Thyroid Gland and Nodules: An Overview

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Thyroid Gland and Nodules:  An Overview




Guest:  Dr. Eric Lentsch – Otolaryngology - Head & Neck Surgery

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Eric Lentsch who is an otolaryngologist, a surgeon who operates on ear, nose and throat, here at the Medical University of South Carolina.  Dr. Lentsch, I know you’re doing some very interesting work on minimally invasive surgery for the thyroid gland.  Minimally invasive surgery is something people are talking a lot about.  What is the advantage of that type of surgery?


Dr. Eric Lentsch:  Well, especially in the head and neck, an area, actually, that’s been sort of slow to develop, at least in our field, but in the head and neck, it allows us, with the thyroid glands particularly, to go from, say, a six to eight centimeter incision down to something that’s more on the order of one and a half centimeters to two centimeters.  Now, that, in the long term, is the only thing that patient is going to see through two, three years after surgery, and it’s going to be their reminder, so it’s a smaller reminder, if you will.  But, in the short term, it’s actually much better in terms of allowing the patient to go home earlier.  Probably 70, 80 percent of our patients go home the same day of surgery.  We’ve almost created an outpatient-type of surgery, whereas when I was in my training, six, seven years ago, we would keep people, routinely, two or three days after this type of an operation.  In addition, there are several studies that show that it’s less cost for the patient as well as less postoperative pain, which can be a big thing as well.


Dr. Linda Austin:  So, to put it into lay terms, instead of two to three inches, it’s just a tiny, maybe half inch to three quarters of an inch, scar that’s left?


Dr. Eric Lentsch:  Yeah.  Essentially, we’re only limited by the size of what we’re taking out.  So, we start out with something on the order of, probably, half an inch, and many of the nodules or, say, tumors, that we’re actually taking out are larger than that, so we extend the incision slightly.  But, usually we can get away with somewhere between half an inch and an inch incision.


Dr. Linda Austin:  Now, you do this form of surgery for thyroid diseases.  Which diseases, in particular, do you treat in this way?


Dr. Eric Lentsch:  We use it most commonly for nodules in the thyroid.  Somewhere around 50 to 60 percent of women will actually be diagnosed.  It is largely something that we find in women.  And the diagnostic challenge that we have, despite our advanced techniques, is finding out whether or not that nodule is actually a cancer or benign.


Dr. Linda Austin:  You said, 50 to 60 percent of women?


Dr. Eric Lentsch:  Fifty to sixty percent of women actually have nodules in their thyroid.


Dr. Linda Austin:  Of all women?


Dr. Eric Lentsch:  Yes.


Dr. Linda Austin:  At what age?

Dr. Eric Lentsch:  At any age.  It typically exists in women above the age of 40.  As you get above that age, your chances of having a nodule in your thyroid are higher.  What we find is that most of these are benign.  But, somewhere between 10, 15 percent will actually be thyroid cancer.  And so, we wind up, actually, doing a variety of tests, including needle aspirations, ultrasounds, to try to determine which of those nodules are actually cancerous.


Dr. Linda Austin:  Now, just explain a little bit more.  If you were to try to say, with words, how a man or a woman might actually feel one of these nodules in their neck, where would they go, what would they look for?


Dr. Eric Lentsch:  It would be the area in the middle of the neck, but very low, just above the collar bone.  And, if you’re actually feeling that area, there’s a little notch right in the middle, and we call that the supraclavicular notch.  And, right above that is where your thyroid gland sits.  So, it’s low in the neck and sits like a butterfly on either side of your windpipe, which is in the middle.  Generally, a nodule of substantial size can be felt through the skin and soft tissues in the neck, done as part of a routine examination by your family practice doctor or internist, but it’s also something patients can feel themselves. 


Dr. Linda Austin:  So, let’s imagine, somebody listening to this now can feel a nodule like that, what would be the next step?


