"THYROID CANCER AND NODULES PARATHYROID SURGERY "

The thyroid is a gland in the lower part of your neck in front of your windpipe (trachea). It is shaped like a butterfly, with a right lobe and a left lobe. The isthmus, a thin piece of tissue, connects the two lobes. A healthy normal thyroid cannot be felt through the skin.

The thyroid uses iodine, a mineral found in some foods and in iodized salt, to help make a hormone called Thyroxine. Thyroxine helps in the control of your heart rate, body temperature, and how quickly food is changed into energy (metabolism).

At the back of your thyroid, there are 4 attached small glands, called parathyroid, two on each side. The Parathyroid hormone is important to control the amount of calcium in the blood.

In most cases, we cannot say what has caused thyroid cancer. There are certain events which are known risk factors for thyroid cancer. However, remember, having a risk factor does not mean that you will definitely get cancer; not having risk factors doesn’t mean that you will not get cancer!

The known risk factors for thyroid cancer are

• Being exposed to radiationto the head and neck as a child.

• Having a history of enlarged thyroid (goiter) due to any reason. In India this is most common due to deficiency of iodine in diet

• Having a family history of thyroid disease or thyroid cancer.

• Rarely certain geneticconditions such as familial medullary thyroid cancer (FMTC), multiple endocrine neoplasia type 2A syndrome

In addition, thyroid cancer is much more common in females, in Asians and in the age between 25 to 65 years.

There are four main types of thyroid cancer:

• Papillary thyroid cancer - By far the most common type of thyroid cancer (80%).

• Follicular thyroid cancer or Hürthlecellcarcinoma – The second most common type of thyroid cancer.

• Medullary thyroid cancer– treated with surgery like papillary and follicular cancer

• Anaplastic thyroid cancer – rarest variety with extremely poor cure rate and survival

• Thyroid lymphoma – This is treated with Radiotherapy and NOT with operation

The first two types of thyroid cancer, Papillary and Follicular, are grouped under differentiated thyroid cancer. These two make up more than 90% of all thyroid cancer and our discussion will primarily focus on their treatment.

Thyroid cancer usually does not produce any distress or discomfort. It is sometimes found during a routine clinical exam or scans for other health problems. Symptoms may occur as the tumor gets bigger. Other conditions may cause the same symptoms. However, it is advisable to get a checkup if you have any of the following problems, especially if you have any of the risk factors mentioned above:

• A lump in the neck

• Trouble breathing

• Trouble swallowing

• Hoarseness

The diagnosis of thyroid cancer usually begins with clinical exam of your body to check for signs of disease, such as lumps or swelling in the neck, voice box, and lymph nodes, and anything else that seems unusual. A history of your health habits and past illnesses and treatments will also be taken. It is common to examine your voice box with a thin tube passed through your nose to see if the vocal cords are moving normally.

In all cases your blood will be checked for abnormal levels of thyroid-stimulating hormone (TSH). In almost all cases with thyroid cancer, this is within NORMAL level. Thereafter an Ultrasound exam of your thyroid gland is carried out. This uses high-energy sound waves (ultrasound) that are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure can show the size of a thyroid tumor and whether it is solid or a fluid -filled cyst.

Ultrasound is used to guide a fine-needle aspiration biopsy. This refers to passing a thin needle into the suspicious looking thyroid nodule while looking with ultrasound to suck few cells from that nodule (called as FNAC). The needle is inserted through the skin into the thyroid while you are awake in the clinic. Several tissue samples are removed from different suspicious parts of the thyroid. A pathologist views the tissue samples under a microscope to look for cancer cells. There are international standards for grading these cells into different types by the pathologist that helps the surgeon give you an idea about the risk of cancer and make decision about your treatment. Ultrasound with needle biopsy may also be done if you have enlarged lymph nodes in your neck. Occasionally further scans such as CT or MRI Scan may be requested, usually to find out if the cancer has spread elsewhere out of your thyroid gland.

In many patients, a definite diagnosis can NOT be made on scan or needle biopsy. In such cases the only way to confirm the presence or absence of thyroid cancer is by removing the lobe of thyroid by operation that has the suspicious nodule. The decision to do so is made after discussing the risk of thyroid cancer in your case based on your examination, history and findings on the needle biopsy.

No, not every thyroid nodule needs treatment.

In fact the vast majority of thyroid nodules do NOT require any treatment at all! Thyroid nodules are incredibly common; some studies in western world indicating that ultrasound scan shows presence of thyroid nodules in more than 50% otherwise healthy adults, the incidence rising with age, especially in females. This figure is likely to be even higher for India due to wide spread Iodine deficiency.

ONLY a small minority, less than5% to 10% of these nodules will have cancer. Generally, no investigation is required if the nodules are smaller than 1 cm, especially if you do NOT have any of the above mentioned risk factor.

