Discover the secrets of the thyroid gland with Dr. Melissa Bochner, ( Breast & Endocrine Surgeon ) as she unravels the mysteries of one of the body's most essential regulators. Prepare to be enlightened about the delicate balance of hormones that orchestrate our metabolism, heart function, and much more. As Dr Gavin Nimon ( Orthopaedic Surgeon and host os Aussie Med Ed) has an enlightening conversation with Dr. Bochner, head of the Breast and Endocrine Unit at Royal Adelaide Hospital, you'll gain insights into the subtle signs that may point to thyroid dysfunction, how these conditions can masquerade as other illnesses, and the particular challenges faced by older patients.
Thyroid health is more than just a blood test; it's a puzzle that requires a keen diagnostic eye. Dr. Bochner walks us through the intricate process of identifying the origins of hyperthyroidism and the crucial role of advanced imaging in crafting a precise treatment plan. Whether it's the unexpected side effects of immunotherapy or the tailored approach to surgery, our discussion with Dr. Bochner provides a deep understanding of the nuance needed in managing thyroid conditions while highlighting the significance of a thorough physical examination.
Step into the surgical suite as we navigate the complexities of thyroid nodule assessment and the considerations that lead to the decision to operate. Dr. Bochner shares the cutting-edge techniques that are transforming thyroid surgeries and minimizing their impact on patients' lives. We also dissect the Bethesda system for thyroid nodule categorization, offering a window into the future of thyroid cancer diagnosis and treatment, and ponder the emerging role of AI in advancing medical precision. Join us for a comprehensive journey into the world of thyroid health, guided by one of its most knowledgeable practitioners.
Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.
Aussie Med Ed is sponsored by Avant Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Gavin Nimon (00:00):
The thyroid gland, while diminutive in size,
is formidable in its impact.
I like to think of it as almostlike a fuel injection of the
car.
The actual fuel mix determineshow fast the car idles at, and
that's what the thyroid seems todo.
It synthesises thyroxine and T3hormones.
That's intramedible inregulating metabolic rate, heart
function, digestive health,muscle control, brain
(00:21):
development and bone maintenance.
It also produces calcitonin.
Well, today we're going tolearn more about it, but with Dr
Melissa Bochner, head of Breastand Endocrine Unit at the Royal
Adelaide Hospital.
G'day and welcome to Aussie MedEd, the podcast with a pragmatic
approach to medical conditions.
I'm Gavin Nimon, orthopaedicsurgeon based in Adelaide, and
I'm broadcasting from Kaurnaland.
I'd like to start the podcastby acknowledging the traditional
(00:43):
custodians of the land on whichthis podcast is produced, the
Kaurna people, and I'd like topay my respects to the elders,
both past, present and emerging.
It's my pleasure now tointroduce Dr Melissa Bochner, a
breast endocrine surgeon, who'sgoing to talk to me about
thyroid disorders.
I'm really pleased to be joinedby Melissa.
She's the head of the breast andendocrine surgery unit at the
Royal Adelaide Hospital.
She trained in general surgeryat the Royal North Shore
(01:04):
Hospital in Sydney, thenspecialised in breast and
endocrine surgery, withfellowships at the Royal
Adelaide Hospital and EdinburghBreast Unit.
Melissa has a research master'sof surgery from the University
of Sydney as well as working atthe Royal Adelaide Hospital and
provides a surgical service forbreast and thyroid diseases at
the Children's Hospital.
She's going to talk to us aboutthyroid diseases in general.
She's going to talk to us aboutthyroid diseases in general.
Welcome, melissa.
Thank you very much for joiningus on Aussie Med Ed.
Dr Melissa Bochner (01:26):
Thank you so much, Gavin.
Thank you for inviting me.
Dr Gavin Nimon (01:29):
Well, it's brilliant to have you on board.
It's quite an crucial organ,the thyroid, and I'd like to
hear more about it today, so I'mreally looking forward to it.
Perhaps we can start off byfirst of all just explaining
what the thyroid does and itsfree function.
I know there's a lot more wecan go into we could spend hours
on it, but just as a briefoverview, what does the thyroid
actually do?
Dr Melissa Bochner (01:48):
The thyroid is very complex, of course, in
its mechanisms becauseessentially it does release the
hormones that you've mentionedT4 and T3, and they have
multiple metabolic effectsthroughout the whole body.
So when I'm talking to apatient I might say to them that
really the thyroid controlsyour energy hormones and your
(02:10):
metabolism hormones.
So in fact, if your thyroiddisappeared tomorrow, you
wouldn't die, but you would getpretty sick and you wouldn't be
able to function properly.
So sometimes it's easier todescribe thyroid function in
terms of the effects that itmight have if you had too much
of it or too little of it.
And, for example, people thathave an overactive thyroid,
(02:33):
where they're making too muchthyroid hormone.
They may be anxious, they won'tbe able to sleep, they may lose
weight, they may have diarrhea,they may have a rapid heart
rate weight, they may havediarrhea, they may have a rapid
heart rate.
People who have too littlethyroid hormone will have the
opposite, so they might feeltired, they might feel depressed
, they may gain weight.
(02:54):
So sometimes the symptoms ofthyroid disease can mimic other
diseases and sometimes they canbe nonspecific and sometimes
they can be difficult to pick upwithout doing the thyroid blood
test.
It's particularly interesting,I think, when you're looking at,
for example, the elderly.
I saw an older man recentlywho'd been admitted under
(03:15):
cardiology with rapid AF veryhard to control.
They knew he had a goit.
Of course this man wassignificantly hyperthyroid and
hyperthyroidism can tip theelderly particularly into
tachycardias, svt and atrialfibrillation.
Dr Gavin Nimon (03:30):
Right.
So is it purely disorders ofthyroid, is it purely actually
metabolic disorders as well, oris it can present in other ways
as well?
Dr Melissa Bochner (03:39):
So I think one of the disclaimers here and
obviously you've mentioned it isthat I'm a surgeon and so I'm
particularly interested in thediseases that are referred to me
.
There will be a slightlydifferent cross-section of
diseases that GPs might see orthat endocrinologists might
manage on their own.
But for surgeons, of course, wewill see what we've already
spoken about patients withabnormalities of function.
(04:01):
We will see patients withabnormalities of structure, and
by that I mean an enlargedthyroid causing local symptoms,
usually due to pressure in theneck there's obviously not a lot
of room in the neck.
And then, of course, we willsee people who do not
necessarily have a symptom fromtheir thyroid but who have a
(04:22):
nodule which may be suspiciousfor malignancy.
They're the three main areasthat we would see in our clinic.
Dr Gavin Nimon (04:28):
Yes, you mentioned hypo and hyperthyroid.
Are they the two main disordersthat occur in the function
level, or can you actually getabnormalities of function with
also normal levels of thyroidlevels in the blood?
Dr Melissa Bochner (04:39):
Usually you will divide it up into hyper and
hypo.
We can see people with otherdiseases, the sick u thyroid,
for example, that GPs are wellaware of and that don't end up
with a surgeon.
But most people are either overor under and that will be easy
really to determine on a thyroidfunction test, on a blood test.
(05:00):
As I mentioned before, theremay be some people who have a
normal T4 and T3, but asuppressed TSH, so they will be
subclinical hyperthyroidism.
But those people, particularlythe elderly, may still have some
symptoms from that.
So they would be the two reallyunder or over.
Dr Gavin Nimon (05:21):
So start off with, say, hypothyroidism, which
a lot of people always worryabout, particularly if they're
carrying a little bit of extraweight and they think there
might be a hypothyroid disorder.
What are the main causes ofhypothyroidism and how common is
that?
Dr Melissa Bochner (05:34):
Obviously, from my point of view, the
patients that I see in my clinicwho have been diagnosed with
hypothyroidism most of them havean autoimmune condition
Hashimoto's, thyroiditis,hypothyroidism Most of them have
an autoimmune conditionHashimoto's, thyroiditis.
Hashimoto's is extremely common, particularly in older women,
and again it may be subclinical.
So sometimes when we'reremoving the thyroid we will
(05:55):
note that it is unduly inflamed,that the operation is somewhat
difficult, but those people willhave normal thyroid function.
But in some people it willprogress to thyroid gland
destruction and that is the mostcommon cause of hypothyroidism,
particularly as you get older.
Clearly that is a disease whichmay sneak up on a person and so
(06:20):
somebody might say it becomesparticularly severe because it's
obviously easy to treat.
Hashimoto's does not requiresurgery most of the time and for
the vast majority of people thegland tends to atrophy and it
isn't particularly big.
The other thing worth talkingabout because I do treat
children and clearly one of thescreening tests for newborn
(06:46):
babies is a thyroid functiontest, because there is a very
small group of people who can beborn with congenital
hypothyroidism, either due tothe gland not being there at all
or not forming properly, orsomething wrong with the way
that the thyroid hormone is madewithin the gland and, of course
(07:06):
, congenital hypothyroidism isagain treatable and a very
important thing to do to preventall of the terrible long-term
effects in neurologicaldevelopment, in particular in
undiagnosed babies.
Dr Gavin Nimon (07:20):
Right.
So you've got hypothyroidismrelated to an autoimmune
disorder called Hashimoto'sdisease.
Slow, insidious onset withsubclinical levels of thyroid
causing low metabolic rates.
You've got a congenital cause.
Are there any other causes ofhyperthyroidism that need to be
considered too?
I presume there must be somepituitary axis issues as well
that can cause it.
Is there or?
Dr Melissa Bochner (07:40):
I think that's right is that,
understandably, the TSH releasedby the pituitary is the driver
of thyroid hormone release andmanufacture, and so, yes, there
is a continuous feedback loopbetween the thyroid function and
the pituitary function.
Because I'm a thyroid surgeon,it's extremely unusual for me to
(08:04):
see anybody with primarypituitary failure, and it is a
much less common cause ofhypothyroidism and, clearly,
again, pretty easy to diagnose.
If you see a patient and theyhave a low TSH and then you do
T3 and T4 and they're low aswell, then you do need to
consider a pituitary cause, butit's much, much less common.
Dr Gavin Nimon (08:26):
All right.
Any other causes of insidiousonset apart from the autoimmune
Hashimoto's, then, or is anythat's really the main cause?
Dr Melissa Bochner (08:34):
I think that would be the main cause.
The other one that you know,obviously, that we do to people
is iatrogenic.
So of course you can seesomeone who's had a
hemithyroidectomy for astructural or diagnostic reason
and then you may expect that theother half of their thyroid
will continue to functionnormally and should compensate
(08:56):
and step up to function normally, but it doesn't always do that.
So certainly for patients whohave had hemithyroidectomy, we
would routinely check thyroidfunction at about three months,
because a significant number ofthem do become hypothyroid after
surgery.
Dr Gavin Nimon (09:09):
And in that scenario, either both the
atrogenic in that scenario orHashimoto's, with replacement of
thyroid hormone.
Are there any other hormonesthat need to be replaced as well
, that we need to consider,because obviously the thyroid is
more than just purely producedthyroxine?
Is there issues with calcitonin, too, that need to be replaced?
Dr Melissa Bochner (09:25):
No, it's really interesting that
calcitonin is produced by thethyroid and only by the thyroid,
but there appear to be noclinical consequences of
removing the thyroid in terms ofcalcitonin.
Dr Gavin Nimon (09:42):
Right.
Dr Melissa Bochner (09:43):
And the only people that you ever see with
an elevated calcitonin, ofcourse, are those with medullary
thyroid cancer.
The medullary thyroid cancersalmost always secrete calcitonin
, and people with metastaticmedullary thyroid cancer, which
can cause symptoms, but theabsence of the thyroid does not
cause any kind of problems withcalcitonin.
Dr Gavin Nimon (10:05):
Right, excellent , okay, melissa.
Can you get paraneoplasticsyndromes causing
hyperthyroidism or producingother hormones as well, such as
calcitonin?
Dr Melissa Bochner (10:14):
You don't normally see ectopic thyroid
hormone replacement, althoughyou can see it occasionally with
metastatic follicular thyroidcancer which can be extremely
well differentiated and canproduce its own thyroid hormone.
It's not common.
I've had patients with itwho've had total thyroidectomy
(10:35):
for metastatic thyroid cancer.
They've done very well.
They've got known metastaticdisease.
They've been quite asymptomaticfrom it and have required very
little thyroxine replacementbecause their metastasis appears
to be making it.
So yes, it happens, but itisn't common.
Dr Gavin Nimon (10:52):
Okay, no worries .
So if we move on to thehyperfunction of thyroid disease
, hyperthyroidism, I believeGraves, is probably the most
common cause and that's anotherautoimmune disorder.
Is that correct?
Dr Melissa Bochner (11:03):
Yes, I think that's right, and I like to
think of Graves and Hashimoto'sas being a sort of a spectrum of
autoimmune thyroid diseases.
