In my last two Gimp posts, I discussed the fact that I need to have a Thyroid Lobectomy due to a suspicious tumor located in the left lobe of my thyroid. I also wrote about how the thyroid works and what it does for the body. In this blog entry, I will discuss thyroid nodules, thyroid cancers, and what happens after thyroid surgery.

Thyroid Nodules

Thyroid Nodules refer to some sort of growth in the thyroid that is not actual thyroid tissue. This could include cysts, benign tumors and malignant tumors. Thyroid nodules are actually quite common and the chances that someone has a nodule increases with age. Fifty percent of 50-yr olds will have at least one thyroid nodule. By the time the individual is 70 years old, the chance increases to 70%. However, it seems that thyroid nodules are about three times more common in women than men. About one in every 12 or 15 young women have a thyroid nodule compared to one in 40 young men.

Does a Thyroid Nodule Mean Cancer?

Thyroid Nodules are usually not cancerous. In fact, the chances of them being cancerous is quite rare. Some reports show that less than 1% of thyroid nodules are cancerous. Many small thyroid nodules go undetected and some people will never know they even have a nodule. But, bigger nodules are usually more noticeable and have a higher chance of being cancerous. If a thyroid nodule is detected, endocrinologists usually opt to perform a biopsy to sample the cells to determine whether the nodule is benign or malignant.

Thyroid Cancer

Though thyroid cancer is rare, it does happen. However, it is one of the most treatable cancers. Most thyroid cancers don’t easily metastasize (spread into other organs), especially if the malignant tumor is removed before it grows too large.

The most common type of thyroid cancer is papillary. About 78% of thyroid cancers fall under this category. Approximately 17% of thyroid cancer cases are follicular or Hurthle cell. And then the remaining cases generally fall under medullary or anaplastic. 97% of papillary and follicular cancers are “cured” when treated. However, anaplastic cancer, though extremely rare, is the most aggressive and has a low cure rate.

Hurthle Cells

Hurthle cells are a cell that looks bigger than a follicular cell and stains pink. My biopsy came back with a high level of Hurthle cells. Hurthle cells are a bit ambiguous because they can be present in both benign and malignant tumors. Reports vary in this respect, saying somewhere between 13 and 67% of tumors containing Hurthle cells are malignant. This is a huge spread! However, it seems that malignancy occurs more often in larger tumors. About 80% of tumors that are 4 cm or larger will be malignant. Tumors that are about 2 cm in size (which mine is) have a much lower chance of being cancerous.

Generally, a biopsy will not determine whether a tumor with Hurthle cells is malignant or benign. Instead, the whole tumor needs to be looked at to determine how Hurthle cells are actually behaving in the tumor. According to emedicine.com, whether this kind of tumor is benign or malignant “is based on vascular invasion and/or capsular invasion, as well as on permanent histologic sections or extrathyroidal tumor spread and lymph node and systemic metastases.” Basically, this requires that the whole tumor be removed to take a look at the behavior of the cells. Benign Hurthle cells do not generally come back once they are removed.

Follicular or Hurthle Cell Cancer

Follicular cancer is often lumped together with Hurthle Cell cancer into the same category, though they are actually a little different.

Follicular cancer is considered to happen in about 15% of thyroid cancer cases. It is more aggressive than the more common papillary cancer and has about an 8-13% of spreading to the lymph nodes. This particular type of cancer seems to be more aggressive as the age of the patient increases, with a definite difference occurring in patients over 40 years of age than under 40. The ability for this cancer to be cured depends on early detection. If it has not spread into the vascular system, it is highly curable.

Hurthle cell cancer is about 1/4 as common as follicular cancer and happens in about 4% of thyroid cancer patients. This cancer tends to occur in older patients, with the median age being 55 yrs. Hurthle cell cancer tends to be a bit more aggressive than follicular cancer, with about 10-33% chance of metastasizing. Like follicular cancer, the curability of Hurthle cell cancer depends on the extent of vascular invasion. Like most thyroid cancers, this seems to be related to the age of the patient and size of the tumor. Vascular invasion is seen more often in older patients. Generally, 75% to 90% of the cases are curable.

If My Tumor is Found to be Benign

If my tumor is found to be benign, I will have only half of my thyroid removed. Though the likelihood for the Hurthle cells to return is low, I will likely stay on Thyroxine for thyroid hormone replacement therapy. The idea behind this is that this will keep my thyroid from working too hard and will help prevent new tumors from forming. However, I will not be dependent on this medicine. My thyroid will still be working. If necessary, the remaining half of the thyroid will take over the full function of the whole thyroid.