Thyroid cancer is primarily treated by operation to remove the cancer

Surgery

Surgery is the most common treatment of thyroid cancer. One of the following procedures may be used:

• Lobectomy- Removal of onethyroid lobe, the one, which has the nodule with, suspected cancer.

• Total thyroidectomy- Removal of the whole thyroid.

• Neck Dissection- This refers to removal of lymph nodes in the neck that contain cancer. This is required if scans or needle biopsy suggest enlarged lymph nodes in your neck. The extent of neck dissection depends upon the area and number of diseased lymph nodes.

In some cases with large thyroid nodules, this may be done even if there are no apparent diseased enlarged lymph nodes because several studies have shown a high rate of microscopic spread of cancer cells in lymph nodes adjacent to the thyroid gland.

Radiation therapy, including radioactive iodine therapy

If your thyroid cancer is large or has spread to the lymph nodes in the neck, we may advise treatment with radioactive Iodine (RAI). RAI is taken as a tablet and kills any remaining thyroid cells, including the cancer, which may have spread to other parts of your body. To prevent effect of radiation coming out from this chemical, you will need to be in the hospital in an isolation room for about 24-48 hours, especially if there are children at your house.

Occasionally we may recommend external beam radiotherapy if the cancer has come back and is causing discomfort.

Chemotherapy

Chemotherapyis rarely used for control of advanced thyroid cancer that has spread to different parts of the body.

Thyroid hormone therapy

Thyroid stimulating hormone (TSH) can cause your thyroid cancer cells to grow. Therefore in some cases, we advise tablet with thyroid hormone, thyroxine, for treatment of your thyroid cancer, to prevent the body from making TSH.

Also, because thyroid cancer treatment kills thyroid cells, the thyroid is not able to make enough thyroid hormone. After treatment you are likelyto require thyroid hormone replacement pills for life.

Papillary and Follicular thyroid cancer has amongst the BEST rate of cure amongst all cancer. The outlook for most people (> 90%) with thyroid cancer is very good with excellent chance of cure with treatment. Most patients who have thyroid cancer do NOT die because of thyroid cancer but die due to other causes (such as other medical disease, age, accidents or from natural causes).

However, as with any other cancer your cure rate can be worse if your cancer is caught at an advanced stage. So, it is important to seek medical help at an early stage.

Some factors that affect the cure rate are mentioned below :

• Your age and sex (cure rate is less for males)

• Your type of thyroid cancer

• Your cancerstage – size of cancer and if has spread out of thyroid gland

• Whether your cancer has just been diagnosed or has recurred

After your treatment for thyroid cancer, you will require follow up with regular checkup and tests. This is required to look for any feature indicative of return of cancer. In addition to clinical examination this usually requires blood test for thyroglobulin performed at regular intervals. Thyroglobulin is a protein that is usually only made by the healthy thyroid gland, but it can also be produced by papillary or follicular thyroid cancer cells. Measuring thyroglobulin levels is a way of detecting any remaining papillary or follicular cancer cells. In addition, you may also have Ultrasound scan, CT scan or radioactive iodine scans from time to time, to ensure there are no thyroid cancer cells in your body.

You can follow this link to learn more about thyroid surgery and associated side effects and possible complications.

The commonest reason for removing your parathyroid gland is when they are secreting abnormal high amount of parathyroid hormone (PTH). In normal circumstances, the amount of PTH that they secrete is tightly linked to the level of calcium in your blood. However due to a benign tumour in these glands or due to excess growth of these glands you can have excess amount of these hormones in your blood, leading to excess calcium in your blood that is taken out mainly from your bones.

Excess calcium due to this reason leads to many side effects; some of the important ones are mentioned below

• Osteoporosis. The loss of calcium often results in osteoporosis, or weak, brittle bones that fracture easily.

• Kidney stones. The excess of calcium in your blood may cause small, hard deposits of calcium and other substances to form in your kidneys. A kidney stone usually causes significant pain as it passes through the urinary tract.

• Cardiovascular disease. Although the exact cause-and-effect link is unclear, high calcium levels are associated with cardiovascular conditions, such as high blood pressure (hypertension) and certain types of heart disease.

• Neonatal hyperparathyroidism. Severe, untreated hyperparathyroidism in pregnant women may cause dangerously low levels of calcium in newborns.

Most patients with hyper-parathyroidism have NO significant discomfort and the diagnosis is accidently made when high calcium level is found in their blood test that is being done for other medical reason.

Symptoms due to hyper-parathyroidism may be so mild and nonspecific that they don't seem at all related to parathyroid function, or they may be severe. The range of signs and symptoms include:

• Kidney stones

• Excessive urination

• Abdominal pain, peptic ulcer disease

• Tiring easily or weakness

• Depression or forgetfulness

• Bone and joint pain

• Frequent complaints of illness with no apparent cause

• Nausea, vomiting or loss of appetite

If you have been found to have excessive calcium in your blood or one of the above symptoms, it is advisable to seek medical opinion.