Graves, of course, is anassociation of symptoms which
includes hyperthyroidism, butalso the eye disease that we're
familiar with and some othersoft tissue depositions which
(11:25):
appears to be related to acirculating protein.
The mechanism of some of thosethings is still not completely
understood, but traditionallyGraves is a spectrum of symptoms
involving more than just thethyroid.
People with Graves disease willbe hyperthyroid and the disease
will affect the whole thyroid,which differentiates it from the
(11:48):
other two causes.
I know we like to talk aboutthings in threes.
So we've got Graves' disease,we've got toxic multinodular
goiter is not uncommon and thenthe third major cause of
overactive thyroid is a toxicnodule, which is often a
solitary toxic nodule.
Dr Gavin Nimon (12:06):
Brilliant.
So there's another group ofthrees we can think of
hypothyroidism with If we goback to the graves.
Actually, one of the commentsyou made just then which
actually just threw me, becauseI always thought the actual
ocular proptosis that occurswith the graves disease was
associated with the thyroidhypothyroidism, but you've
implied that it actually is aparaprotein that causes it and
actually separate to thehypothyroidism the cause and
(12:28):
actually separate to thehypothyroidism.
Dr Melissa Bochner (12:28):
It's part of the Graves.
So if you've that's right ifyou've got eye disease, then you
have Graves, you don't havetoxic goiter and you don't have
a toxic nodule and you're notover replaced with thyroxine
usually yes, and that's why oneof the interesting things about
the treatment of Graves disease,because obviously there are
medical treatments for Gravesdisease but if you remove the
thyroid, then you are alsoremoving the source of perhaps
(12:52):
the abnormal antibody in theprotein and that may improve the
eye disease.
So one of the indications forsurgery in Graves' disease in
fact is significant eye disease.
Dr Gavin Nimon (13:02):
Moving on to the treatments of those three
conditions, then you'vementioned surgery.
A question that comes to mindfirst of all actually is, when
you talk about autoimmunedisorders both for Hashimoto's
and Graves use of biologicagents for treating autoimmune
disorders.
Is that one of the medicalmanagements for these conditions
as well?
Dr Melissa Bochner (13:17):
No, we would not use biological agent for
treatment, but it does bring meto our old friend, yatrogenic,
again as causes ofhyperthyroidism.
So a little bit of a fourthcause that we need to think
about.
Amiodarone, of course, has beenlong known to cause
hyperthyroidism, which isdifficult to treat, and one of
(13:40):
the other diseases that I treat,as you would be aware through
my practice at the RoyalAdelaide, is breast cancer.
There's been a big change insome of the treatments for
breast cancer lately, includingthe use of immunotherapy for
women with triple negativebreast cancer, and the drug that
our patients get is calledpembrolizumab.
Pembrolizumab has a lot ofautoimmune side effects and our
(14:04):
patients will frequently developthyroid disease as part of
their breast cancer treatment.
So I think that one of thethings that treating doctors
need to be aware now is thatcertainly some of our
immunotherapies can actuallycause thyroid disease.
Dr Gavin Nimon (14:23):
Right.
Is that a hypo orhyperthyroidism?
Dr Melissa Bochner (14:26):
Either.
So certainly when we're comingaround to operate on these
people, you know, becausethey'll complete their
neoadjuvant chemo and then we'regetting them worked up for
surgery and we need to be verycareful to make sure that their
thyroid function is normal, aswell as adrenal function, with
those drugs.
Dr Gavin Nimon (14:42):
Right.
So we've got hyperthyroidism,which can be treated medically
with replacement or with surgeryto excise the thyroid.
You've got hyperthyroidismthat's similar, with some
medical treatment and surgery inthat scenario, and that
includes the toxic multinodulargoiter as well as the toxic
nodule.
Dr Melissa Bochner (14:59):
I think that the thing that you know,
because we will be sent patientswith hyperthyroidism for
treatment and I think,surgically, it is important for
us to understand the cause ofthe hyperthyroidism because we
need to know how much of thethyroid to remove to try and
cure the person.
So if we go back to theetiology, we actually want to
(15:19):
know which of those diseases itis.
We will be happy that theperson is hyperthyroid, based on
pretty standard blood tests,which is the suppressed TSH and
the elevated T4 and or T3.
Clearly again, when you'relooking at blood tests, you
sometimes see someone with anormal T4 who has an elevated T3
(15:42):
.
So they may have purely T3thyrotoxicosis, which can be
tricky when you're orderingthyroid function tests.
If you don't put T3 in there,the lab won't do it and then
you'll have to come back andorder it again.
So yes, we can say, okay, you'vegot hyperthyroidism.
We're not sure why.
You can order thyroidantibodies, which are often
(16:02):
elevated in people withautoimmune thyroid disease.
So people who are hypothyroidwith Hashimoto's will have an
elevated autoantibodies.
People with hyperthyroidism mayhave elevated TSH receptor
antibodies and that may be worthmeasuring.
But the most important thing Ithink for people that are
hyperthyroid is to have anuclear medicine scan so that we
(16:24):
know which part of the thyroidis abnormal, so that, for
example, with Graves' disease,the whole thyroid will light up
on nuclear medicine and youcan't cure them unless you take
out the whole thyroid, whereaswith a toxic goiter they may
have a more patchy uptake or adominant hyperthyroid nodule or
(16:45):
collection of nodules, and forpeople with a toxic solitary
nodule, then clearly they have asingle focus for their
hyperthyroidism and you onlyneed to do a hemothyroidectomy
under those circumstances.
So as surgeons we like to knowexactly which bit of the thyroid
is overactive, so that we canthen make the correct
recommendation to the patient.
Dr Gavin Nimon (17:06):
So the workup is the bloods, including thyroid
antibodies T3 and T4s,progressing to nuclear medical
scan.
Do you include ultrasound aspart of your workup as well, or
was it a CT or MRI as well?
Dr Melissa Bochner (17:18):
The nuclear medicine scan is a functional
scan, so that will tell us whichbit of the thyroid is
overactive.
Clearly, when you're offeringsomeone an operation, you want
to be able to talk to them aboutthe risks and how long the
operation is going to take andwhat you're removing.
So ultrasound is very importantand for us really, we consider
(17:39):
that to be an adjunct toclinical examination.
So we have these days aportable ultrasound machine in
all of our clinics and in ouroffice, and so I would normally
examine a patient, examine theirneck with the standard thyroid
examination, and then I wouldactually look at their thyroid
with ultrasound myself, and thethings I'm most interested in
(18:03):
would be how big is it and whereis it?
Is it in the neck or does it godown into the chest?
Because that's really importantwhen you're talking to someone
about surgery.
Dr Gavin Nimon (18:12):
And for the examination part, you've
mentioned the standardexamination.
What are the key things for amedical student to watch out for
?
Obviously, we've talked aboutproptosis for Graves' disease.
We've talked about, obviously,irregular shape to the thyroid
and a bit more prominence.
Is there anything elsesystemically that we need to
look for as well?
Dr Melissa Bochner (18:27):
Yeah, I think the standard thyroid
examination that you do as amedical student and particularly
if you were in an exam or ifyou didn't have an
endocrinologist in your clinicwhich we luckily do at the Royal
Adelaide would include pulserate, blood pressure, you would
look for a tremor, you wouldlook for the eye signs, which
(18:49):
includes the proptosis, but alsothe external ophthalmoplegia,
so perhaps diplopia on lateralgaze, and you may also then be,
as I said, interested in theneck examination as to how big
the thyroid is.
A lot of people with Graves'disease can have a moderately
enlarged gland which is notretrosternal but which can be
(19:11):
quite firm because of theinflammation.
So the thyroid examination isclearly important.
Dr Gavin Nimon (19:20):
Okay, with that examination out of the way, then
, and obviously with theultrasound you talked about and
the investigations, includingthe blood tests and the nuclear
medical scan you mentioned, themedical management Is that
managed by purely anendocrinologist and you come in
for the surgery part of it, oris that something that you get
involved in as well?
Dr Melissa Bochner (19:36):
We have a multidisciplinary team in our
clinic at the Royal Adelaide andwe're really lucky because in
fact management of thyroiddisease includes endocrinology,
nuclear medicine, specialty andsurgery, because the one thing
that we haven't spoken about forhyperthyroidism is in fact use
of radioactive iodine to controlthyroid function.
(19:57):
So we have all of thosespecialties within our clinic
and we can share patients sothey can talk to the
endocrinologist who might sayyou can try a drug such as
carbamazole.
Many patients with Graves'disease in particular will be
well controlled on carbamazole.
They won't need to come and seeanybody else.
(20:17):
They will go into remission andstay in remission.
So not everybody with Graves'disease even sees a surgeon.
The ones who end up coming backfor surgery will be the
patients who relapse, becausemultiple relapses or prolonged
Graves' disease probably willnot be cured and will need more
(20:38):
definitive management.
People with a very largethyroid who have pressure
symptoms, as mentioned before,people with eye disease may be
better having surgery.
And then there are people whocan't tolerate the drugs or
people who shouldn't have thedrugs, and I'm including here
young women who may wish to havea pregnancy, where the thyroid
(21:02):
function can be very difficultto control during pregnancy and
we know that abnormalities ofthyroid function during
pregnancy are not good for thebaby.
It may increase risk ofmiscarriage, for example.
So there is a group of peoplewho will come through for
definitive management.
At that point they may wish tospeak to the nuclear medicine
physician about the use ofradioactive iodine to destroy
(21:23):
the thyroid and then they maywant to speak to the surgeon
about surgical management.
Clearly those two things aredifferent.
Radioactive iodine is appealingfor some patients.
It's obviously non-surgical.
They don't need an operation.
They don't get a cut in theirneck.
They don't have to consider thecomplications of surgery, the
(21:43):
worst of which is damage to therecurrent laryngeal nerves.
The downsides to nuclearmedicine, of course, is that
some people don't like the ideaof a radioactive treatment.
There may be an increased riskof some malignancies down the
track after use of radioactiveiodine.
It doesn't work immediately.
So if you need to control thethyroid straight away, then that
(22:05):
isn't the right treatment.
It may not work as well in verylarge multinodular goiters
because of the patchy nature ofthe uptake.
It may shrink the gland alittle bit, but it will not make
a very large glandsignificantly small if someone
also has compression symptoms.
(22:26):
So there are pros and cons toeach of the treatments, and we
like our patients withhyperthyroidism to have the
opportunity to talk to all thedifferent specialists and make
an informed decision.
Dr Gavin Nimon (22:38):
So there's obviously some medical
management, the radioactivethyroid and the surgical options
as well.
How often do you seeabnormalities of structure as
well, Melissa?
Dr Melissa Bochner (22:46):
A lot, and I think one of the statistics
that I've been quoted is that50% of women over 50 have a
thyroid nodule.
So lots of people have athyroid nodule and actually the
trick for us as specialists isworking out which ones to ignore
and which ones to do somethingabout.
There is clearly a group ofpeople who have a multinodular
(23:10):
goiter and who have pressuresymptoms in the neck relating to
that.
Now, that might be a morenon-specific feeling of pressure
across the front of the neck.
Some people will complain thatthey wake up at night feeling
that they can't breathe, thatsomething's pressing on their
(23:30):
neck.
Sometimes I think that's justbecause when you're asleep and
the head goes down, the pressureeffects are worse.
Some people will complain ofdifficulty swallowing and will
say that they can feel somethingwhen they swallow, that the
food passes past an obstructionand clearly in the the
worst-case scenario, people willpresent with a stridor or
(23:53):
difficulty breathing.
Again, there is a lot of peopleout there who get a bit of a
weird sensation in their neck.
They see their GP, they have anultrasound and thyroid nodules
are seen.
So there is a significant numberof people whose thyroid nodules
are coincidental to theirsymptom and it can be difficult
(24:14):
sometimes working through that,because clearly removing the
thyroid and having someone stilltelling you that their symptom
is still there is veryunsatisfactory.
So sometimes we do need to workwith colleagues in ENT, for
example, or in gastroenterology.
Sometimes we do need to workwith colleagues in ENT, for
example, or in gastroenterology,where abnormal sensations in
the neck may be related, forexample, to reflux, esophagitis,
(24:35):
pharyngitis, sinusitis and awhole lot of other things.
So you have to really look verycarefully at the patient and
what symptom they're describingand whether you think the
nodules that they have arecausing that symptom.
I find that thyroid ultrasoundis very good for looking at the
characteristics of individualthyroid nodules.
(24:56):
It is not very good at lookingat local structures in the neck
and determining whether thethyroid is compressing them or
not.
So for me, if I think someone'stelling me that they've got an
obstructing symptom, then I willorder them a CT scan of their
neck and always include thechest in that, because sometimes
(25:17):
the thyroid in the neck is justthe tip of a thyroid iceberg
and the rest of it's inside thechest.
Dr Gavin Nimon (25:23):
And is that CT?
Is that just purely a plain CT,or do they need to have like a
barium swallow or anything likethat at all?