If My Tumor is Found to be Malignant

If my tumor is found to be malignant, then I will need to have my whole thyroid removed. The chance that malignant Hurthle cells will return is much higher than benign Hurthle cells. This is why they whole thyroid gland is removed. It is possible, not not common, for the malignant Hurthle cells to return in other organs around the thyroid once the thyroid is removed. Generally, chemotherapy is not used to treat this kind of cancer unless vascular invasion is extensive.

After having my whole thyroid removed, I will be dependent on the synthetic hormone Thyroxine.

How does synthetic Thyroxine Work?

Thyroxine is a type of hormone that is produced by your thyroid, also called T4. Thyroxine in synthetic form (taken as a medication) is often called Levothyroxine, Synthroid, or Levoxyl. There are different levels of thyroxine which can be prescribed by a doctor. I currently am taking 88 mcg per day for thyroid hormone replacement therapy. However, if my whole thyroid is removed, I will likely be bumped up to 125 mcg.

As a reminder, T4 is used by your body to regulate metabolism. T3, also produced by the thyroid, has about 4 times the power of T4 in regulating metabolism. So, why are people without thyroids only prescribed T4 (Thyroxine) and not a T3 drug? Well, it’s because your body can do amazing things! A person without a thyroid can take synthetic T4 and the body will use that to produce. This will happen in the liver and kidneys, assuming these organs have enough cortisol. If not, a synthetic drug that has T3 in it can be taken. It is commonly called Cytomel or Liothyronine. However, if you can get your body to produce the needed about of T3, this is always better than a synthetic option.

In a Nutshell

Yes, my biopsy came back with Hurthle cells- a lot of them. But, given my age and the size of the tumor, it is not highly likely that the tumor is cancerous. Still, it’s better to know, I think, than to not know. It’s better to catch a cancerous tumor before it spreads to the lymph nodes than after. This is why I’m having the thyroid surgery.

Resources
1) Hurthle Cell Carcinoma- http://emedicine.medscape.com/article/279462-overview
2) Hurthle Cell Thyroid Tumor- http://www.endocrineweb.com/hurthle.html
3) Thyroid Cancer- http://www.endocrineweb.com/thyroidca.html
4) Thyroid Cancer: Follicular Cancer- http://www.endocrineweb.com/cafol.html
5) Thyroid Nodules- http://www.endocrineweb.com/nodule.html
6) Why Isn’t My Thyroxine Working?- http://endocrine-disorders.suite101.com/article.cfm/why_isnt_my_thyroxine_working

So, as promised, I’ll tell you a little bit about the thyroid.

For those who are completely clueless, the thyroid is located in the neck. Most people are aware of the “Adam’s apple”, which moves up and down as you swallow. Well, that is the thyroid cartilage. The thyroid is more or less located just below the Adam’s apple.

Here, you can see in this picture where the thyroid is located in the neck. The larynx is more or less the voice box and the trachea is the airway.

The thyroid has two halves on each side of the neck called lobes. They are connected by an isthmus.

The two major risks of thyroid surgery involve damage to the laryngeal nerve and to the parathyroid glands. The laryngeal nerve are the “vocal cords” and the parathyroid glands regulate the calcium levels in your body. In this picture, you can see just how close this nerve and gland are to the actual thyroid gland.

Why is the thyroid important?

Metabolism- Most people are familiar with the fact that the thyroid is involved in metabolism. Most people just don’t know how. Basically, the thyroid uptakes iodine. It’s the only organ in your body that actually uptakes and uses iodine. It takes this iodine and combines it with an amino acid called tyrosine to create two hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid glands typically produce a ratio of 80% T4 to 20% T3. However, T3 is about four times stronger than T4. These two hormones are sent through the blood stream where they are carried to cells. The hormones then pass through the cell membranes and allow cells to metabolize both carbohydrates and lipids. As with most hormone-secreting organs, the thyroid is regulated by the pituitary gland. The pituitary gland sends out more TSH (thyroid stimulating hormone) when T3 and T4 levels are low, and stops sending the TSH when levels are sufficient. The pituitary gland itself is controlled by the hypothalamus which is located in the brain. The hypothalamus basically tells the pituitary gland how much TSH to send out.