The Parathyroid are in such position and so small that they are almost never felt from outside, even when enlarged.

The common tests for management are mentioned below

Blood tests

If the result of a blood test indicates you have elevated calcium in your blood, we will likely repeat the test to confirm the results after you have not eaten for a period of time (fasted). A number of conditions can raise calcium levels, but we can make a diagnosis of hyperparathyroidism if blood tests show you also have elevated parathyroid hormone.

Imaging tests before surgery

If we recommend surgery, we will likely use a combination of two imaging tests to locate the parathyroid gland or glands that are causing problems:

Ultrasound. Ultrasound uses sound waves to create images of your parathyroid glands and surrounding tissue. A small device held against your skin (transducer) emits high-pitched sound waves and records the sound wave echoes as they reflect off internal structures. A computer converts the echoes into images on a monitor.

Sestamibi scan. Sestamibi is a specially designed radioactive compound that is absorbed by overactive parathyroid glands and can be detected on computerized tomography (CT) scans. A small dose of the compound is injected into your bloodstream before the imaging test is done.

If facilities are available, this can be done on the morning of surgery and during operation special instrument (gamma camera) can show the area of maximum radioactivity to help guide us to the correct gland.

Treatment of hyper-parathyroidism is surgery to remove them.

However, if the below mentioned conditions are met, it may be safe to simply monitor you if you do not want operation

• Your calcium levels are only slightly elevated

• Your kidneys are functioning normally

• Your bone density is normal or only slightly below normal

• You have no other symptoms that may improve with treatment

If you choose this watch-and-wait approach, you'll likely need a test to check your blood-calcium levels at least twice a year and have the below mentioned monitoring tests done at least once a year.

• Bone mineral density test (bone densitometry). The most common test to measure bone mineral density is dual energy X-ray absorptiometry, or a DXA scan. This test uses special X-ray devices to measure how many grams of calcium and other bone minerals are packed into a segment of bone.

• Urine tests. A 24-hour collection of urine can provide information on how well your kidneys function and how much calcium is excreted in your urine. This test may help in judging the severity of hyperparathyroidism or diagnosing a kidney disorder causing hyperparathyroidism.

• Imaging tests of kidneys.We will also order X-rays or other imaging tests of your abdomen to determine if you have kidney stones or other kidney abnormalities.

Surgery

Surgery is the most common treatment for hyperparathyroidism and provides a cure in at least 90 percent of all cases. We will remove only those glands that are enlarged or have a tumor (adenoma). If all four glands are affected, we will likely remove only three glands and perhaps a portion of the fourth — leaving some functioning parathyroid tissue.

Surgery is usually done through a small neck incision in the lower part of your neck and you can usually go home after 12-24 hours.

If you have chosen to monitor, rather than treat, your hyperparathyroidism, the following suggestions can help prevent complications:

• Monitor how much calcium and vitamin D you get in your diet- I recommend 1,000 milligrams (mg) of calcium a day for adults ages 19 to 50. That calcium recommendation increases to 1,200 mg a day if you're a woman age 51 or older or a man age 71 or older. In addition, I also recommend 600 international units (IUs) of vitamin D a day for adults ages 19 to 70 and 800 IUs a day for adults age 71 and older.

• Drink plenty of water - Drink six to eight glasses of water daily to lessen the risk of kidney stones.

• Exercise regularly - Regular exercise, including strength training, helps maintain strong bones. Exercise program that involve weight bearing are the best for your bone strength.

• Don't smoke - Smoking increases bone loss as well as increase your risk of a number of serious health problems.

• Avoid calcium-raising drugs. Certain medications, including some diuretics (water tablets given for high BP) and lithium, can raise calcium levels. If you take such drugs, ask your doctor whether another medication may be appropriate for you

Many surgeons offer thyroid and Parathyroid surgery across India. Your cancer cure and complication from operation are heavily influenced by the expertise and skills of your surgeon. To avoid the risk of injury to the nerve to your voice box, it is important that no part of the thyroid gland is left behind over the nerve. This can lead to worse cancer outcome due to higher rate of cancer recurrence. If you have incomplete removal of the thyroid gland, we can not use blood test to monitor for cancer recurrence. In addition, the risk of injury to the nerve to your voice box is also higher in revision surgery.

By choosing me as your surgeon, you will be choosing someone who has extensive experience in quality thyroid and Parathyroid surgery in the best centers of UK, USA and Australia. I can ensure good quality operation with minimal risk of complications. The difference is in quality. You have one body and it deserves the very best.

If your cancer has spread to lymph nodes in the neck, I can do neck dissection at the same time. You can follow this link to learn more about neck dissection.

In addition, I can also offer robotic thyroid surgery, which will allow you to avoid any visible scar in your body. You can follow this link to learn more about robotic surgery.

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