Dr Melissa Bochner (25:29):
I think intravenous contrast is always
good because you can sort of seewhere the vascular structures
are.
So you don't need a bariumswallow, particularly although
there are some people that youthink actually this is a
esophageal problem, not athyroid problem.
So we do order the occasionalbarium swallow for people, for
(25:49):
example, with dysmotility, whichis why it is good to have that
multidisciplinary input,including from radiology, in our
thyroid clinic.
Multinodular goiter isobviously very common around the
world.
There are a lot of countrieswhere endemic goiter occurs, and
in our multicultural societythat we have here, we have a lot
(26:09):
of patients who come from areasof endemic goiter and we see a
lot of patients withmultinodular goiter, some of
which is asymptomatic and someof which is very symptomatic.
Endemic goiter is generallycaused by iodine deficiency, and
so you will see that in peoplewho have grown up in regions
often mountains and away fromthe sea where the iodine leaches
(26:32):
out of the soil so some areasin Central Asia and Central
Africa and so some of thosepopulations seem to have more
goiter than some of the peoplewho have grown up eating an
iodine-rich diet, which includesseafood and, of course, the
iodine that's added to our food.
Dr Gavin Nimon (26:52):
There's a lot of iodine added to bread.
I understand, but is that thesame for all the local bakeries
and stuff?
Will they be adding iodine tothe bread as well?
Dr Melissa Bochner (26:59):
I think most of them would, because it's in
the salt Right and so mostpeople would, and I advise
people to cook with iodinatedsalt and that I think that some
of the thyroid problems that wesee may be related to trendy
salt, because if you bake yourown bread with trendy salt and
you don't eat any seafood andyou have a restricted diet for
(27:19):
whatever reason, then you mayactually be iodine replacement
in the diet and havingsatisfactory dietary iodine is
very important to avoidunnecessary goiter in
communities, and we know thatthe very groundbreaking work
(27:41):
done, for example, in Nepal,where iodine was added to the
diet, changed the outcome for ageneration of people there who
were living with severe iodinedeficiency up until then.
Dr Gavin Nimon (27:55):
And that leads to a hyperthyroidism type
multinodular goiter.
Dr Melissa Bochner (27:59):
Often the thyroid function is actually
normal, but the gland isenlarged.
Dr Gavin Nimon (28:03):
Okay.
Dr Melissa Bochner (28:04):
So we will see people with normal thyroid
function and very large thyroidswould be the usual situation.
Dr Gavin Nimon (28:13):
Is a goiter, the terminology used to define an
abnormality in structure of thethyroid, because you can get
hyperthyroid goiter.
Dr Melissa Bochner (28:19):
That's right .
I think goiter is a generalterm that implies enlarged
thyroid, for whatever cause.
Dr Gavin Nimon (28:24):
Right.
Dr Melissa Bochner (28:24):
Yeah.
Dr Gavin Nimon (28:25):
Okay.
So once you've assessed someonefor abnormality of structure,
you've done a ct scan.
Then I presume, assuming it'snot a correctable cause such as
like an iodine deficiency, Ipresume surgery is recommended
in that scenario if it's causingsymptoms.
Is that correct?
Dr Melissa Bochner (28:42):
that's correct.
If somebody's got obstructiveor compressive symptoms, you're
comfortable that the thyroid'scausing it, then surgery would
be recommended.
For a lot of people thatdisease is symptomatic but not
life-threatening.
So it is not unreasonable totalk to a patient and say to
them I believe your thyroidnodule is touching your trachea
(29:05):
or it's touching your esophagusand your symptoms will probably
be relieved by removing half orall of your thyroid, and talk to
them about the risks andbenefits and allow them to make
the decision.
And they may not wish to makethat decision very quickly and
we have people coming back toour clinic over and over again
over many years.
The goiter slowly enlarges andat some point they may decide to
(29:27):
do it.
The situation where we feelthat surgery needs to be
strongly recommended, of course,is when the trachea is narrowed
.
Most of the time that occurs ina retrosternal goiter because,
understandably, if the thyroidenlarges in the neck it will
tend to enlarge anteriorly andit'll be visually obvious but
(29:50):
perhaps not symptomatic ascompared to the thyroid that
goes down into the chest.
It's got nowhere to go andthose are the ones that can
cause very significant and quitefrightening tracheal narrowing.
Dr Gavin Nimon (30:05):
Right, because, as I understand, the thyroid is
not really well encapsulated.
Dr Melissa Bochner (30:09):
It has a very loose capsule over the
front but when it enlarges itgoes down the path of least
resistance and it will push theother structures out of the way,
you know, unless it's amalignant thyroid.
So you'll find that a patientwill have a lot of disease in
their chest, their carotidartery, jugular veins will be
(30:30):
pushed to the side.
So they're close, but notparticularly in a lot of danger.
But going back to the clinicalexamination, of course the
Pemberton sign is the one whereyou ask the patient to put up
their arms above their head andtheir face goes blue.
That's venous obstruction fromthe thyroid, often intrathoracic
(30:52):
, and patients may come andcomplain of that symptom.
When I go to hang out thewashing, my face goes blue, I
feel faint, I can't keep going.
So those people need surgeryand we, you know, particularly
if someone's got significantairway narrowing where the
tracheal calibre can be down tofour millimetres or so, then
they have to do something.
Dr Gavin Nimon (31:14):
And, of course, surgery, as you mentioned, has
got risk with the recurrentlaryngeal nerve.
There's obviously a few otherstructures around the area that
are at risk as well.
Dr Melissa Bochner (31:21):
The main risks of thyroid surgery in the
immediate period time will bebleeding.
The thyroid is very vascular.
In graves it can be amazinglyvascular and coupled with the
venous obstruction that you getin very large thyroids, then
(31:45):
every tiny blood vessel that youtouch can just bleed, even
small ones.
So there is a risk of bleed,even small ones.
So there is a risk of bleedingintraoperatively and
postoperatively and patientsneed to be managed by
experienced nursing staffimmediately postoperatively.
For that reason there is a riskto the recurrent laryngeal
(32:06):
nerve, one on each side the riskof permanent damage to that we
would normally quote at onepercent.
But at least five percent ofpeople have a voice change after
thyroid surgery, which improves.
And then, of course, there areour friends that we haven't
spoken about already theparathyroid glands.
The parathyroids unlike thethyroid, which I said, if it
(32:29):
disappeared, you probablywouldn't die if your
parathyroids unlike the thyroid,which I said, if it disappeared
you probably wouldn't die.
If your parathyroid'sdisappeared now, you'd probably
die in about 10 minutes, maybe abit longer, because you need
your parathyroids to controlyour serum calcium.
So parathyroid preservation isreally, really important and
(32:50):
they're often very close to thethyroid.
They're very easy to injure orto remove inadvertently because
they're very small and theyoften share a blood supply, so
we do worry about causingpermanent hypoparathyroidism in
somebody having thyroid surgery.
It's a very annoyingcomplication for the patient to
(33:13):
have to have because they needto be on a lifelong calcium and
calcitriol replacement and theywill get symptomatic if they
can't take it.
Dr Gavin Nimon (33:22):
Right and through an anterior approach.
You mentioned before a cut inthe neck.
Dr Melissa Bochner (33:28):
Usually all large thyroids will be done
through a cut in the neck.
Usually all large thyroids willbe done through a cut in the
neck.
Sometimes for the massivethyroids we've had to ask our
cardiothoracic friends to comeand do a sternotomy as well.
Not common and there is alittle bit of a trend which
hasn't taken off particularlywell, particularly in Australia,
(33:48):
for a minimally invasiveapproach to the thyroidectomy
through the mouth, and somepeople overseas are doing them
robotically through the axillaor other remote approaches in
order to try and avoid theincision on the neck which some
people will find cosmeticallyunacceptable.
(34:10):
Countries like Korea havereally pioneered the transoral
and robotic thyroidectomy toavoid the neck incision.
Dr Gavin Nimon (34:18):
So obviously these are for the structural but
benign conditions, butobviously malignancy is also an
issue too.
What are the main types ofmalignancies you do see, and how
common are they in thyroid?
Are they something I need to beaware of, being an orthopedic
surgeon and doing a lot of imageintensifier in theatre?
Dr Melissa Bochner (34:33):
Certainly If you haven't been wearing your
thyroid shield.
Thyroid cancer is interestingand it's certainly increasing
worldwide and there's some kindof thyroid cancer epidemic which
we're not sure why.
It is possibly or almostcertainly due to increased
(34:55):
detection because of many peoplehaving more neck imaging for
these non-specific neck symptomsthat they get.
So there is more thyroidmalignancy around and the issue
again for us with thyroidmalignancy around and the issue
again for us with thyroidmalignancy is trying to diagnose
it accurately, differentiatingit from non-malignant nodules
(35:18):
and making the correct treatmentrecommendation.
Because I suppose that it'scounterintuitive for a lot of
patients that if you say tosomebody, well, you've got a 10
millimeter thyroid cancer and itdoesn't matter, that doesn't
sound right to them because mostother cancers it matters,
whereas thyroid cancer may notbe life-threatening except for
(35:40):
over a very long period of time,and so it is a disease where we
worry a lot aboutover-diagnosis and
over-treatment and it'sdifficult to choose which
procedure to do on which person.
So if we see a patient with asolitary thyroid nodule, there
is a lot of effort made intotrying to work out.
(36:02):
Am I worried about that nodule?
Is that something that I needto biopsy?
Is it something I need toremove, or is it something that
I need to follow up, or is itsomething that I can reassure
the patient and let them go?
Having said that, lots ofpeople have got solitary nodules
and there are lots of causesfor having a solitary nodule,
which would include a dominantnodule within a multinodular
(36:25):
goiter, what's called a colloidnodule, so just an overactive or
hyperplastic nodule or a benigntumour like an adenoma.
And then some people will have athyroid cyst, a benign cyst.
So there are quite a lot ofnodules that people have and
they will come into the thyroidclinic and we have to try and
work out what to do about them.
There are, I suppose, twodifferent ways of classifying
(36:50):
thyroid nodules and trying toget a bit closer to a diagnosis.
One of them is using ultrasoundcharacterization.
There's a system called TYRADS,which is a radiology
classification which tries tostratify nodules into a risk of
them being malignant andtherefore the need for those
(37:11):
nodules to have a needle biopsy.
So TyRADS has five differentcomponents that can be assessed
on ultrasound and they all getgiven a score and then you add
up the score and you end up witha TyRADS classification of a
nodule, and there are five ofthose.
(37:34):
So, someone will come into theclinic and will say this lady
had a funny feeling in her neckand we've done a thyroid
ultrasound and she's got atirads 3 nodule.
Thanks for looking after her.
And one of the problems withthe tirad system which I think
is a bit of a flaw is that theway that they're categorized can
(37:57):
be frightening for the GP andfor the patient.
So a TIRADS 1 nodule is benignand a TIRADS 5 nodule is highly
suspicious, but the one that Ijust mentioned, tirads 3, which
is almost certainly fine, forsome reason they decided to call
that mildly suspicious on theclassification Right.
Dr Gavin Nimon (38:15):
okay.
Dr Melissa Bochner (38:17):
So GPs will say got a woman with a
suspicious thyroid nodule, whichis correct because it's called
mildly suspicious, because whattirads hasn't helped them to do
is understand how many of thoseare actually cancers and most of
them are not.
So tirads can sometimes be aproblem for us and our patients
(38:38):
just because of the way they'vedecided to name it, and we need
to be a little bit careful aboutthe way that we speak to people
and what we call someone'snodule that we're suggesting
that they don't have anythingdone to, including not even
biopsied.
The thing about tirads is itdoes try to stratify management
of thyroid nodules.
(38:59):
So it looks at thecharacteristics of the nodule
under ultrasound, which mightinclude something like the
composition Is it solid, is itcystic, does it have
calcifications in it, does ithave a regular border, for
example.
But it also looks at the sizeof the nodule.
And that's when we come back tobeing a little bit
counterintuitive, because youmay have a nodule which ticks
all the boxes for looking like acancer, but because it's very
(39:21):
small, they might say this doesnot need a biopsy, even though
it has some suspicious features.
On the flip side, some largernodules that look benign will be
called more suspicious or needmore investigation because of
their size.
So tirades can be a trickysystem to work and there is an
(39:45):
app.
You know everything's got anapp.
You can download the app onyour phone.
I quite like redoing the tiradeswhen I see a patient.
I look at the nodule myself andreclassify it, and sometimes I
agree with the radiologist andsometimes I don't, because there
is quite a lot of variabilityin the way you might choose to
(40:06):
interpret some of the ultrasoundfeatures.
Most particularly, papillarythyroid cancer may have micro
calcifications in the nodule.
So calcifications, especiallytiny little punctate ones in a
thyroid nodule, can be quitesuspicious.