Other fuctions- There is no doubt that the thyroid,T3, and T4 hormones are involved in other functions in the body besides metabolism. The thyroid is involved in development of the brain in the fetus. This connection continues in childhood. Under-functioning thyroids in children have been linked to mental retardation. Thyroid hormones have large effects on a persons nervous system, cardiovascular system, and even reproductive system. Too much or too little thyroid hormone can adversely impact any of these systems. Thyroids can have a large effect on emotions as well. Under-functioning thyroids can trigger depression while over-functioning thyroids can cause a person to be anxious and even have insomnia. It is clear that the thyroid has a huge impact on many systems within the human body. Many of these impacts are still not fully understood.

Resources

How the Thyroid Works- http://www.endocrineweb.com/thyfunction.html

Mechanism of Action and Physiologic Effects of Thyroid Hormones – http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/thyroid/physio.html

When it rains it pours. That’s been my life in 2009. This year will go down as the year that my life was turned upside down and rebuilt from scratch. Not only have I moved to a new town and changed jobs, but I’ve had my share of medical issues. My left ACL was torn and rebuilt, I took a silly fall which resulted in a small scratch that turned into a huge infection, and now I will be having a thyroid lobectomy.

Lets rewind to 6 years ago. It was the end of the school year and I was visiting a doctor (a PA to be exact) in Boulder because I had an unimaginably painful sore throat. While I was swallowing, she noticed a small lump in my neck. She said, “Do you have a thyroid nodule.” “Huh?” She recommended I get the lump checked out by the Boulder Medical Center’s endocrinologist.

So, I did. The endocrinologist I saw there was an unpersonable old man who had a very matter-of-fact way of treating a thyroid nodule. He basically told me that I had a tumor in my thyroid, which may or may not be cancerous- like it it was no big deal. As I spiraled through the emotional roller-coaster of how this was going to impact my life, the doctor decided to do biopsy. He told me it came back with only cystic fluid, so the tumor must be benign. But then he came out with this- “Oh, but you need to take thyroid medication for the rest of your life.” Typical doctor. Like it’s no big deal I’m on some medication for the rest of my life.

He put me on Synthroid, a thyroid hormone. Basically, he was treating me with thyroid hormone replacement therapy. Your thyroid produces hormones which are eventually involved in regulating your metabolism. By replacing this hormone, a message is sent back to the thyroid that there’s enough in your system, so it doesn’t need to produce as much of this hormone. Essentially, the thyroid barely does any work anymore. It’s put on retirement. The theory behind this is by preventing the thyroid from having to do much work, the thyroid nodule will hopefully keep from growing any larger.

So, I stayed on this plan for a number of years. But the move to Crested Butte made me seek out new health insurance and new doctors. In June, I saw Dr. Maruca, an endocrinologist located in Grand Junction. He took one look at my old medical records and basically told me they were a load of horse-crap. My old endocrinologist simply didn’t keep good records. There was no record of the original size of the tumor, to compare and see if it was growing. And I distinctly remember doing two biopsies in Boulder, yet record of the second had mysteriously disappeared.

But, the worst news was that my old biopsy was in fact inconclusive. Dr. Maruca explained to me that to have a true idea of what is actually in a thyroid nodule, solid components need to be obtained from five different sections of the tumor. Well, I remember the biopsy needle poking into my neck five times (how could I forget that!), yet it came back with mere blood smears. There were no solid components. So, in essence, whether the tumor was malignant or benign was inconclusive. Yet, my doctor at the time decided to tell me it was benign. Because of this, Dr. Maruca suggested that I have another biopsy. Believe me, I wasn’t thrilled about having a needle poked into my neck five times again. But, I saw the value in it. Plus, due to my ACL surgery earlier this year causing me to meet all insurance deductibles, the otherwise costly biopsy would be basically free.

I did the biopsy and then went home. I kind of put the whole thing out of my mind. Though, I was expecting a phone call. But, doctors rarely call when things are fine. They just don’t. So, that’s what I assumed was going on. I assumed my test results were fine. But then one afternoon at the end of June I checked a message on my voice mail and it was Dr. Maruca himself. “This can’t be good,” I thought to myself. So, I called him the next morning.

Dr. Maruca basically informed me that the results of my biopsy had come back from the pathologist having a specific kind of cell that may or may not be cancerous. He went on to explain that you can’t tell if this cell is cancerous until you take a larger sample, which would involve thyroid surgery. “There’s about a 1 in 20 chance that it’s cancerous,” he said, “I think you should just have your whole thyroid out.”

