. Decreased calcium in bones can cause weaker bones leading to osteoporosis and fractures. Kidney stones can also form at a higher rate because of the increased concentration in the kidneys and urinary system. High levels of calcium in the calcium can lead to many different symptoms including cardiac arrhythmias, altered mood and mental status, depression, fatigue, muscle weakness, aches and pains.

Abnormal parathyroid glands almost never get large enough to notice by the naked eye.

Diagnosis of Parathyroid Disease

In hyperparathyroidism, increased blood calcium levels along with increased parathyroid hormone (PTH) levels are usually diagnostic. Different lab draws including Vitamin D levels, urine calcium levels among other lab tests can help differentiate between primary hyperparathyroidism and other disease leading to increased blood calcium levels.

The following are common imaging studies which can help localize an abnormally enlarged parathyroid gland.

  • Ultrasound of neck
  • Sestamibi scan (Technetium  (99mTc) Sestamibi)
  • SPECT-CT (Single-photon emission CT with CT scanning)
  • 4D-CT scan
  • MRI
Treatment of Parathyroid Disease

The treatment of hyperparathyroidism caused by a parathyroid adenoma is surgical excision. We will discuss the benefits of surgery versus waiting depending the patient’s individual health and symptoms.

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