However, there is an ultrasoundappearance called comet tails
(40:26):
which is associated withsometimes with the appearance of
colloid within a nodule, whichis benign, but sometimes those
comet tails look likecalcifications, and so probably
the major cause of disagreementabout the thyroid classification
of a nodule is what you think.
The little echogenic foci arewithin the thyroid nodule and
(40:47):
different people have differentopinions on that particular
scoring point.
Dr Gavin Nimon (40:51):
So, for the intern or the GP or the thyroid
classifications, what do theyneed to know?
They need to know, basically,the ultrasound will help guide
them and then refer them to abreast endocrine surgeon, or
they need to know more detailabout that.
Dr Melissa Bochner (41:05):
I think that they need to just read the
report really carefully and ifit says a Tyrad's 3 nodule, as
per the guidelines, this noduleis 30 millimetres in size and
FNA is recommended.
I'm happy with all of that.
Or a Tyrad's 3 nodule this is 5millimetres in size, suggests
an ultrasound in 12 months.
(41:26):
I'm happy with that too.
I don't mind it.
What I mind is the fact thatit's called mildly suspicious,
because that frightens everybody.
So my point really is that mostthyroid nodules aren't cancer
and don't get upset when you seethat word suspicious,
particularly if it's a Tyrad's 3or 4.
We're happy to see them, butpeople arrive quite upset.
(41:50):
My doctor told me I've gotthyroid cancer.
Oh, hang on a minute.
You know, let's just clear thatup for a minute because usually
they don't.
So it's really it's acommunication practice point
rather than anything else.
Absolutely most of our needlebiopsies are done under
(42:23):
ultrasound.
Back in the olden days we usedto do them freehand, but of
course now we've all gotultrasound, so they're done
under ultrasound.
And again, I think that overthe last what 10 to years we've
had an improvement in ourstratification of cytology on
thyroid nodules and so again, ifyou send a patient for a needle
biopsy of their thyroid nodule,then you will come back with
(42:46):
what's called a Bethesdacategory on that nodule and that
Bethesda category willcorrelate with a risk of
malignancy.
So in fact there are sixBethesda categories and we about
a long time ago now, maybe 10years ago, when Bethesda had
been around for a while, welooked at our own cohort of
(43:09):
patients at the Royal Adelaidewho'd had a Bethesda category on
their needle biopsy and thenwent on to have thyroid surgery.
So we could correlate theBethesda category with the final
pathology and the categoriesmatched up pretty well with
international standards.
(43:29):
So we know that if someone tellsyou that your nodule is a
Bethesda 2, which is benign,then there is a 4% chance that
that's a cancer.
If someone tells you that yourBethesda category is 3, then
that's atypia, so there's a 15%chance it's a cancer.
A four is 25 to 30% chance ofcancer.
(43:53):
Fives and sixes are pretty highrisk of being cancer, but
neither of them is 100%.
And when we're talking aboutthat, clearly we're talking more
about papillary thyroid cancerthan the other subtypes, because
papillary thyroid cancer iseasier to diagnose on a needle
(44:15):
biopsy than the other types.
And I know you're going to askme what are the types of thyroid
cancer, because we didn't seethat before.
Dr Gavin Nimon (44:22):
yeah, well, perhaps we can go through those,
yeah that's right.
Dr Melissa Bochner (44:25):
Papillary thyroid cancer is the most
common by far, and we see thatin all age groups and certainly
we do see that in our children.
Then there is follicularthyroid cancer, which is the
next most common, and that wouldbe the two that we see most of.
Medullary thyroid cancer that Imentioned briefly earlier is a
cancer of the c-cells of thethyroid.
(44:46):
It's not a true thyroid cancerper se, although obviously only
occurs in the thyroid.
It's very, very rare, but we dosee it in people with a genetic
condition, men2.
And so people who are born withthat genetic condition may need
prophylactic thyroidectomy whenthey're children.
And then other rare subtypes,including anaplastic, which
tends to be a fatal disease ofolder people.
(45:09):
So papillary and follicular arethe two most common, and they
would be the ones that we'd bethinking about when doing a
needle biopsy of the thyroid.
Again, if you have a patientwho's got a Bethesda category of
four, five or six, the risk ofmalignancy is felt to be high
(45:31):
enough to warrant diagnostichemothyroidectomy.
At least If the Bethesdacategory is three, where we're
sitting at about 15% malignancy,then it's worth redoing the
needle biopsy after a period oftime, just in case the cellular
atypia is, for a reason, not dueto an intrinsic problem with
(45:52):
the thyroid.
Obviously, if you do a needlebiopsy, sometimes you can make
the cells abnormal by crushingthem when you do the smear, or
abnormalities with the fixation.
So we will tend to repeat aBethesda 3.
A Bethesda 2, we will normallyaccept as being benign but might
wish to follow it up.
And obviously in our serieswhere we had 116 patients having
(46:15):
removal of Bethesda 2 nodules,most of those were because they
were symptomatic, not because wewere worried about them being
cancer.
So a small Bethesda 2, you canprobably reassure that patient.
So we like the Bethesda system.
It's clear If you think aboutit from a patient's point of
view, of course.
Having said that, if you've gota Bethesda 4, maybe it's 30%
risk of malignancy.
(46:35):
So we're now talking about agroup of people who may be
asymptomatic.
They've had a thyroid nodulepicked up for many of the
reasons we pick up thyroidnodules these days Ultrasound
done for another reason, ct donefor another reason, pet scan
done for another reason.
They've now another reason petscan done for another reason.
They've now got a bethesda 4nodule.
We're telling them they need adiagnostic hemothyroidectomy.
(46:58):
So we know, that maybe 60percent of those people 60 to 70
percent of those people don'thave thyroid cancer.
Maybe they've got a follicularadenoma and it's worth taking
that out because that willprobably grow and it may have
malignant potential.
But there's still a significantnumber of diagnostic
(47:18):
hemothyroidic tomies being donethat you'd like to think you
wouldn't have to do if you had abetter diagnostic tool for
thyroid cancer.
So that's one of the holygrails of thyroid diagnosis
really is having a more accuratepreoperative thyroid
histopathology diagnosis, andwe're not there yet.
Dr Gavin Nimon (47:38):
Well, listening to this, you've got a
classification system based onultrasound to decide whether you
observe it or do an aspirationor final aspirate.
Then you've got aclassification system based upon
that final aspirate and thenyou've got a classification
system based upon the actualhemithyroideectomy and the
actual cytology of their cells.
They're three different typesof classification systems.
(47:58):
Would the artificialintelligence and AI help combine
those three to actually helpwith that Holy Grail?
Dr Melissa Bochner (48:04):
I've never seen an AI that was able to
combine tirads and Bethesda, butI think that would be great,
and what we need is somebodywith a massive series to be able
to do that, because I think youneed a lot of numbers.
So if you said it was a Tyradsomething and a Bethesda
something else, then maybe thatwould be good.
There are some diagnostic teststhat are available in the
(48:26):
United States looking at tumormolecules and cancer markers and
a few more nuanced thingswithin the cells in the needle
biopsy.
At the moment they're not superaccurate either and they are
super expensive and they're onlyavailable in the States and
(48:46):
you've got to send them away andpeople don't really want to
spend $3,000 on their thyroidFNA either.
So I think there is movement inthat space, but we're just
waiting for a good test tobecome available One of the
things about thyroid cancer isthat thyroid cancer cells are
often very well differentiated,which is good, you know.
they're less aggressive cancerswith a very good prognosis.
(49:08):
But it makes the job of acytopathologist very, very
difficult to tell the differencebetween a benign and a
malignant thyroid cell on aneedle biopsy.
Very big thyroids you canimagine that you can do a core
biopsy on and that can happen.
But it's a bit of tiger countryin the neck Throwing a core
into the neck with all thestructures and the thyroid is
(49:29):
quite vascular so you canoccasionally do it but it's very
uncommon to be able to get anactual piece of tissue out of
the thyroid.
Dr Gavin Nimon (49:38):
Thinking about cancers in general.
I know in breast cancer youoften do a lymph node clearance
to assess actually a risk ofmetastases.
Is that done in thyroid surgeryas well?
And also, what adjuvanttreatment do you use after
thyroid surgery as well in thatscenario?
Dr Melissa Bochner (49:52):
So I think if you know that you're
operating on someone withthyroid cancer because you're
almost sure they've got abethesda five or six, they've
got characteristic ultrasoundfindings etc then yes, you might
do a prophylactic central neckdissection, which is really
those lymph nodes that sit infront of the trachea, just below
the thyroid.
(50:13):
That's called level six orlevel seven.
You can get, you know, half adozen lymph nodes from that area
.
The risk of doing thatadditional little bit of lymph
node surgery is that it's oftenthe area where the lower
parathyroid sits.
So you do risk removing aparathyroid inadvertently.
And to do a proper level sixnode dissection you actually
(50:35):
have to dissect down therecurrent laryngeal nerve and
then remove all of the tissue inbetween the nerve and the
trachea, including in front ofthe trachea.
So there is a slightlyincreased risk of damaging the
nerve while you're trying toprotect it.
Interestingly, the mortalityfor thyroid cancer is not
(50:56):
particularly altered by thepresence of nodal disease.
So it's not like the cancersthat we worry about colon cancer
, breast cancer where you needto know how many nodes are
involved and you need to get ridof them.
Your nodes are involved and youneed to get rid of them.
People with positive nodes,particularly for papillary
thyroid cancer, will end up withmore local regional disease and
(51:19):
may end up having moreprocedures, but they're probably
not more likely to die.
So we are more cautious inremoving normal lymph nodes in
people with thyroid disease.
You would not do a routine neckdissection for node negative
disease, except for the unusualcircumstance of medullary, which
is different, but the papillaryand the follicular you wouldn't
(51:42):
do it.
Having said that, there will besome people who will present
with a lot of lateral nodedisease and therapeutic node
dissection for known positivedisease is the correct thing to
do.
So some of the children that Itreat actually present with a
lot of nodal disease in the neckand so I would generally do a
(52:04):
total thoracotomy and neckdissection for them, and I work
quite closely with head and neckcolleagues at the Children's
Hospital on those procedures.
So adjuvant treatment.
Going back to that, one of thethings, of course, is what we're
saying is that thyroid cancergenerally has a pretty good
prognosis.
So again, you don't want tooverdo it.
So back when I was training,which was a long time ago,
(52:25):
everyone with thyroid cancer hada total thyroidectomy and then
they had radioactive iodine andsuppressive thyroxine dose to
suppress the TSH down low, it'sbecome clear that not everybody
needs all of those treatments.
So, there will be a group ofpeople with a
well-differentiated papillary orfollicular cancer which is not
(52:46):
super big.
It's sitting in the middle ofthe thyroid, there's nothing
else that looks abnormal.
You can treat them with ahemothyroidectomy and
observation.
The people with the increasedrisk of disease may need a total
thyroidectomy and radioactiveiodine and clearly sometimes
you'll do a hemithyroidectomyfor a nodule that you're not
sure what it is.
You'll find out that it's acancer.
(53:09):
You'll decide to giveradioiodine and then you need to
go back and do a completionthyroidectomy for the other side
.
Because if we think about howradioactive iodine works, it's a
radioactively labeled iodinemolecule which is taken up into
functioning thyroid cells, ofwhich we know that cancer is
part of.
(53:29):
But if you've got normalthyroid tissue in your neck,
then that will take it uppreferentially and you'll be
treating the normal thyroid, notany potential residual disease.
So radioactive iodine inprinciple is only given to
people that have had a totalthyroidectomy.
So I think the modern timeswe're doing a lot more
(53:50):
hemothyroidectomy, observationrather than the total
thyroidectomy for thyroid cancerwell, we've covered a fair bit.
Dr Gavin Nimon (53:55):
Where do you think thyroid treatment's going
in the future?
Dr Melissa Bochner (53:58):
I mean what are the sort of forefronts of?
Dr Gavin Nimon (54:00):
research where things heading in the next 20
years.
Dr Melissa Bochner (54:03):
They say yeah, I think that, um, there's
a few different areas.
One of them is, as I've said,in the diagnosis.
I think it would be really niceto be able to rule out.
You know a bunch of peoplehaving purely diagnostic thyroid
surgery when they've got nosymptoms and you really think
that it's too much for them.
So improvements in thyroidnodule diagnosis would be great.
(54:26):
And then I know we spoke earlierabout biologicals for treatment
of thyroid disease and clearlythere are some biologicals that
are used for treatment ofmetastatic thyroid cancer or
inoperable thyroid cancer,because, unlike a lot of
oncology, really thyroid diseasehas maintained the realm of the
surgeon and there are not manymedical treatments for thyroid
(54:51):
disease and some of thetreatments that we do give to
people with metastatic diseaseare quite toxic and poorly
tolerated and may not work verywell.
