Thyroid for Dummies (28 page)

Therefore, many surgeons do a near-total thyroidectomy, leaving a small piece of one lobe of the thyroid intact, when the tumour is this small.

Other surgeons elect to do a total thyroidectomy on all thyroid cancer patients. They offer fairly convincing arguments:

ߜ The morbidity and mortality rate of this surgery in their hands is very low.

ߜ Thyroid cancer is often bilateral, meaning that it affects both lobes of the thyroid. If radiation is the cause of cancer, it’s almost always bilateral.

ߜ Scanning for evidence of new tumours, and treating any new tumours, is much easier when no thyroid gland remains to take up radioactive iodine.

ߜ After surgery, levels of thyroglobulin in the blood fall to zero. Therefore, if blood tests later show that a patient’s thyroglobulin levels are rising, that’s a strong indicator that a tumour is recurring.

After all or part of the thyroid is removed, the question arises as to whether to remove lymph nodes, especially if none are enlarged. The British Thyroid Association and the Royal College of Physicians of London guidelines recommend that all lymph nodes in the central compartment of the neck be removed because cancer often spreads there first. Other nodes along the sides of the neck are felt and, if any suspicious nodes are discovered, biopsies are taken and sent for immediate analysis. If the pathologist confirms that the cancer has spread to these nodes, then lymph nodes on the side of the neck are carefully dissected out, too. This procedure is called a
modified radical neck dissection
.

A more extensive form of this surgery, called an
unmodified radical neck dissection
, involves removing muscles and other tissues, too. No study has ever shown that this extensive surgery improves mortality rates and, as it leaves the patient disfigured for no reason, is now rarely required.

If surgery is deemed necessary, the surgeon attempts to remove as much cancer and thyroid as possible if the tumour is the undifferentiated (anaplastic) type (refer to Chapter 8). By the time surgery is performed, these tumours usually have already spread, but surgery can sometimes slow the inevitable local spread of this aggressive type of cancer.

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A tumour of the medullary type (refer to Chapter 8) is managed with a total thyroidectomy and the removal of the central nodes around the trachea; lateral nodes to the side of the thyroid are removed only if they are visibly enlarged. Medullary tumours often secrete hormones that cause diarrhoea or stimulate the adrenal gland, so removing as much tissue as possible prevents or reverses these complications.

Papillary cancer (refer to Chapter 8) with tumours greater than 1 cm in diameter, plus nodes or secondaries, and those with familial disease or disease due to radioactive exposure, undergo surgery for a total thyroidectomy and local lymph nodes. With a small papillary thyroid cancer of less than 1 centimetre in diameter with no nodes or signs of secondary malignant growths, surgery involves removal of just the thyroid lobe in which the cancer is situated, plus the middle bit of the thyroid (isthmus). This operation is called a
lobectomy
and leaves part of the thyroid intact as the chance that cancer has spread into the other lobe is small.

For follicular cancer (refer to Chapter 8), a lobectomy is performed where the tumour is confined to the thyroid gland.

If a surgeon has any concern about bleeding after surgery, or if so much tissue is removed that a large space is left in the neck, the surgeon leaves a drain in the wound. A drain is needed only rarely and is usually removed after a day or two in any case. The drain helps prevent fluid accumulation and results in a better cosmetic outcome.

Considering a New Approach

Recently, some surgeons are trying a less invasive approach to thyroid surgery called
endoscopic thyroid surgery
. This type of surgery is done when a diagnosis of cancer is uncertain and they just want to remove a nodule for examination under a microscope. A tiny tube is inserted in the neck, and a stream of carbon dioxide gas opens up the area. The surgeon uses high magnification to see the area in excellent anatomical detail. Another tube inserted into the area has a cutting edge that allows for removal of the nodule. The result is a less unsightly scar and a quicker return to activity for most people, although the amount of pain that these patients feel is about the same as for those who have a conventional operation.