The thought of having my whole thyroid removed was not new to me. This was presented to me as an option by my old endocrinologist, although he did not recommend it. Thankfully, I was able to work past Dr. Maruca’s matter-of-fact statement that I need to have surgery to remove my whole thyroid and ask the right questions. He investigated my medical records further. And I did some research on the Internet. With all that is at stake between cancer vs. my metabolism being messed up sans-thyroid I decided that the best route for me was to have a partial thyroid removal.

Today, I visited Dr. Harthorne, an otolaryngologist/surgeon in Grand Junction who will be performing my surgery. I was able to set a surgery date- it will be Monday, August 3rd. And he was able to answer the last few remaining questions I had about the procedure. Based on the research I’ve done and what Dr. Hartshorn explained to me, I will do my best to explain the procedure.

The surgery is done with general anesthesia. They pump your neck full of saline, so this can make your neck very sore. But, this allows them to make a smaller incision which will scar less. The saline will be used to expand the working area. They will take great measures to protect my parathyroid gland, which regulates calcium levels, and also my vocal cords which can easily be damaged in this surgery. The surgery will last somewhere between 1.5 – 3 hours.

The thyroid is divided into two lobes on the right and left side of your neck, connected by something called the isthmus. Since the tumor lies my left lobe, this half will be completely removed. Thyroids are a unique organ in the sense that they have a huge blood supply. Blood is always being fed to the organ. This makes removal of a partial lobe basically impossible. They can’t remove just the tumor itself because the thyroid tissue around it will bleed too much. This internal bleeding can cause a lot more problems than actual removal of the thyroid itself. So, if a tumor is found in a lobe, the whole lobe must be removed.

Remember, the reason why they are removing this left thyroid lobe on me is to be able to take a better look at the tumor. They want to determine if it’s cancerous or not. So, they will take out the lobe, remove the tumor, instantly freeze it, and then slice it. This is called a “frozen section”. They will send this frozen section down to pathology where they will run tests to decide if it is benign or malignant. If it is malignant, the other half of my thyroid will need to be removed, on the spot. If the tumor is benign, or even if it is questionable if it is benign or malignant, they will leave the right half of my thyroid in tact. Here, there is a small risk that I may need to have another surgery to take out the right half of my thyroid – if the tumor is questionable, and they have to do more extensive tests that cannot be done within the timeline of my actual surgery. But, this is a small risk.

When the surgery is all said and done, there are risks of certain side-effects. Aside from the normal problems with possible nausea and infection associated with all surgeries, I will likely have trouble swallowing and eating for a few days. But there are two relatively common side effects that pertain directly to this surgery. One is damage to the parathyroid gland. This gland regulates calcium levels. There is one of these glands on each side of your neck. With a partial thyroid removal this is hardly a problem, because if one parathyroid gland is damaged, the other just takes over. But, another main risk is damage to the vocal cords. Vocal cords can be severed in this surgery, which results in completely losing the voice, permanently. But, this risk is rare. More common is damage to the vocal cords which causes them to become temporarily paralyzed. It is not uncommon for people who’ve had thyroid surgery to lose their voices for somewhere between 1 and 3 months.

I must say, this vocal cord thing is my greatest concern. I suppose I can handle losing my voice for a couple of months. But, to lose it permanently would be devastating. I mean, I can’t be a teacher if I can’t talk. It just won’t work. But, the doctor saw my concern about this and elaborated . He explained that there are two vocal cords and the likelihood of both being severed is very very rare. He said that the vocal cords work by kind of squeezing together back and forth. If one is severed, a gap occurs which prevents the full squeezing from happening. But, a plastic implant can be surgically placed there to allow the other vocal cord to squeeze it instead, making it so you can have your voice back. Knowing this bit of information has calmed me considerably.

If I have half of my thyroid removed, I don’t need to spend the night in the hospital. But, if it turns out that I need to have both lobes removed, I will have to spend one (or more if my calcium levels are not right) nights in the hospital.

Generally, the first few days after the surgery will suck, obviously. But, it seems that most people continue regular activities within 2-3 weeks after surgery.

Check back, for more blogs about this. I’ll be doing some blogs about how the actual function of the thyroid as well as what my life will be like with only half a thyroid.

For those who care, I found this to be one of the best sources of information about the surgery I’ll be having.

Texas Center for Facial Plastic and Reconstructive Surgery

Thanks for reading!