So finding a good medicaloncology agent for people the
rare group of people withadvanced disease locally
advanced or metastatic diseaseis going to be really important
(55:11):
as well, and thyroid disease isa long way behind some of our
other diseases at the moment formedical oncology treatments.
Dr Gavin Nimon (55:19):
Right.
Well, it's been fantastichearing about these conditions.
There's so many different areasof it.
Appreciate you coming on boardand thank you very much, Melissa
.
I really appreciate your effortand thanks a lot for coming on
Aussie Med Ed.
Dr Melissa Bochner (55:30):
Thank you, gavin, it's been really great
talking to you.
I've enjoyed it.
Dr Gavin Nimon (55:33):
I'd like to remind you that the information
provided today is just onemedical opinion, and this may
vary depending on the region inwhich you're studying,
practising or being treated.
If you've enjoyed the podcast,please subscribe to the podcast
for the next episode.
Until then, please stay safeand we'll see you again for our
next episode.
The thyroid gland, while diminutive in size,
is formidable in its impact.
I like to think of it as almostlike a fuel injection of the
car.
The actual fuel mix determineshow fast the car idles at, and
that's what the thyroid seems todo.
It synthesises thyroxine and T3hormones.
That's intramedible inregulating metabolic rate, heart
function, digestive health,muscle control, brain
(00:21):
development and bone maintenance.
It also produces calcitonin.
Well, today we're going tolearn more about it, but with Dr
Melissa Bochner, head of Breastand Endocrine Unit at the Royal
Adelaide Hospital.
G'day and welcome to Aussie MedEd, the podcast with a pragmatic
approach to medical conditions.
I'm Gavin Nimon, orthopaedicsurgeon based in Adelaide, and
I'm broadcasting from Kaurnaland.
I'd like to start the podcastby acknowledging the traditional
(00:43):
custodians of the land on whichthis podcast is produced, the
Kaurna people, and I'd like topay my respects to the elders,
both past, present and emerging.
It's my pleasure now tointroduce Dr Melissa Bochner, a
breast endocrine surgeon, who'sgoing to talk to me about
thyroid disorders.
I'm really pleased to be joinedby Melissa.
She's the head of the breast andendocrine surgery unit at the
Royal Adelaide Hospital.
She trained in general surgeryat the Royal North Shore
(01:04):
Hospital in Sydney, thenspecialised in breast and
endocrine surgery, withfellowships at the Royal
Adelaide Hospital and EdinburghBreast Unit.
Melissa has a research master'sof surgery from the University
of Sydney as well as working atthe Royal Adelaide Hospital and
provides a surgical service forbreast and thyroid diseases at
the Children's Hospital.
She's going to talk to us aboutthyroid diseases in general.
She's going to talk to us aboutthyroid diseases in general.
Welcome, melissa.
Thank you very much for joiningus on Aussie Med Ed.
Dr Melissa Bochner (01:26):
Thank you so much, Gavin.
Thank you for inviting me.
Dr Gavin Nimon (01:29):
Well, it's brilliant to have you on board.
It's quite an crucial organ,the thyroid, and I'd like to
hear more about it today, so I'mreally looking forward to it.
Perhaps we can start off byfirst of all just explaining
what the thyroid does and itsfree function.
I know there's a lot more wecan go into we could spend hours
on it, but just as a briefoverview, what does the thyroid
actually do?
Dr Melissa Bochner (01:48):
The thyroid is very complex, of course, in
its mechanisms becauseessentially it does release the
hormones that you've mentionedT4 and T3, and they have
multiple metabolic effectsthroughout the whole body.
So when I'm talking to apatient I might say to them that
really the thyroid controlsyour energy hormones and your
(02:10):
metabolism hormones.
So in fact, if your thyroiddisappeared tomorrow, you
wouldn't die, but you would getpretty sick and you wouldn't be
able to function properly.
So sometimes it's easier todescribe thyroid function in
terms of the effects that itmight have if you had too much
of it or too little of it.
And, for example, people thathave an overactive thyroid,
(02:33):
where they're making too muchthyroid hormone.
They may be anxious, they won'tbe able to sleep, they may lose
weight, they may have diarrhea,they may have a rapid heart
rate weight, they may havediarrhea, they may have a rapid
heart rate.
People who have too littlethyroid hormone will have the
opposite, so they might feeltired, they might feel depressed
, they may gain weight.
(02:54):
So sometimes the symptoms ofthyroid disease can mimic other
diseases and sometimes they canbe nonspecific and sometimes
they can be difficult to pick upwithout doing the thyroid blood
test.
It's particularly interesting,I think, when you're looking at,
for example, the elderly.
I saw an older man recentlywho'd been admitted under
(03:15):
cardiology with rapid AF veryhard to control.
They knew he had a goit.
Of course this man wassignificantly hyperthyroid and
hyperthyroidism can tip theelderly particularly into
tachycardias, svt and atrialfibrillation.
Dr Gavin Nimon (03:30):
Right.
So is it purely disorders ofthyroid, is it purely actually
metabolic disorders as well, oris it can present in other ways
as well?
Dr Melissa Bochner (03:39):
So I think one of the disclaimers here and
obviously you've mentioned it isthat I'm a surgeon and so I'm
particularly interested in thediseases that are referred to me
.
There will be a slightlydifferent cross-section of
diseases that GPs might see orthat endocrinologists might
manage on their own.
But for surgeons, of course, wewill see what we've already
spoken about patients withabnormalities of function.
(04:01):
We will see patients withabnormalities of structure, and
by that I mean an enlargedthyroid causing local symptoms,
usually due to pressure in theneck there's obviously not a lot
of room in the neck.
And then, of course, we willsee people who do not
necessarily have a symptom fromtheir thyroid but who have a
(04:22):
nodule which may be suspiciousfor malignancy.
They're the three main areasthat we would see in our clinic.
Dr Gavin Nimon (04:28):
Yes, you mentioned hypo and hyperthyroid.
Are they the two main disordersthat occur in the function
level, or can you actually getabnormalities of function with
also normal levels of thyroidlevels in the blood?
Dr Melissa Bochner (04:39):
Usually you will divide it up into hyper and
hypo.
We can see people with otherdiseases, the sick u thyroid,
for example, that GPs are wellaware of and that don't end up
with a surgeon.
But most people are either overor under and that will be easy
really to determine on a thyroidfunction test, on a blood test.
(05:00):
As I mentioned before, theremay be some people who have a
normal T4 and T3, but asuppressed TSH, so they will be
subclinical hyperthyroidism.
But those people, particularlythe elderly, may still have some
symptoms from that.
So they would be the two reallyunder or over.
Dr Gavin Nimon (05:21):
So start off with, say, hypothyroidism, which
a lot of people always worryabout, particularly if they're
carrying a little bit of extraweight and they think there
might be a hypothyroid disorder.
What are the main causes ofhypothyroidism and how common is
that?
Dr Melissa Bochner (05:34):
Obviously, from my point of view, the
patients that I see in my clinicwho have been diagnosed with
hypothyroidism most of them havean autoimmune condition
Hashimoto's, thyroiditis,hypothyroidism Most of them have
an autoimmune conditionHashimoto's, thyroiditis.
Hashimoto's is extremely common, particularly in older women,
and again it may be subclinical.
So sometimes when we'reremoving the thyroid we will
(05:55):
note that it is unduly inflamed,that the operation is somewhat
difficult, but those people willhave normal thyroid function.
But in some people it willprogress to thyroid gland
destruction and that is the mostcommon cause of hypothyroidism,
particularly as you get older.
Clearly that is a disease whichmay sneak up on a person and so
(06:20):
somebody might say it becomesparticularly severe because it's
obviously easy to treat.
Hashimoto's does not requiresurgery most of the time and for
the vast majority of people thegland tends to atrophy and it
isn't particularly big.
The other thing worth talkingabout because I do treat
children and clearly one of thescreening tests for newborn
(06:46):
babies is a thyroid functiontest, because there is a very
small group of people who can beborn with congenital
hypothyroidism, either due tothe gland not being there at all
or not forming properly, orsomething wrong with the way
that the thyroid hormone is madewithin the gland and, of course
(07:06):
, congenital hypothyroidism isagain treatable and a very
important thing to do to preventall of the terrible long-term
effects in neurologicaldevelopment, in particular in
undiagnosed babies.
Dr Gavin Nimon (07:20):
Right.
So you've got hypothyroidismrelated to an autoimmune
disorder called Hashimoto'sdisease.
Slow, insidious onset withsubclinical levels of thyroid
causing low metabolic rates.
You've got a congenital cause.
Are there any other causes ofhyperthyroidism that need to be
considered too?
I presume there must be somepituitary axis issues as well
that can cause it.
Is there or?
Dr Melissa Bochner (07:40):
I think that's right is that,
understandably, the TSH releasedby the pituitary is the driver
of thyroid hormone release andmanufacture, and so, yes, there
is a continuous feedback loopbetween the thyroid function and
the pituitary function.
Because I'm a thyroid surgeon,it's extremely unusual for me to
(08:04):
see anybody with primarypituitary failure, and it is a
much less common cause ofhypothyroidism and, clearly,
again, pretty easy to diagnose.
If you see a patient and theyhave a low TSH and then you do
T3 and T4 and they're low aswell, then you do need to
consider a pituitary cause, butit's much, much less common.
Dr Gavin Nimon (08:26):
All right.
Any other causes of insidiousonset apart from the autoimmune
Hashimoto's, then, or is anythat's really the main cause?
Dr Melissa Bochner (08:34):
I think that would be the main cause.
The other one that you know,obviously, that we do to people
is iatrogenic.
So of course you can seesomeone who's had a
hemithyroidectomy for astructural or diagnostic reason
and then you may expect that theother half of their thyroid
will continue to functionnormally and should compensate
(08:56):
and step up to function normally, but it doesn't always do that.
So certainly for patients whohave had hemithyroidectomy, we
would routinely check thyroidfunction at about three months,
because a significant number ofthem do become hypothyroid after
surgery.
Dr Gavin Nimon (09:09):
And in that scenario, either both the
atrogenic in that scenario orHashimoto's, with replacement of
thyroid hormone.
Are there any other hormonesthat need to be replaced as well
, that we need to consider,because obviously the thyroid is
more than just purely producedthyroxine?
Is there issues with calcitonin, too, that need to be replaced?
Dr Melissa Bochner (09:25):
No, it's really interesting that
calcitonin is produced by thethyroid and only by the thyroid,
but there appear to be noclinical consequences of
removing the thyroid in terms ofcalcitonin.
Dr Gavin Nimon (09:42):
Right.
Dr Melissa Bochner (09:43):
And the only people that you ever see with
an elevated calcitonin, ofcourse, are those with medullary
thyroid cancer.
The medullary thyroid cancersalmost always secrete calcitonin
, and people with metastaticmedullary thyroid cancer, which
can cause symptoms, but theabsence of the thyroid does not
cause any kind of problems withcalcitonin.
Dr Gavin Nimon (10:05):
Right, excellent , okay, melissa.
Can you get paraneoplasticsyndromes causing
hyperthyroidism or producingother hormones as well, such as
calcitonin?
Dr Melissa Bochner (10:14):
You don't normally see ectopic thyroid
hormone replacement, althoughyou can see it occasionally with
metastatic follicular thyroidcancer which can be extremely
well differentiated and canproduce its own thyroid hormone.
It's not common.
I've had patients with itwho've had total thyroidectomy
(10:35):
for metastatic thyroid cancer.
They've done very well.
They've got known metastaticdisease.
They've been quite asymptomaticfrom it and have required very
little thyroxine replacementbecause their metastasis appears
to be making it.
So yes, it happens, but itisn't common.
Dr Gavin Nimon (10:52):
Okay, no worries .
So if we move on to thehyperfunction of thyroid disease
, hyperthyroidism, I believeGraves, is probably the most
common cause and that's anotherautoimmune disorder.
Is that correct?
Dr Melissa Bochner (11:03):
Yes, I think that's right, and I like to
think of Graves and Hashimoto'sas being a sort of a spectrum of
autoimmune thyroid diseases.
Graves, of course, is anassociation of symptoms which
includes hyperthyroidism, butalso the eye disease that we're
familiar with and some othersoft tissue depositions which
(11:25):
appears to be related to acirculating protein.
The mechanism of some of thosethings is still not completely
understood, but traditionallyGraves is a spectrum of symptoms
involving more than just thethyroid.
People with Graves disease willbe hyperthyroid and the disease
will affect the whole thyroid,which differentiates it from the
(11:48):
other two causes.
I know we like to talk aboutthings in threes.
So we've got Graves' disease,we've got toxic multinodular
goiter is not uncommon and thenthe third major cause of
overactive thyroid is a toxicnodule, which is often a
solitary toxic nodule.
Dr Gavin Nimon (12:06):
Brilliant.
So there's another group ofthrees we can think of
hypothyroidism with If we goback to the graves.