This surgery may take a little longer than an open operation. If cancer is found during the endoscopic surgery, the surgeon usually opens the neck to proceed with an open, total thyroidectomy. However, this operation is promising as a 19_031727 ch13.qxp 9/6/06 10:46 PM Page 155

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way to avoid large scars and shorten the time between surgery and returning to work. As surgeons gain more experience with this method, it may start to replace the open operation.

Possible Complications

The section ‘Recurrent laryngeal nerves’ earlier in the chapter tells you what happens if you suffer recurrent laryngeal nerve damage or the loss of parathyroid gland function. You need to know about a few other possible complications from thyroid surgery that, although rare, do occur.

One complication is bleeding. If bleeding occurs, it happens in the first few hours after surgery and occasionally prompts the surgeon to go back in and tie off the bleeding vessels. Placing a bandage over the site of the operation is often necessary. If the bandage is too tight and bleeding occurs, the bleeding can compress the trachea and cause breathing difficulties.

Any surgery also opens up the possibility of wound infection, which responds to antibiotics.

Major operations also thicken the blood as a result of inflammation, immobil-ity, and sometimes dehydration. As thickening can lead to unwanted and potentially dangerous blood clots in the deep veins of the legs, steps are taken during the operation to help prevent these deep vein thromboses. The precautions include wearing graduated compression hose (stockings) and the use of pneumatic devices that compress your calves during surgery to stop blood pooling in your legs. In some cases, injections of heparin, which thins the blood, are given as well.

Recuperating After the Operation

Anyone who has had extensive removal of their thyroid needs to take thyroid hormone replacement tablets for the rest of their life. If the operation is for thyroid cancer, you are given enough thyroid hormone to mildly suppress your thyroid-stimulating hormone (TSH).

Most people leave the hospital the same day of the surgery if no complications develop, which is usually the case.

The usual recovery time from the surgery is about a week. During that time, you feel some neck stiffness and tenderness. Your throat is sore and your voice is hoarse. You have a cough for a few days and feel some pain when 19_031727 ch13.qxp 9/6/06 10:46 PM Page 156

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you swallow. The scar becomes hard initially and then softens over the next few months. Occasionally, a person forms a very thick scar called a
keloid
.

Unfortunately, attempts to remove a keloid with plastic surgery often result in new keloid formation. Fortunately, the appearance of most healed scars is improved by applying an adhesive, silicone gel sheet (for example, Cica-Care and Boots Scar Reduction Patches) that flatten, soften, and fade red and raised scars. Another approach is to massage in Rosa Mosqueta oil, which is pressed from the seeds of an Andean wild rose. The oil is exceptionally rich in linoleic and linolenic essential fatty acids that also help to improve the appearance of scars.

The only recommended post-operative restriction is that you should not sub-merge the wound in water for the first day or two. You can drive a car as soon as your head can turn without difficulty. Many people are back at work in two weeks. The surgeon often wants to see you again about three weeks after surgery to check on your results.

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Chapter 14

Exciting New Approaches

in Thyroid Treatment

In This Chapter

ᮣ Dealing with excessive iodine

ᮣ Understanding subclinical hypothyroidism

ᮣ Managing hyperthyroidism

ᮣ Shrinking nodules and goitres

ᮣ Overcoming thyroid cancer

ᮣ Correcting iodine deficiency

This chapter tells you about a selection of the most important discoveries in thyroid medicine during the last few years. Single studies of a subject are sometimes revised or even overturned when someone else does a similar study, so keep an open mind when new (and not necessarily validated) material such as this is presented.

Appendix B in this book points you towards Web site resources that are updated more frequently than is possible for a book, so don’t hesitate to make use of these as well.

Preventing Ill Effects of

Large Doses of Iodine

Many of the agents that allow radiologists to view the insides of things, such as the bowels, contain a lot of iodine. Just how much does all this iodine affect thyroid function? That uncertainty was what a group from Germany studied and published in the periodical
Endoscopy
in March 2001. They looked at 70 people who didn’t have known thyroid disease (TSH normal), all of whom needed a test called – take a deep breath – an
endoscopic retrograde
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cholangiopancreatogram
or ERCP for short. This study involves placing a tube into the bile duct system and injecting an iodine-containing agent to look for bile stones or other obstructions. Each person gets a large dose of iodine in the process. The thyroid glands of these people were studied with an ultrasound examination (refer to Chapter 4) prior to their bile duct tests, which divided them into four groups based on thyroid gland size and the presence or absence of previously undiagnosed nodules.