Dr. Eric Lentsch:  The next step would be to have it checked out by a physician, usually your general practice physician or internist.  They can then verify that it is indeed in the thyroid, because some of these are not actually thyroid glands.  There may be lymph nodes in the area or other masses.  Once it’s been determined that it’s in the thyroid then, probably, the next step is actually to get an ultrasound to determine the size of it, the shape, and other characteristics that can be seen on the ultrasound.


Dr. Linda Austin:  Now, after the ultrasound, what is the next step?


Dr. Eric Lentsch:  Typically, again, if the nodule is of sufficient size, and I usually use around one centimeter for this, I would recommend something called a needle biopsy.  That’s where a small needle is used to go through the skin and into the thyroid gland, which just lies below the skin, and we’re able to draw out a certain number of cells, anywhere from 50 to 200, look at them on slides and see whether or not what we’re dealing with is a benign nodule or suspicious for cancer.


Dr. Linda Austin:  And then, if it does look suspicious at that point, you would make the decision to go to surgery?


Dr. Eric Lentsch:  Exactly.  And, typically, I tell patients, we get one of three answers from the needle biopsy.  They either tell us it’s completely benign, in which case we’ll still keep an eye on it to make sure it’s not growing, but I feel much more comfortable letting patients sort of go about their business.  However, they often will tell us that there are suspicious cells and/or, frankly, cancerous cells.  The decision is easy then.  We do need to do surgery to remove it.  A certain amount of time, however, we actually get a third answer and that is, we don’t see anything that tells us there’s cancer there but there are some atypical cells.  And that’s where I have to sit down with the patient and really discuss what he/she wants to do about it, because it’s something that can be observed very closely for signs of change, or the decision can be made at that point to go to the operating room and remove the nodule.


Dr. Linda Austin:  What do most patients opt to do at that point?  What usually happens then?


Dr. Eric Lentsch:  Well, it’s interesting, and it plays into the new technique that we’re able to offer them.  I think, when I was in training, it was sometimes difficult to talk patients into a surgery that would leave them in the hospital for several days and leave them with a fairly sizeable scar.  At that point, I’d say, maybe, 40, 50 percent of patients would opt for the surgery, and the other half would say, I want to take a wait-and-see approach.

These days, I’m able to talk to them about something through a half inch incision and, basically, an outpatient procedure.  It’s probably somewhere between 80 and 90 percent of patients that say they’d rather know, and that’s exactly what we’re able to do.  By taking it out, we’re able to give them a definitive answer as to what’s in there.  So, I think the minimally invasive techniques allow us to give a better answer to a lot more patients.


Dr. Linda Austin:  How about blood work that would be done as part of that?  What would a doctor be looking for?


Dr. Eric Lentsch:  Typically, blood work is done because we can easily measure thyroid hormone levels and thyroid stimulating hormone levels through routine blood tests.  However, the vast majority of the time, with simple nodules, they’re actually not effective, so those blood tests will return as normal.  So, if we rely heavily on the ultrasound, and if the ultrasound does, indeed, identify a nodule that’s of a significant enough size, typically that’s about one centimeter, then we would usually recommend moving on to some sort of a biopsy.


Dr. Linda Austin:  So, you would then remove this using the minimally invasive technique that you’ve described.  What would happen then?


Dr. Eric Lentsch:  For the minimally invasive technique, it’s done as an operation, so it’s in the operating room and the patient is asleep.  We make a very small, again, half centimeter, incision, just in the area of the low-neck.  We try to hide it in a crease.  We all, fortunately or unfortunately, have creases in our neck, and we hide it in one of the low-neck creases.  Basically, I tell my patients that the gland itself is underneath the skin and one layer of muscle, and it’s right there.  It’s one of the easier operations that we do in terms of removal of things.  It’s not very deep.  It’s an easy area to get to.  And, with the visualization afforded by the scopes that we use, it has become a fairly routine technique in this institution.


Dr. Linda Austin:  How long does that surgery usually take you to perform?


Dr. Eric Lentsch:  It can take anywhere from 45 minutes to about 2 hours, in general.