Actually, one of the commentsyou made just then which
actually just threw me, becauseI always thought the actual
ocular proptosis that occurswith the graves disease was
associated with the thyroidhypothyroidism, but you've
implied that it actually is aparaprotein that causes it and
actually separate to thehypothyroidism the cause and
(12:28):
actually separate to thehypothyroidism.
Dr Melissa Bochner (12:28):
It's part of the Graves.
So if you've that's right ifyou've got eye disease, then you
have Graves, you don't havetoxic goiter and you don't have
a toxic nodule and you're notover replaced with thyroxine
usually yes, and that's why oneof the interesting things about
the treatment of Graves disease,because obviously there are
medical treatments for Gravesdisease but if you remove the
thyroid, then you are alsoremoving the source of perhaps
(12:52):
the abnormal antibody in theprotein and that may improve the
eye disease.
So one of the indications forsurgery in Graves' disease in
fact is significant eye disease.
Dr Gavin Nimon (13:02):
Moving on to the treatments of those three
conditions, then you'vementioned surgery.
A question that comes to mindfirst of all actually is, when
you talk about autoimmunedisorders both for Hashimoto's
and Graves use of biologicagents for treating autoimmune
disorders.
Is that one of the medicalmanagements for these conditions
as well?
Dr Melissa Bochner (13:17):
No, we would not use biological agent for
treatment, but it does bring meto our old friend, yatrogenic,
again as causes ofhyperthyroidism.
So a little bit of a fourthcause that we need to think
about.
Amiodarone, of course, has beenlong known to cause
hyperthyroidism, which isdifficult to treat, and one of
(13:40):
the other diseases that I treat,as you would be aware through
my practice at the RoyalAdelaide, is breast cancer.
There's been a big change insome of the treatments for
breast cancer lately, includingthe use of immunotherapy for
women with triple negativebreast cancer, and the drug that
our patients get is calledpembrolizumab.
Pembrolizumab has a lot ofautoimmune side effects and our
(14:04):
patients will frequently developthyroid disease as part of
their breast cancer treatment.
So I think that one of thethings that treating doctors
need to be aware now is thatcertainly some of our
immunotherapies can actuallycause thyroid disease.
Dr Gavin Nimon (14:23):
Right.
Is that a hypo orhyperthyroidism?
Dr Melissa Bochner (14:26):
Either.
So certainly when we're comingaround to operate on these
people, you know, becausethey'll complete their
neoadjuvant chemo and then we'regetting them worked up for
surgery and we need to be verycareful to make sure that their
thyroid function is normal, aswell as adrenal function, with
those drugs.
Dr Gavin Nimon (14:42):
Right.
So we've got hyperthyroidism,which can be treated medically
with replacement or with surgeryto excise the thyroid.
You've got hyperthyroidismthat's similar, with some
medical treatment and surgery inthat scenario, and that
includes the toxic multinodulargoiter as well as the toxic
nodule.
Dr Melissa Bochner (14:59):
I think that the thing that you know,
because we will be sent patientswith hyperthyroidism for
treatment and I think,surgically, it is important for
us to understand the cause ofthe hyperthyroidism because we
need to know how much of thethyroid to remove to try and
cure the person.
So if we go back to theetiology, we actually want to
(15:19):
know which of those diseases itis.
We will be happy that theperson is hyperthyroid, based on
pretty standard blood tests,which is the suppressed TSH and
the elevated T4 and or T3.
Clearly again, when you'relooking at blood tests, you
sometimes see someone with anormal T4 who has an elevated T3
(15:42):
.
So they may have purely T3thyrotoxicosis, which can be
tricky when you're orderingthyroid function tests.
If you don't put T3 in there,the lab won't do it and then
you'll have to come back andorder it again.
So yes, we can say, okay, you'vegot hyperthyroidism.
We're not sure why.
You can order thyroidantibodies, which are often
(16:02):
elevated in people withautoimmune thyroid disease.
So people who are hypothyroidwith Hashimoto's will have an
elevated autoantibodies.
People with hyperthyroidism mayhave elevated TSH receptor
antibodies and that may be worthmeasuring.
But the most important thing Ithink for people that are
hyperthyroid is to have anuclear medicine scan so that we
(16:24):
know which part of the thyroidis abnormal, so that, for
example, with Graves' disease,the whole thyroid will light up
on nuclear medicine and youcan't cure them unless you take
out the whole thyroid, whereaswith a toxic goiter they may
have a more patchy uptake or adominant hyperthyroid nodule or
(16:45):
collection of nodules, and forpeople with a toxic solitary
nodule, then clearly they have asingle focus for their
hyperthyroidism and you onlyneed to do a hemothyroidectomy
under those circumstances.
So as surgeons we like to knowexactly which bit of the thyroid
is overactive, so that we canthen make the correct
recommendation to the patient.
Dr Gavin Nimon (17:06):
So the workup is the bloods, including thyroid
antibodies T3 and T4s,progressing to nuclear medical
scan.
Do you include ultrasound aspart of your workup as well, or
was it a CT or MRI as well?
Dr Melissa Bochner (17:18):
The nuclear medicine scan is a functional
scan, so that will tell us whichbit of the thyroid is
overactive.
Clearly, when you're offeringsomeone an operation, you want
to be able to talk to them aboutthe risks and how long the
operation is going to take andwhat you're removing.
So ultrasound is very importantand for us really, we consider
(17:39):
that to be an adjunct toclinical examination.
So we have these days aportable ultrasound machine in
all of our clinics and in ouroffice, and so I would normally
examine a patient, examine theirneck with the standard thyroid
examination, and then I wouldactually look at their thyroid
with ultrasound myself, and thethings I'm most interested in
(18:03):
would be how big is it and whereis it?
Is it in the neck or does it godown into the chest?
Because that's really importantwhen you're talking to someone
about surgery.
Dr Gavin Nimon (18:12):
And for the examination part, you've
mentioned the standardexamination.
What are the key things for amedical student to watch out for
?
Obviously, we've talked aboutproptosis for Graves' disease.
We've talked about, obviously,irregular shape to the thyroid
and a bit more prominence.
Is there anything elsesystemically that we need to
look for as well?
Dr Melissa Bochner (18:27):
Yeah, I think the standard thyroid
examination that you do as amedical student and particularly
if you were in an exam or ifyou didn't have an
endocrinologist in your clinicwhich we luckily do at the Royal
Adelaide would include pulserate, blood pressure, you would
look for a tremor, you wouldlook for the eye signs, which
(18:49):
includes the proptosis, but alsothe external ophthalmoplegia,
so perhaps diplopia on lateralgaze, and you may also then be,
as I said, interested in theneck examination as to how big
the thyroid is.
A lot of people with Graves'disease can have a moderately
enlarged gland which is notretrosternal but which can be
(19:11):
quite firm because of theinflammation.
So the thyroid examination isclearly important.
Dr Gavin Nimon (19:20):
Okay, with that examination out of the way, then
, and obviously with theultrasound you talked about and
the investigations, includingthe blood tests and the nuclear
medical scan you mentioned, themedical management Is that
managed by purely anendocrinologist and you come in
for the surgery part of it, oris that something that you get
involved in as well?
Dr Melissa Bochner (19:36):
We have a multidisciplinary team in our
clinic at the Royal Adelaide andwe're really lucky because in
fact management of thyroiddisease includes endocrinology,
nuclear medicine, specialty andsurgery, because the one thing
that we haven't spoken about forhyperthyroidism is in fact use
of radioactive iodine to controlthyroid function.
(19:57):
So we have all of thosespecialties within our clinic
and we can share patients sothey can talk to the
endocrinologist who might sayyou can try a drug such as
carbamazole.
Many patients with Graves'disease in particular will be
well controlled on carbamazole.
They won't need to come and seeanybody else.
(20:17):
They will go into remission andstay in remission.
So not everybody with Graves'disease even sees a surgeon.
The ones who end up coming backfor surgery will be the
patients who relapse, becausemultiple relapses or prolonged
Graves' disease probably willnot be cured and will need more
(20:38):
definitive management.
People with a very largethyroid who have pressure
symptoms, as mentioned before,people with eye disease may be
better having surgery.
And then there are people whocan't tolerate the drugs or
people who shouldn't have thedrugs, and I'm including here
young women who may wish to havea pregnancy, where the thyroid
(21:02):
function can be very difficultto control during pregnancy and
we know that abnormalities ofthyroid function during
pregnancy are not good for thebaby.
It may increase risk ofmiscarriage, for example.
So there is a group of peoplewho will come through for
definitive management.
At that point they may wish tospeak to the nuclear medicine
physician about the use ofradioactive iodine to destroy
(21:23):
the thyroid and then they maywant to speak to the surgeon
about surgical management.
Clearly those two things aredifferent.
Radioactive iodine is appealingfor some patients.
It's obviously non-surgical.
They don't need an operation.
They don't get a cut in theirneck.
They don't have to consider thecomplications of surgery, the
(21:43):
worst of which is damage to therecurrent laryngeal nerves.
The downsides to nuclearmedicine, of course, is that
some people don't like the ideaof a radioactive treatment.
There may be an increased riskof some malignancies down the
track after use of radioactiveiodine.
It doesn't work immediately.
So if you need to control thethyroid straight away, then that
(22:05):
isn't the right treatment.
It may not work as well in verylarge multinodular goiters
because of the patchy nature ofthe uptake.
It may shrink the gland alittle bit, but it will not make
a very large glandsignificantly small if someone
also has compression symptoms.
(22:26):
So there are pros and cons toeach of the treatments, and we
like our patients withhyperthyroidism to have the
opportunity to talk to all thedifferent specialists and make
an informed decision.
Dr Gavin Nimon (22:38):
So there's obviously some medical
management, the radioactivethyroid and the surgical options
as well.
How often do you seeabnormalities of structure as
well, Melissa?
Dr Melissa Bochner (22:46):
A lot, and I think one of the statistics
that I've been quoted is that50% of women over 50 have a
thyroid nodule.
So lots of people have athyroid nodule and actually the
trick for us as specialists isworking out which ones to ignore
and which ones to do somethingabout.
There is clearly a group ofpeople who have a multinodular
(23:10):
goiter and who have pressuresymptoms in the neck relating to
that.
Now, that might be a morenon-specific feeling of pressure
across the front of the neck.
Some people will complain thatthey wake up at night feeling
that they can't breathe, thatsomething's pressing on their
(23:30):
neck.
Sometimes I think that's justbecause when you're asleep and
the head goes down, the pressureeffects are worse.
Some people will complain ofdifficulty swallowing and will
say that they can feel somethingwhen they swallow, that the
food passes past an obstructionand clearly in the the
worst-case scenario, people willpresent with a stridor or
(23:53):
difficulty breathing.
Again, there is a lot of peopleout there who get a bit of a
weird sensation in their neck.
They see their GP, they have anultrasound and thyroid nodules
are seen.
So there is a significant numberof people whose thyroid nodules
are coincidental to theirsymptom and it can be difficult
(24:14):
sometimes working through that,because clearly removing the
thyroid and having someone stilltelling you that their symptom
is still there is veryunsatisfactory.
So sometimes we do need to workwith colleagues in ENT, for
example, or in gastroenterology.
Sometimes we do need to workwith colleagues in ENT, for
example, or in gastroenterology,where abnormal sensations in
the neck may be related, forexample, to reflux, esophagitis,
(24:35):
pharyngitis, sinusitis and awhole lot of other things.
So you have to really look verycarefully at the patient and
what symptom they're describingand whether you think the
nodules that they have arecausing that symptom.
I find that thyroid ultrasoundis very good for looking at the
characteristics of individualthyroid nodules.
(24:56):
It is not very good at lookingat local structures in the neck
and determining whether thethyroid is compressing them or
not.
So for me, if I think someone'stelling me that they've got an
obstructing symptom, then I willorder them a CT scan of their
neck and always include thechest in that, because sometimes
(25:17):
the thyroid in the neck is justthe tip of a thyroid iceberg
and the rest of it's inside thechest.
Dr Gavin Nimon (25:23):
And is that CT?
Is that just purely a plain CT,or do they need to have like a
barium swallow or anything likethat at all?
Dr Melissa Bochner (25:29):
I think intravenous contrast is always
good because you can sort of seewhere the vascular structures
are.
So you don't need a bariumswallow, particularly although
there are some people that youthink actually this is a
esophageal problem, not athyroid problem.
So we do order the occasionalbarium swallow for people, for
(25:49):
example, with dysmotility, whichis why it is good to have that
multidisciplinary input,including from radiology, in our
thyroid clinic.
Multinodular goiter isobviously very common around the
world.
There are a lot of countrieswhere endemic goiter occurs, and
in our multicultural societythat we have here, we have a lot
(26:09):
of patients who come from areasof endemic goiter and we see a
lot of patients withmultinodular goiter, some of
which is asymptomatic and someof which is very symptomatic.
