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Unraveling Thyroid Mysteries on Cancer Conversations · Talking FACS

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  Welcome to Talking FACS, and thank you for tuning in to Cancer Conversations
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  on Talking FACS, a podcast collaboration between the University of Kentucky
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  Markey Cancer Center and the UK Martin-Gatton College of Agriculture,
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  Food, and Environment's Cooperative Extension Service.
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  We will share with you the latest developments in cancer prevention,
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  diagnosis, treatment, and research from the experts at Markey Cancer Center,
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  Kentucky's only National Cancer Institute designated Comprehensive Cancer Center.
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  Talking Facts is hosted by the UK Family and Consumer Sciences Extension Program.
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  Our educators share research knowledge with individuals, families,
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  and communities to improve quality of life.
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  Hello and welcome to Cancer Conversations on Talking FACS.
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  This is a partnership presentation between the University of Kentucky Markey
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  Cancer Center and the Martin-Gatten College of Agriculture, Food,
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  and Environment's Cooperative Extension Service.
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  Together, we are raising awareness and bringing cancer information to local
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  communities across the Commonwealth.
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  I am your host, Mindy McCulley, Extension Specialist for Instructional Support
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  with Family and Consumer Sciences Extension.
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  Most people might not give much thought to their thyroid gland until it develops
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  a problem or just maybe a little issue, but it is essential to maintaining normal
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  functioning of many of our organs and systems.
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  My guest today, Dr. Joseph Valentino, a professor of Otolaryngology or ENT,
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  is here to talk about thyroid cancer.
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  Welcome, Dr. Valentino. How are you?
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  I'm doing very well. It's good to be here. Well, I'm so glad that you're here
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  to talk about this because I will be honest with you. I don't know a whole lot about the thyroid.
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  And so I think that maybe our listeners too might want to know a little bit
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  more about what does the thyroid do?
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  Well, the thyroid gland is a very important organ. It's a gland that produces
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  hormone and the hormone is actually named after the gland. We call it thyroid hormone.
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  And the way in which that hormone is very important in the body,
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  it helps to regulate our body's metabolism.
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  So it affects cells and every organ system in terms of how well it,
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  metabolism we mean, how well the cells will burn up calories and do their particular jobs.
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  And so essentially we can think about it like a throttle on an engine.
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  And so we can make that throttle open up so that things move really quickly
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  and burn up lots of energy. And we can also throttle it back so things are more slow.
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  And so the body likes to have some place in the middle.
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  Our needs and metabolic needs change, and so the body's needs for thyroid hormone change and alter.
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  And so as a person's body changes for various issues and things,
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  the needs for the thyroid hormone changes.
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  And so one good example is the one woman is pregnant, will find the thyroid
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  gland will hypertrophy and produce more hormone for sustaining that portion of thyroid.
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  That state of the body in order to keep the pregnancy going.
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  And so we'll see lots of times where the body will have alterations in those needs.
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  The gland, therefore, when it's not functioning well and that hormone is not
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  doing its job well, we'll see challenges that will reflect what you would think
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  about if the body was to slow down.
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  And so if we have the thyroid hormone levels being too low, say your gland is
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  not producing enough hormone, we will see people will have their bowels slowing
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  down and troubles with constipation.
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  The hair won't grow quite the same, and we'll see patients will have hair falling
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  out or thinning. We'll see changes in the skin.
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  We'll have problems with the energy level. A person will be more tired and fatigued.
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  People with low thyroid won't have burned up as many calories,
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  and so we'll see sometimes associated weight gain during those times.
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  Unfortunately, it represents only about 2% of the reasons why people are obese
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  or have troubles with their weight, which is a real problem in Kentucky.
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  But we find that the thyroid, we always check for it because it's an easy thing to fix.
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  But unfortunately, it's only about one in 50 of our patients who are obese will
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  actually have a thyroid problem. So the vast majority of those are from other causes.
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  But if it's running too fast, we can see patients will have challenges where
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  they'll have trouble sleeping at night.
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  They'll be up, their heart will race, they'll have troubles with diarrhea and
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  maybe bowel cramps and things of that nature.
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  And so we'll see just the opposite end of a body that's burning the candle at both ends.
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  And sometimes we'll see problems with maintaining weight and things like that.
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  Again, that gives you just a general gestalt for how that thyroid gland works
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  and what its hormone does.
