Gland and Nodules: An Overview
Guest: Dr. Eric Lentsch – Otolaryngology - Head & Neck
Host: Dr. Linda Austin – Psychiatry
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?
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
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?
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
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
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
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
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
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
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
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
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
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
Dr. Linda Austin: Dr. Lentsch, thanks so much for talking with
Dr. Eric Lentsch: Thank you very much.
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