Dr. Linda Austin:  What are the risks of the surgery?


Dr. Eric Lentsch:  The risks are similar to a standard thyroidectomy.  Two things that I really have to worry about are a major nerve that lies underneath the gland itself, it’s a nerve that goes to the vocal cords and can cause some disruption of the function of the vocal cords and can lead to hoarseness afterwards.  That’s a risk that occurs, or comes to fruition, about half of a percent of the time when this operation is done.  The second risk we have to worry about is risk to glands right around the thyroid, called the parathyroid.  Those control the calcium levels in our body, and if those are removed inadvertently with the thyroid gland, the calcium levels can drop.  Again, that’s a risk that probably occurs about one percent of the time in these patients.


Dr. Linda Austin:  What kind of anesthesia is used in this procedure?


Dr. Eric Lentsch:  Here at MUSC, we use general anesthetic for this.  We think it’s more comfortable for the patient as well as for us.  It actually has been reported and can be done under local anesthesia. 


Dr. Linda Austin:  And then the patient stays, how long afterwards?


Dr. Eric Lentsch:  About 70 or 80 percent of our patients go home the same day now with this procedure, and it’s one of the big advantages of it.  About 20 percent will wind up staying overnight and going home the next day.  A lot of times that’s simply because the patients live far away and would feel more comfortable spending the night, which is a very reasonable thing.  But the vast majority of our patients are able to go home the same day.


Dr. Linda Austin:  Now, I would imagine that the nodule that you have removed goes to the pathologist to be examined.  Is that right?


Dr. Eric Lentsch:  Yes.  After taking out the gland, the pathologist then has the whole nodule to work with, and they can determine, after a day or two of looking at, whether or not the nodule itself has cancer or any part of the nodule has cancer cells in it.  If there is cancer, that may require further removal of remnants of the thyroid gland.  By that, I mean, the typical operation removes about half of the thyroid gland, and we may have to go back and remove the other half with a second operation if cancer is found.


Dr. Linda Austin:  And then, is that usually it for the patient, or might they have radiation or chemotherapy after that, if it is cancer?


Dr. Eric Lentsch:  If cancer is found, the vast majority of patients will undergo a type of radiation, called radioactive iodine treatments.  It’s a little different than the standard radiation treatments where you’re getting a machine that’s sending an external beam of radiation at the patient.  With this, the patient is given an iodine pill that is radioactively tagged.  Iodine is really only taken up by thyroid cells, so if there are any remnant thyroid cells in the body, they will pick up the iodine with the radioactive tag and actually be destroyed.  Most of our patients will receive radioactive iodine treatments, but not your standard, typical, external beam radiation.


Dr. Lind Austin:  How serious is this form of cancer?


Dr. Eric Lentsch:  It’s actually a difficult question to answer, and the reason I say that is it’s really a spectrum of disease.  There are some very well differentiated types of thyroid cancer that are actually very easily cured.  And, luckily, most of the thyroid cancers we deal with fall into this category, such that with a good operation and with postoperative radioactive iodine, we’re curing upwards of 95 percent of people.  However, there are a few very aggressive types of thyroid cancer that can be much more morbid and actually have a much higher death rate associated with them.  It all depends on the final pathology and what type of thyroid cancer we’re dealing with.


Dr. Linda Austin:  I would think that it would be important for people to get regular physical examinations and, in particular, if they’re feeling their neck and they feel something that they’re concerned about, to get medical treatment sooner rather than later.


Dr. Eric Lentsch:  Yeah, I think it’s important for the patient to be able to take that upon themselves, for one.  And, if anything is present in the neck or any area of the body, obviously, for a period of time that, say, exceeds two weeks or so, I usually tell patients, you need to get it looked at by an expert in the field, and that could be your family doctor or your ear, nose, and throat doctor.


Dr. Linda Austin:  Dr. Lentsch, thanks so much for talking with us today.


Dr. Eric Lentsch:  Thank you very much.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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