Endemic goiter is generallycaused by iodine deficiency, and
so you will see that in peoplewho have grown up in regions
often mountains and away fromthe sea where the iodine leaches
(26:32):
out of the soil so some areasin Central Asia and Central
Africa and so some of thosepopulations seem to have more
goiter than some of the peoplewho have grown up eating an
iodine-rich diet, which includesseafood and, of course, the
iodine that's added to our food.
Dr Gavin Nimon (26:52):
There's a lot of iodine added to bread.
I understand, but is that thesame for all the local bakeries
and stuff?
Will they be adding iodine tothe bread as well?
Dr Melissa Bochner (26:59):
I think most of them would, because it's in
the salt Right and so mostpeople would, and I advise
people to cook with iodinatedsalt and that I think that some
of the thyroid problems that wesee may be related to trendy
salt, because if you bake yourown bread with trendy salt and
you don't eat any seafood andyou have a restricted diet for
(27:19):
whatever reason, then you mayactually be iodine replacement
in the diet and havingsatisfactory dietary iodine is
very important to avoidunnecessary goiter in
communities, and we know thatthe very groundbreaking work
(27:41):
done, for example, in Nepal,where iodine was added to the
diet, changed the outcome for ageneration of people there who
were living with severe iodinedeficiency up until then.
Dr Gavin Nimon (27:55):
And that leads to a hyperthyroidism type
multinodular goiter.
Dr Melissa Bochner (27:59):
Often the thyroid function is actually
normal, but the gland isenlarged.
Dr Gavin Nimon (28:03):
Okay.
Dr Melissa Bochner (28:04):
So we will see people with normal thyroid
function and very large thyroidswould be the usual situation.
Dr Gavin Nimon (28:13):
Is a goiter, the terminology used to define an
abnormality in structure of thethyroid, because you can get
hyperthyroid goiter.
Dr Melissa Bochner (28:19):
That's right .
I think goiter is a generalterm that implies enlarged
thyroid, for whatever cause.
Dr Gavin Nimon (28:24):
Right.
Dr Melissa Bochner (28:24):
Yeah.
Dr Gavin Nimon (28:25):
Okay.
So once you've assessed someonefor abnormality of structure,
you've done a ct scan.
Then I presume, assuming it'snot a correctable cause such as
like an iodine deficiency, Ipresume surgery is recommended
in that scenario if it's causingsymptoms.
Is that correct?
Dr Melissa Bochner (28:42):
that's correct.
If somebody's got obstructiveor compressive symptoms, you're
comfortable that the thyroid'scausing it, then surgery would
be recommended.
For a lot of people thatdisease is symptomatic but not
life-threatening.
So it is not unreasonable totalk to a patient and say to
them I believe your thyroidnodule is touching your trachea
(29:05):
or it's touching your esophagusand your symptoms will probably
be relieved by removing half orall of your thyroid, and talk to
them about the risks andbenefits and allow them to make
the decision.
And they may not wish to makethat decision very quickly and
we have people coming back toour clinic over and over again
over many years.
The goiter slowly enlarges andat some point they may decide to
(29:27):
do it.
The situation where we feelthat surgery needs to be
strongly recommended, of course,is when the trachea is narrowed
.
Most of the time that occurs ina retrosternal goiter because,
understandably, if the thyroidenlarges in the neck it will
tend to enlarge anteriorly andit'll be visually obvious but
(29:50):
perhaps not symptomatic ascompared to the thyroid that
goes down into the chest.
It's got nowhere to go andthose are the ones that can
cause very significant and quitefrightening tracheal narrowing.
Dr Gavin Nimon (30:05):
Right, because, as I understand, the thyroid is
not really well encapsulated.
Dr Melissa Bochner (30:09):
It has a very loose capsule over the
front but when it enlarges itgoes down the path of least
resistance and it will push theother structures out of the way,
you know, unless it's amalignant thyroid.
So you'll find that a patientwill have a lot of disease in
their chest, their carotidartery, jugular veins will be
(30:30):
pushed to the side.
So they're close, but notparticularly in a lot of danger.
But going back to the clinicalexamination, of course the
Pemberton sign is the one whereyou ask the patient to put up
their arms above their head andtheir face goes blue.
That's venous obstruction fromthe thyroid, often intrathoracic
(30:52):
, and patients may come andcomplain of that symptom.
When I go to hang out thewashing, my face goes blue, I
feel faint, I can't keep going.
So those people need surgeryand we, you know, particularly
if someone's got significantairway narrowing where the
tracheal calibre can be down tofour millimetres or so, then
they have to do something.
Dr Gavin Nimon (31:14):
And, of course, surgery, as you mentioned, has
got risk with the recurrentlaryngeal nerve.
There's obviously a few otherstructures around the area that
are at risk as well.
Dr Melissa Bochner (31:21):
The main risks of thyroid surgery in the
immediate period time will bebleeding.
The thyroid is very vascular.
In graves it can be amazinglyvascular and coupled with the
venous obstruction that you getin very large thyroids, then
(31:45):
every tiny blood vessel that youtouch can just bleed, even
small ones.
So there is a risk of bleed,even small ones.
So there is a risk of bleedingintraoperatively and
postoperatively and patientsneed to be managed by
experienced nursing staffimmediately postoperatively.
For that reason there is a riskto the recurrent laryngeal
(32:06):
nerve, one on each side the riskof permanent damage to that we
would normally quote at onepercent.
But at least five percent ofpeople have a voice change after
thyroid surgery, which improves.
And then, of course, there areour friends that we haven't
spoken about already theparathyroid glands.
The parathyroids unlike thethyroid, which I said, if it
(32:29):
disappeared, you probablywouldn't die if your
parathyroids unlike the thyroid,which I said, if it disappeared
you probably wouldn't die.
If your parathyroid'sdisappeared now, you'd probably
die in about 10 minutes, maybe abit longer, because you need
your parathyroids to controlyour serum calcium.
So parathyroid preservation isreally, really important and
(32:50):
they're often very close to thethyroid.
They're very easy to injure orto remove inadvertently because
they're very small and theyoften share a blood supply, so
we do worry about causingpermanent hypoparathyroidism in
somebody having thyroid surgery.
It's a very annoyingcomplication for the patient to
(33:13):
have to have because they needto be on a lifelong calcium and
calcitriol replacement and theywill get symptomatic if they
can't take it.
Dr Gavin Nimon (33:22):
Right and through an anterior approach.
You mentioned before a cut inthe neck.
Dr Melissa Bochner (33:28):
Usually all large thyroids will be done
through a cut in the neck.
Usually all large thyroids willbe done through a cut in the
neck.
Sometimes for the massivethyroids we've had to ask our
cardiothoracic friends to comeand do a sternotomy as well.
Not common and there is alittle bit of a trend which
hasn't taken off particularlywell, particularly in Australia,
(33:48):
for a minimally invasiveapproach to the thyroidectomy
through the mouth, and somepeople overseas are doing them
robotically through the axillaor other remote approaches in
order to try and avoid theincision on the neck which some
people will find cosmeticallyunacceptable.
(34:10):
Countries like Korea havereally pioneered the transoral
and robotic thyroidectomy toavoid the neck incision.
Dr Gavin Nimon (34:18):
So obviously these are for the structural but
benign conditions, butobviously malignancy is also an
issue too.
What are the main types ofmalignancies you do see, and how
common are they in thyroid?
Are they something I need to beaware of, being an orthopedic
surgeon and doing a lot of imageintensifier in theatre?
Dr Melissa Bochner (34:33):
Certainly If you haven't been wearing your
thyroid shield.
Thyroid cancer is interestingand it's certainly increasing
worldwide and there's some kindof thyroid cancer epidemic which
we're not sure why.
It is possibly or almostcertainly due to increased
(34:55):
detection because of many peoplehaving more neck imaging for
these non-specific neck symptomsthat they get.
So there is more thyroidmalignancy around and the issue
again for us with thyroidmalignancy around and the issue
again for us with thyroidmalignancy is trying to diagnose
it accurately, differentiatingit from non-malignant nodules
(35:18):
and making the correct treatmentrecommendation.
Because I suppose that it'scounterintuitive for a lot of
patients that if you say tosomebody, well, you've got a 10
millimeter thyroid cancer and itdoesn't matter, that doesn't
sound right to them because mostother cancers it matters,
whereas thyroid cancer may notbe life-threatening except for
(35:40):
over a very long period of time,and so it is a disease where we
worry a lot aboutover-diagnosis and
over-treatment and it'sdifficult to choose which
procedure to do on which person.
So if we see a patient with asolitary thyroid nodule, there
is a lot of effort made intotrying to work out.
(36:02):
Am I worried about that nodule?
Is that something that I needto biopsy?
Is it something I need toremove, or is it something that
I need to follow up, or is itsomething that I can reassure
the patient and let them go?
Having said that, lots ofpeople have got solitary nodules
and there are lots of causesfor having a solitary nodule,
which would include a dominantnodule within a multinodular
(36:25):
goiter, what's called a colloidnodule, so just an overactive or
hyperplastic nodule or a benigntumour like an adenoma.
And then some people will have athyroid cyst, a benign cyst.
So there are quite a lot ofnodules that people have and
they will come into the thyroidclinic and we have to try and
work out what to do about them.
There are, I suppose, twodifferent ways of classifying
(36:50):
thyroid nodules and trying toget a bit closer to a diagnosis.
One of them is using ultrasoundcharacterization.
There's a system called TYRADS,which is a radiology
classification which tries tostratify nodules into a risk of
them being malignant andtherefore the need for those
(37:11):
nodules to have a needle biopsy.
So TyRADS has five differentcomponents that can be assessed
on ultrasound and they all getgiven a score and then you add
up the score and you end up witha TyRADS classification of a
nodule, and there are five ofthose.
(37:34):
So, someone will come into theclinic and will say this lady
had a funny feeling in her neckand we've done a thyroid
ultrasound and she's got atirads 3 nodule.
Thanks for looking after her.
And one of the problems withthe tirad system which I think
is a bit of a flaw is that theway that they're categorized can
(37:57):
be frightening for the GP andfor the patient.
So a TIRADS 1 nodule is benignand a TIRADS 5 nodule is highly
suspicious, but the one that Ijust mentioned, tirads 3, which
is almost certainly fine, forsome reason they decided to call
that mildly suspicious on theclassification Right.
Dr Gavin Nimon (38:15):
okay.
Dr Melissa Bochner (38:17):
So GPs will say got a woman with a
suspicious thyroid nodule, whichis correct because it's called
mildly suspicious, because whattirads hasn't helped them to do
is understand how many of thoseare actually cancers and most of
them are not.
So tirads can sometimes be aproblem for us and our patients
(38:38):
just because of the way they'vedecided to name it, and we need
to be a little bit careful aboutthe way that we speak to people
and what we call someone'snodule that we're suggesting
that they don't have anythingdone to, including not even
biopsied.
The thing about tirads is itdoes try to stratify management
of thyroid nodules.
(38:59):
So it looks at thecharacteristics of the nodule
under ultrasound, which mightinclude something like the
composition Is it solid, is itcystic, does it have
calcifications in it, does ithave a regular border, for
example.
But it also looks at the sizeof the nodule.
And that's when we come back tobeing a little bit
counterintuitive, because youmay have a nodule which ticks
all the boxes for looking like acancer, but because it's very
(39:21):
small, they might say this doesnot need a biopsy, even though
it has some suspicious features.
On the flip side, some largernodules that look benign will be
called more suspicious or needmore investigation because of
their size.
So tirades can be a trickysystem to work and there is an
(39:45):
app.
You know everything's got anapp.
You can download the app onyour phone.
I quite like redoing the tiradeswhen I see a patient.
I look at the nodule myself andreclassify it, and sometimes I
agree with the radiologist andsometimes I don't, because there
is quite a lot of variabilityin the way you might choose to
(40:06):
interpret some of the ultrasoundfeatures.
Most particularly, papillarythyroid cancer may have micro
calcifications in the nodule.
So calcifications, especiallytiny little punctate ones in a
thyroid nodule, can be quitesuspicious.
However, there is an ultrasoundappearance called comet tails
(40:26):
which is associated withsometimes with the appearance of
colloid within a nodule, whichis benign, but sometimes those
comet tails look likecalcifications, and so probably
the major cause of disagreementabout the thyroid classification
of a nodule is what you think.
The little echogenic foci arewithin the thyroid nodule and
(40:47):
different people have differentopinions on that particular
scoring point.
Dr Gavin Nimon (40:51):
So, for the intern or the GP or the thyroid
classifications, what do theyneed to know?
They need to know, basically,the ultrasound will help guide
them and then refer them to abreast endocrine surgeon, or
they need to know more detailabout that.
Dr Melissa Bochner (41:05):
I think that they need to just read the
report really carefully and ifit says a Tyrad's 3 nodule, as
per the guidelines, this noduleis 30 millimetres in size and
FNA is recommended.
I'm happy with all of that.