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  So when cancer develops in the thyroid, I'm guessing that there are probably
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  lots of factors that are affected across the body then.
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  Well, the thing that's kind of interesting is that the thyroid tumors or things
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  that grow inside the gland will typically not necessarily affect the way in
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  which the gland makes its hormone.
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  So if you think about the gland as being this organ to a certain size,
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  if we have a tumor that grows up in one little corner of the thing,
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  the rest of the gland will still percolate on and do its job.
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  And so, in most cases, we won't see significant changes or alteration in the
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  thyroid function related to neoplasms or growths that occur within the gland.
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  And so, although there are some increased numbers of thyroid nodule processes
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  and the like, and people who run, say, a slightly lower thyroid function, people who have some,
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  their thyroid gland is hypofunctioning, and those patients who may see a few
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  more problems with nodules and tumors,
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  it's typically not the nodules and tumors that caused it because they just more
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  or less grow and push the normal gland out of the way and the normal gland is
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  just slightly displaced and still there doing its job.
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  So we don't necessarily see changes in the hormone levels associated with thyroid
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  tumors or specifically thyroid cancers.
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  Our body is a remarkable thing in that it does seem to accommodate whatever happens, right?
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  It keeps on ticking. It's an amazing, amazing, miraculous machine,
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  the way in which it works.
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  And I tell you, it never fails to impress me how God designed this thing and
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  makes it roll on despite what we do to it and despite what the rest of the world
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  does to it. That is exactly right.
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  So when we do see these thyroid cancers develop, if it doesn't really affect
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  the thyroid function very much, what does happen?
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  The most common reason why we'll see or discover thyroid malignancies or thyroid
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  tumors is usually the patient has a growth.
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  There's some mass or nodule within the gland itself.
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  And so unlike you'll find a doctor will pick that up or a patient will pick
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  that up just feeling their neck and say, well, wait, there's a knot here that
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  wasn't there before, or this is unusual. I feel one side's bigger than the other.
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  Sometimes it's because it gets so big that it's pushing on things and causing
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  some symptoms in that local area.
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  The thyroid gland lives down at the base of your neck, about where a bow tie
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  would sit across the neck, and it has a similar shape, actually.
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  And so it wraps itself around the windpipe and comes back around towards the esophagus as well.
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  And so as it starts, something grows in that area, it can push on those structures,
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  make you feel a tightness across the base of your neck, or sometimes a growth
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  in that area, whether it's benign or malignant,
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  can lead you to troubles with swallowing, where you'll feel things hanging up
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  at the throat, or if it gets large enough, it could actually crush or squeeze
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  the windpipe down, make it a little bit tighter, so it gives a person troubles with their breathing,
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  especially if they maneuver in certain positions, lifting your arms above your
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  head, so to speak, can cause some of those troubles.
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  The other things that we'll see.
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  Is that as something grows, if it's truly malignant and a cancer that's insinuating
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  itself and growing into things,
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  it can actually grow into structures and affect nerves that could cause the
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  person to have weakness of a voice or it could make the vocal cord paralyzed.
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  It's when they're very aggressive and far advanced, they actually can grow into
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  the windpipe and create bleeding or hemorrhage that you might cough up blood.
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  So those would be very unusual ways in which the disease presents.
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  It's the vast majority of times it's from a mass.
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  And these days with technology, the way that it is, people get scans all the time.
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  They get ultrasounds for looking at blood vessels.
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  They get CAT scans because they were in a car wreck, their neck's hurting them.
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  So they get a scan done to make sure their neck bones are all aligned.
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  And in those scans, they happen to scan through and the radiologists will say,
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  oh, and by the way, there's some nodules in this thyroid that need to be looked at.
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  And so many of our patients come in because they've had a nodule in the thyroid
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  or a mass in the thyroid that's been discovered incidentally.
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  Just, you know, oh, by the way, you've got this problem that we did or scanned
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  for, but we also see this.
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  And that sends you to the next doc or to the next study that needs to be done to look into that.
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  Is thyroid cancer a cancer that's real prevalent in Kentucky or in the nation?
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  Cancer, thyroid cancer is pretty evenly distributed through the states.
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  It's not something where we have a rash, a lot of it in Kentucky versus other places.
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  Kentucky has the moniker of
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  having a lot of advanced malignancies in patients who are dying of cancer.