The researchers found that the iodine causes a lasting decrease in thyroid-stimulating hormone (TSH), especially in those who have large thyroids with nodules. The free T3 hormone level increased in all of them, but the free T4

level increased particularly in the people with enlarged nodular thyroid glands.

The amount of iodine excreted in their urine greatly increased after the test.

The conclusion of the study is that, before giving someone an iodine-containing contrast agent, it is a good idea to evaluate them first with a thyroid ultrasound, rather than relying on TSH measurement. This two-step procedure identifies those at high risk for developing hyperthyroidism as a result of the iodine exposure.

If you need a test that requires you to receive a large dose of iodine, ask your doctor to check your thyroid carefully prior to the test. A thyroid ultrasound is probably the best test to rule out thyroid disease in this situation. The ultrasound can help you and your doctor prepare for the consequences of giving a lot of iodine if you have an abnormal thyroid gland.

Finding Out More about Hypothyroidism

Many recent studies focus on the proper treatment of hypothyroidism. The following sections offer just a sampling of the research carried out in the last few years. (Check out Chapter 5 for the symptoms of hypothyroidism –

underactive thyroid function – and what causes it.)

Treating (or not treating) subclinical

hypothyroidism

One of the great debates in thyroid management is what to do about subclinical hypothyroidism. This condition is where someone’s TSH level is slightly elevated, their free T4 level is normal, and they have some non-specific symptoms that may result from hypothyroidism or something else. Doctors have looked for signs of low thyroid function or a response to thyroid medication in these people, as they are unsure whether or not treatment is necessary.

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One study from Italy, published in the
Journal of Clinical Endocrinology and
Metabolism
in March 2001, looked at the function of the heart in 20 people with subclinical hypothyroidism, all of whom showed some abnormality in heart activity. Half the study participants were given thyroid treatment, and the other half was given a placebo. The study found that people given the thyroid treatment drug showed an improvement in heart function, while those given a placebo showed no change. The conclusion was that people with subclinical hypothyroidism have measurable abnormalities that are improved with thyroid treatment.

Another study from Germany, published in
Thyroid
in August 2000, looked at heart disease and heart attacks in people with subclinical hypothyroidism.

The author found a definite increase in heart disease and heart attacks compared with people without the condition. Various tests of normal heart function, such as changes in heart rate with exercise, indicated that those functions were impaired in people with subclinical hypothyroidism. The most at-risk people were women over the age of 50 who smoked and had elevated TSH levels. Giving thyroid medication improved these functions and also improved the levels of fats in the blood. The author of this study felt that these changes justified the use of thyroid treatment in subclinical hypothyroidism.

The author notes, however, that giving a patient replacement thyroid hormone tends to speed up the heart rate and may worsen chest pain, which is an important consideration when treating someone with this condition.

However, researchers at the University of Pennsylvania School of Medicine recently published a paper, in the March 1, 2006 issue of the
Journal of the
American Medical Association
, claiming that leaving a mildly underactive thyroid gland untreated does not lead to an increased risk of cardiovascular disease – at least in older people. These scientists measured thyroid function in 3,200 men and women, aged 65 or over, none of whom were taking thyroid hormone replacement. Participants were divided into groups based on their thyroid function and then followed for 13 years. They found that 15 per cent of the study population had a mildly underactive thyroid gland, and that they showed no greater risk of developing a heart attack, stroke, or death from any other cause, than those with normal thyroid function. Of those who had mildly overactive thyroid glands (subclinical hyperthyroidism), 1.5 per cent had an increased risk of developing an abnormal heart rhythm or atrial fibrillation, but even so, they did not have an increased risk of cardiovascular threats such as heart attacks or stroke, either.