Or a Tyrad's 3 nodule this is 5millimetres in size, suggests
an ultrasound in 12 months.
(41:26):
I'm happy with that too.
I don't mind it.
What I mind is the fact thatit's called mildly suspicious,
because that frightens everybody.
So my point really is that mostthyroid nodules aren't cancer
and don't get upset when you seethat word suspicious,
particularly if it's a Tyrad's 3or 4.
We're happy to see them, butpeople arrive quite upset.
(41:50):
My doctor told me I've gotthyroid cancer.
Oh, hang on a minute.
You know, let's just clear thatup for a minute because usually
they don't.
So it's really it's acommunication practice point
rather than anything else.
Absolutely most of our needlebiopsies are done under
(42:23):
ultrasound.
Back in the olden days we usedto do them freehand, but of
course now we've all gotultrasound, so they're done
under ultrasound.
And again, I think that overthe last what 10 to years we've
had an improvement in ourstratification of cytology on
thyroid nodules and so again, ifyou send a patient for a needle
biopsy of their thyroid nodule,then you will come back with
(42:46):
what's called a Bethesdacategory on that nodule and that
Bethesda category willcorrelate with a risk of
malignancy.
So in fact there are sixBethesda categories and we about
a long time ago now, maybe 10years ago, when Bethesda had
been around for a while, welooked at our own cohort of
(43:09):
patients at the Royal Adelaidewho'd had a Bethesda category on
their needle biopsy and thenwent on to have thyroid surgery.
So we could correlate theBethesda category with the final
pathology and the categoriesmatched up pretty well with
international standards.
(43:29):
So we know that if someone tellsyou that your nodule is a
Bethesda 2, which is benign,then there is a 4% chance that
that's a cancer.
If someone tells you that yourBethesda category is 3, then
that's atypia, so there's a 15%chance it's a cancer.
A four is 25 to 30% chance ofcancer.
(43:53):
Fives and sixes are pretty highrisk of being cancer, but
neither of them is 100%.
And when we're talking aboutthat, clearly we're talking more
about papillary thyroid cancerthan the other subtypes, because
papillary thyroid cancer iseasier to diagnose on a needle
(44:15):
biopsy than the other types.
And I know you're going to askme what are the types of thyroid
cancer, because we didn't seethat before.
Dr Gavin Nimon (44:22):
yeah, well, perhaps we can go through those,
yeah that's right.
Dr Melissa Bochner (44:25):
Papillary thyroid cancer is the most
common by far, and we see thatin all age groups and certainly
we do see that in our children.
Then there is follicularthyroid cancer, which is the
next most common, and that wouldbe the two that we see most of.
Medullary thyroid cancer that Imentioned briefly earlier is a
cancer of the c-cells of thethyroid.
(44:46):
It's not a true thyroid cancerper se, although obviously only
occurs in the thyroid.
It's very, very rare, but we dosee it in people with a genetic
condition, men2.
And so people who are born withthat genetic condition may need
prophylactic thyroidectomy whenthey're children.
And then other rare subtypes,including anaplastic, which
tends to be a fatal disease ofolder people.
(45:09):
So papillary and follicular arethe two most common, and they
would be the ones that we'd bethinking about when doing a
needle biopsy of the thyroid.
Again, if you have a patientwho's got a Bethesda category of
four, five or six, the risk ofmalignancy is felt to be high
(45:31):
enough to warrant diagnostichemothyroidectomy.
At least If the Bethesdacategory is three, where we're
sitting at about 15% malignancy,then it's worth redoing the
needle biopsy after a period oftime, just in case the cellular
atypia is, for a reason, not dueto an intrinsic problem with
(45:52):
the thyroid.
Obviously, if you do a needlebiopsy, sometimes you can make
the cells abnormal by crushingthem when you do the smear, or
abnormalities with the fixation.
So we will tend to repeat aBethesda 3.
A Bethesda 2, we will normallyaccept as being benign but might
wish to follow it up.
And obviously in our serieswhere we had 116 patients having
(46:15):
removal of Bethesda 2 nodules,most of those were because they
were symptomatic, not because wewere worried about them being
cancer.
So a small Bethesda 2, you canprobably reassure that patient.
So we like the Bethesda system.
It's clear If you think aboutit from a patient's point of
view, of course.
Having said that, if you've gota Bethesda 4, maybe it's 30%
risk of malignancy.
(46:35):
So we're now talking about agroup of people who may be
asymptomatic.
They've had a thyroid nodulepicked up for many of the
reasons we pick up thyroidnodules these days Ultrasound
done for another reason, ct donefor another reason, pet scan
done for another reason.
They've now another reason petscan done for another reason.
They've now got a bethesda 4nodule.
We're telling them they need adiagnostic hemothyroidectomy.
(46:58):
So we know, that maybe 60percent of those people 60 to 70
percent of those people don'thave thyroid cancer.
Maybe they've got a follicularadenoma and it's worth taking
that out because that willprobably grow and it may have
malignant potential.
But there's still a significantnumber of diagnostic
(47:18):
hemothyroidic tomies being donethat you'd like to think you
wouldn't have to do if you had abetter diagnostic tool for
thyroid cancer.
So that's one of the holygrails of thyroid diagnosis
really is having a more accuratepreoperative thyroid
histopathology diagnosis, andwe're not there yet.
Dr Gavin Nimon (47:38):
Well, listening to this, you've got a
classification system based onultrasound to decide whether you
observe it or do an aspirationor final aspirate.
Then you've got aclassification system based upon
that final aspirate and thenyou've got a classification
system based upon the actualhemithyroideectomy and the
actual cytology of their cells.
They're three different typesof classification systems.
(47:58):
Would the artificialintelligence and AI help combine
those three to actually helpwith that Holy Grail?
Dr Melissa Bochner (48:04):
I've never seen an AI that was able to
combine tirads and Bethesda, butI think that would be great,
and what we need is somebodywith a massive series to be able
to do that, because I think youneed a lot of numbers.
So if you said it was a Tyradsomething and a Bethesda
something else, then maybe thatwould be good.
There are some diagnostic teststhat are available in the
(48:26):
United States looking at tumormolecules and cancer markers and
a few more nuanced thingswithin the cells in the needle
biopsy.
At the moment they're not superaccurate either and they are
super expensive and they're onlyavailable in the States and
(48:46):
you've got to send them away andpeople don't really want to
spend $3,000 on their thyroidFNA either.
So I think there is movement inthat space, but we're just
waiting for a good test tobecome available One of the
things about thyroid cancer isthat thyroid cancer cells are
often very well differentiated,which is good, you know.
they're less aggressive cancerswith a very good prognosis.
(49:08):
But it makes the job of acytopathologist very, very
difficult to tell the differencebetween a benign and a
malignant thyroid cell on aneedle biopsy.
Very big thyroids you canimagine that you can do a core
biopsy on and that can happen.
But it's a bit of tiger countryin the neck Throwing a core
into the neck with all thestructures and the thyroid is
(49:29):
quite vascular so you canoccasionally do it but it's very
uncommon to be able to get anactual piece of tissue out of
the thyroid.
Dr Gavin Nimon (49:38):
Thinking about cancers in general.
I know in breast cancer youoften do a lymph node clearance
to assess actually a risk ofmetastases.
Is that done in thyroid surgeryas well?
And also, what adjuvanttreatment do you use after
thyroid surgery as well in thatscenario?
Dr Melissa Bochner (49:52):
So I think if you know that you're
operating on someone withthyroid cancer because you're
almost sure they've got abethesda five or six, they've
got characteristic ultrasoundfindings etc then yes, you might
do a prophylactic central neckdissection, which is really
those lymph nodes that sit infront of the trachea, just below
the thyroid.
(50:13):
That's called level six orlevel seven.
You can get, you know, half adozen lymph nodes from that area
.
The risk of doing thatadditional little bit of lymph
node surgery is that it's oftenthe area where the lower
parathyroid sits.
So you do risk removing aparathyroid inadvertently.
And to do a proper level sixnode dissection you actually
(50:35):
have to dissect down therecurrent laryngeal nerve and
then remove all of the tissue inbetween the nerve and the
trachea, including in front ofthe trachea.
So there is a slightlyincreased risk of damaging the
nerve while you're trying toprotect it.
Interestingly, the mortalityfor thyroid cancer is not
(50:56):
particularly altered by thepresence of nodal disease.
So it's not like the cancersthat we worry about colon cancer
, breast cancer where you needto know how many nodes are
involved and you need to get ridof them.
Your nodes are involved and youneed to get rid of them.
People with positive nodes,particularly for papillary
thyroid cancer, will end up withmore local regional disease and
(51:19):
may end up having moreprocedures, but they're probably
not more likely to die.
So we are more cautious inremoving normal lymph nodes in
people with thyroid disease.
You would not do a routine neckdissection for node negative
disease, except for the unusualcircumstance of medullary, which
is different, but the papillaryand the follicular you wouldn't
(51:42):
do it.
Having said that, there will besome people who will present
with a lot of lateral nodedisease and therapeutic node
dissection for known positivedisease is the correct thing to
do.
So some of the children that Itreat actually present with a
lot of nodal disease in the neckand so I would generally do a
(52:04):
total thoracotomy and neckdissection for them, and I work
quite closely with head and neckcolleagues at the Children's
Hospital on those procedures.
So adjuvant treatment.
Going back to that, one of thethings, of course, is what we're
saying is that thyroid cancergenerally has a pretty good
prognosis.
So again, you don't want tooverdo it.
So back when I was training,which was a long time ago,
(52:25):
everyone with thyroid cancer hada total thyroidectomy and then
they had radioactive iodine andsuppressive thyroxine dose to
suppress the TSH down low, it'sbecome clear that not everybody
needs all of those treatments.
So, there will be a group ofpeople with a
well-differentiated papillary orfollicular cancer which is not
(52:46):
super big.
It's sitting in the middle ofthe thyroid, there's nothing
else that looks abnormal.
You can treat them with ahemothyroidectomy and
observation.
The people with the increasedrisk of disease may need a total
thyroidectomy and radioactiveiodine and clearly sometimes
you'll do a hemithyroidectomyfor a nodule that you're not
sure what it is.
You'll find out that it's acancer.
(53:09):
You'll decide to giveradioiodine and then you need to
go back and do a completionthyroidectomy for the other side
.
Because if we think about howradioactive iodine works, it's a
radioactively labeled iodinemolecule which is taken up into
functioning thyroid cells, ofwhich we know that cancer is
part of.
(53:29):
But if you've got normalthyroid tissue in your neck,
then that will take it uppreferentially and you'll be
treating the normal thyroid, notany potential residual disease.
So radioactive iodine inprinciple is only given to
people that have had a totalthyroidectomy.
So I think the modern timeswe're doing a lot more
(53:50):
hemothyroidectomy, observationrather than the total
thyroidectomy for thyroid cancerwell, we've covered a fair bit.
Dr Gavin Nimon (53:55):
Where do you think thyroid treatment's going
in the future?
Dr Melissa Bochner (53:58):
I mean what are the sort of forefronts of?
Dr Gavin Nimon (54:00):
research where things heading in the next 20
years.
Dr Melissa Bochner (54:03):
They say yeah, I think that, um, there's
a few different areas.
One of them is, as I've said,in the diagnosis.
I think it would be really niceto be able to rule out.
You know a bunch of peoplehaving purely diagnostic thyroid
surgery when they've got nosymptoms and you really think
that it's too much for them.
So improvements in thyroidnodule diagnosis would be great.
(54:26):
And then I know we spoke earlierabout biologicals for treatment
of thyroid disease and clearlythere are some biologicals that
are used for treatment ofmetastatic thyroid cancer or
inoperable thyroid cancer,because, unlike a lot of
oncology, really thyroid diseasehas maintained the realm of the
surgeon and there are not manymedical treatments for thyroid
(54:51):
disease and some of thetreatments that we do give to
people with metastatic diseaseare quite toxic and poorly
tolerated and may not work verywell.
So finding a good medicaloncology agent for people the
rare group of people withadvanced disease locally
advanced or metastatic diseaseis going to be really important
(55:11):
as well, and thyroid disease isa long way behind some of our
other diseases at the moment formedical oncology treatments.
Dr Gavin Nimon (55:19):
Right.
Well, it's been fantastichearing about these conditions.
There's so many different areasof it.
Appreciate you coming on boardand thank you very much, Melissa
.
I really appreciate your effortand thanks a lot for coming on
Aussie Med Ed.
Dr Melissa Bochner (55:30):
Thank you, gavin, it's been really great
talking to you.
I've enjoyed it.
Dr Gavin Nimon (55:33):
I'd like to remind you that the information
provided today is just onemedical opinion, and this may
vary depending on the region inwhich you're studying,
practising or being treated.
If you've enjoyed the podcast,please subscribe to the podcast
for the next episode.
Until then, please stay safeand we'll see you again for our
next episode.
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