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  So much of that is behavioral-based cancers.
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  In other words, cancers that come from people who smoke too much,
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  who have troubles with obesity, those types of things, but people at risk for
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  developing malignancies. These tumors aren't necessarily, aren't associated with that.
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  And so they're more random in the way in which they affect people,
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  but they are quite common.
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  But it does represent about 3% of malignancies in adults.
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  And we actually are seeing a relative increase in the number of patients with
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  the diagnosis of thyroid cancer over the last 20 years.
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  And we think that a lot of that is because of the advanced imaging that happens now.
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  Many of these tumors are indolent in other words they don't
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  grow rapidly they move more slowly in time
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  and so they'll grow slowly over a number of years and so
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  we'll discover them in some patients tumors will
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  grow so slowly they never trouble them it's interesting in that if you look
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  at some research studies have been done actually many years ago and they would
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  look at patients who had had autopsy for dying in hospitals for any reason and
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  yet if you take the thyroid gland out and section it and look at it very, very carefully.
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  You'll find an incidentally discovered thyroid cancer in about one in 10 patients
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  who would die from other causes in hospitals.
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  So we see that many patients would take their disease to the grave,
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  so to speak, without it ever causing trouble.
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  And so our challenge in medicine is trying to sort out, is this one I need to
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  worry about or is this one I don't need to worry about?
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  And so since we were just now discovering so many of them. When we first started, we thought,
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  oh my goodness, all these patients need to have very, very aggressive surgery
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  and radiation treatments and things like that because we've only discovered
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  thyroid cancers 20, 30 years ago because they got big enough to feel.
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  Now that we're finding these little bitty ones that might not cause trouble down the road,
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  we've actually started to backpedal a little bit on how aggressive to be with
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  some of these thyroid cancers and depending on the specifics of what they look
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  like under the microscope, what their genetic makeup is,
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  how they look on ultrasound, we can then make decisions as to how aggressive
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  to be with the treatment of that disease.
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  So, in talking with some of our other doctors on cancer conversations,
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  I know that there are markers that show if cancer is going to grow rapidly.
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  And do we see that the same with thyroid cancer?
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  Well, actually, we do. It's really pretty cool. When I first started,
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  we really had not very good means of trying to look at a thyroid mass and figure
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  out, is this something that's cancer or not?
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  And so we have certain ways of looking at things, but over the last 20 years,
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  the technology has evolved rather rapidly.
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  And so we've now can look at the ultrasound characteristics of a thyroid gland and a thyroid mass.
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  And there's ways of looking at those characteristics and determining what the
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  chance of thyroid mass being cancer or being benign.
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  And so we can make that first look, see, with just the diagnostic imaging.
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  Many times, as they start to have some features that are more worrisome,
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  we can sample the nodule by placing a very, very fine needle,
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  and we actually call the procedure fine needle aspiration, and we can put a
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  needle into a small nodule.
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  We usually don't try to biopsy anything that's smaller than about half an inch,
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  10 millimeters or so is when we would start to say, this is big enough to worry about.
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  So once they get to be about 10 millimeters or so, we can get a needle into
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  them pretty reliably and draw off some cells.
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  And then we can look at those cells under the microscope and see what they look like.
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  And the pathologist is able to many times look at those cells and say,
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  these are cells that I only see in this kind of cancer, or these are cells that
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  I only see in benign nodules.
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  And so therefore we can, sometimes the pathologist can tell us just by the look of those cells.
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  Many times they'll tell us, well, sometimes I see these types of cells in cancers,
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  And sometimes these same cells can be in benign nodules, and I'm not sure.
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  And so they give us a, well, it could be.
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  It's indeterminate or it's atypical.
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  And then we have the ability to send those off to the laboratory where they
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  can take those cells, extract the DNA, do special studies on the DNA,
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  and look for the changes in the genetic makeup of that tumor.
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  And then to be able to give us a genetic profile of those cells to say,
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  and then we can further refine and say, oh, this looks like it has only a 5%
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  chance of being malignant.
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  Or many sometimes will come back and tell us, well, this is a 50% chance or
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  a 75%, or I'm sure this is a malignancy.
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  And with that genetic material, we can also get some information as to how aggressive
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  the tumor might be by looking at certain types of genetic abnormalities that
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  would occur that we would see on these tests that we would order. Wow.
