Saving Thyroids - One Step at a Time
Patients most commonly come to see me in the clinic for a reassurance that they do not need treatment, especially surgery, for the condition that they have. Sometimes they attend their appointment with me because they need an operation, like for the treatment of cancers. Sometimes they come because of the fear of unknown.
15 + years ago, we used to operate on thyroids infrequently as we did not have very sensitive investigations to let us know how common thyroid nodules are. We used to operate on enlarged thyroids or large nodules that were only visible to the naked eye.
Development of the high-quality neck ultrasound has enabled us as doctors to investigate the thyroids with ease, and since then, we have been overwhelmed with the finding of thyroid nodules. This poses a problem of what to do with these nodules. And for patients knowing that these nodules are present, lead to fear of what these might be.
And I believe that the fear of the unknown is the hardest thing that has to deal with. So we as doctors always talk about this fear (or at least we should). What the possible diagnosis might be, what are the next steps in finding the diagnosis and what the potential treatment plans are for each diagnosis. And then we talk about taking one step at the time and concentrating on only that one step. Because the whole journey of dealing with unknown is unbearable to think of. Ticking off small steps or small goals, like putting one step in front of other is going forward, and slowly dealing with the fear of the unknown.
These are the steps that lead to less thyroid surgery, whether this is taking whole or just half of the thyroid:
Knowing which nodules not to investigate further with biopsy or knowing which ones to follow-up with further imaging
Which nodules need to be removed according to biopsy results
Can we minimise the extent of surgery for thyroid cancer
Knowing which nodules not to investigate further with biopsy or knowing which ones to follow-up with further imaging
And high-quality ultrasound and multiple studies have enabled us to stratify these nodules according to the risk that they may be cancer and what should we do about these.
Previously we have done a biopsy (FNA, fine needle aspiration) of most nodules, now we know that there is no need to investigate the majority of nodules. So in this situation, we just need to reassure our patients that the risk of these nodules is very low and that these nodules only need to be imaged - leads to less surgery and SAVED THYROIDS.
Which nodules need to be removed according to biopsy results
These days we only remove nodules if they are suspicious for thyroid cancer or are proved to be thyroid cancer. Previously we used to say that nodules over 4cm (despite benign FNA) should be removed as they may hide cancer within it (sampling error). These days we know that this is not true, so we do not recommend anymore that patients have surgery only due to the size of the module, FNA is enough. All this leads to less thyroid surgery. SAVED THYROIDS.
Can we minimise the extent of surgery for thyroid cancer?
For most thyroid cancers, the treatment was total thyroidectomy (removal of the whole thyroid gland) and radioiodine treatment. Now we know that radioiodine treatment is not required for the majority of smaller thyroid cancers (less than 2cm) and possibly up to 4cm. If radioiodine treatment is not needed, then we do not need to remove the whole thyroid, but just the half that had cancer within it. SAVED THYROIDS
Small papillary thyroid cancers less then 1cm (micro PTC) can be safely observed according to the studies from Japan. So far, in the western world, we have struggled not to operate on these patients. And in these cases even if we have offered the observation, majority, and in my case, all of my patients, have chosen to have thyroid gland or half of it removed. So I believe that we need to work harder to change this over-treatment of small papillary thyroid cancers. This also will lead to SAVING THYROIDS.
The reason we are trying to SAVE THYROIDS or minimise the extent of thyroid operation is that every thyroid operation may lead to complications like voice disturbances and endocrine disturbances in thyroid and parathyroid hormones. And these complications have an impact on a person's quality of life while the majority of thyroid conditions that have led to the operation have an excellent prognosis.