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  And I'm fascinated by all that we've talked about.
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  You know, there's so much that we think about with cancers.
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  And until you have had these conversations,
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  you don't really know what questions to ask, right? Exactly.
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  Well, and that's part of why we do the podcast, because we do hope that as people
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  find themselves in a situation that maybe they'll think, oh,
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  you know, I heard that on the podcast.
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  Let me ask about this. And so, do you find that there are questions that you
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  get regularly from patients that maybe can help put people's minds at ease?
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  Our job is we take care of, and this is all physicians, and thyroid nodules are pretty common.
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  So, if we tried to take, say, okay, everybody who's got a thyroid nodule has
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  got to come to UK to be seen.
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  Right. We'd be overrun. And so most patients will have providers in their community
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  who will do this initial looking and seeing and try to sort things out.
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  And then our job is to take care of the more complex.
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  And there are some times where something just is frankly confusing.
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  You know, they're looking down and the primary care doc's got this information
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  from the radiologist and this information from the pathologist.
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  And it's just not sure what to do with this.
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  And so the patients will come in to see us and we'll make some decisions.
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  Is this something that needs to be removed? Is this something that doesn't?
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  And so what is very important for everybody who's taking care of thyroid disease
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  to understand is that there are choices and decisions that we make that aren't grounded in absolutes.
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  So most of the time when a doctor gets back an answer to a test,
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  very rarely do you have someone tell you, absolutely, 99% of the time,
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  this is going to be a cancer and you have to do this operation to fix it.
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  Most of the time, there's a judgment call that's being made that you've got
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  a 50% chance of malignancy, and then you've got a patient who has,
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  okay, well, we would probably take that out under most circumstances,
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  but the doctor needs to look and say, well, what's this patient's general health?
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  What other health conditions do they have?
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  It was a person in the midst of being treated for some other aggressive malignancy,
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  or they've got terrible heart disease.
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  They just had cardiac stents placed,
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  and so now they're going to be on anticoagulants for the next six months.
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  How aggressive do I need to be? And so then the judgment comes into play that
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  the doc and the patient have to sit down together and talk about things.
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  And I talk and teach all of my medical students about trying to understand where the patient is, too.
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  We decide to take out a thyroid and whether or not somebody needs to have surgery
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  for this, which is usually the first step in the management of this disease
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  process, by trying to figure out what I would consider the worry about cancer in the room.
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  And I say, I use those words because there's worry that I have based on the
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  tests, based on the scans, based on the information at hand and what I know
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  about the patient and their family history.
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  And then there's also the worry that the patient has. I've been through this
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  before and I had needle biopsies done in the past for my prostate and they had
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  me on the fence and my cancer got delayed and I can't possibly,
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  I'm not going to sleep for the next month.
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  And so there's that type of patient. And there's the patient who says,
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  well, my three cousins had surgery and they had terrible outcomes and they all
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  died of heart attacks after their operations. And I would never have an operation.
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  I'd rather take the risk to my cancer. And so you have patients who bring different
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  issues to the exam room and that you have to take into account as you try to
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  figure out and tailor the therapy to what makes the most sense for that particular patient.
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  And so we have algorithms and we have schemas that are given to us and there's
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  recommendations that are made by large bodies of surgeons and scientists.
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  But those are recommendations that we have that we have to then take and tailor
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  to the patient's specific needs.
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  Sure. And that is so important that we always remember the patient.
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  Dr. Valentina, I have enjoyed this conversation so much,
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  and I appreciate you taking the time to share with our listeners all that goes
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  into putting together a diagnosis for thyroid cancer and then how to actually
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  treat it and treat the patient, not so much as the cancer.
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  Yes, ma'am. And so next time we sit down, we can talk about other things.
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  We here at Markey do lots of things, and this is just a general information piece for what goes on.
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  And some of the things that we do that are special is we take care of the advanced
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  disease, the recurrent disease, the patients who have been battling this and
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  their local surgeon is at wit's end or they've already had an operation.
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  And so we need to do the next steps.
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  And so those are the things where we really shine, where we can take care of
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  putting together the team of docs.
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  And so there's things that we do that are very, very exciting for how to take
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  and have people survive with this disease process, as well as,
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  you know, just the general overall management of thyroid disease and malignancy.
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  That is exactly right. Yes, I would love that. Thank you so much.
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