Head and Neck Surgery Consultations

Kevin T. Brumund, M.D.
Appointments:  (858) 822-6197

Consultation for Thyroid Nodule

This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most commonly-encountered patients with this specific disorder. Where gender, age, or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.

The patient is an adult, but could just as well be a child with an unusual vocabulary. The patient could be male or female. The patient could even be you.


Doctor:   Hello, I am Dr. Brumund.  It’s a pleasure to meet you. How are you today?

Patient:    I am fine, thank you.

Doctor:     I understand you are here to see me for evaluation of a thyroid nodule. Is that correct?

Patient:     Well, I went to my primary care doctor, who I have been seeing for many years, and she noticed that I have a lump in my neck and recommended I see you.

Doctor:    Prior to her pointing this out to you, is this something you had noticed?

Patient:    You know, I had noticed a little sort of lump there, but I guess it has been there a long time, and I have been trying to ignore it.

Doctor:    Has it caused you any pain or discomfort?

Patient:    No.

Doctor:    Have you noted any change in your eating, breathing, chewing, or swallowing, or change in your voice?

Patient:    Not that I recall.

Doctor:    Very good.  Have there been any recent changes in your weight, energy level, digestion, hair, or skin?

Patient:    No; I am 35, and my skin has started to get dryer, particularly in summer time, but I haven’t noticed any other changes.

Doctor:    Do you have any family history of any thyroid disease, thyroid nodules, or thyroid cancer?

Patient:    I think my grandfather had cancer in his thyroid gland, and one of my uncles did, too.

Doctor:    Do you have any personal history of exposure to ionizing radiation, excessive amounts of radiation, other than x-rays? 

Patient:    When I was in high school, we lived in a small town in the Midwest. I had pretty bad acne and was treated with some radiation, but that was just on the skin.

Doctor:    Do you have any other medical problems?  Do you take medication for anything?

Patient:    I occasionally take pills for anxiety. I try to take vitamins, but nothing else.

Doctor:    Any allergies to medications?

Patient:    I am very allergic to penicillin.

Doctor:    What happens when you take that?

Patient:    When I was five, I was given penicillin and broke out in a rash all over my body.  I was told not to take it again.

Doctor:    If it’s ok with you, I would like to perform a comprehensive head and neck exam now.

Patient:    That would be fine.

The examination is performed.

Doctor:    After performing a comprehensive head and neck exam, I do feel that you have a mass, or lump, growing within your thyroid gland. The thyroid gland sits low in the center of the neck over your trachea, or windpipe.  It consists of two halves, or “lobes,” a right and left, and I believe there is a mass within the right lobe of your thyroid gland.

Patient:    When you say mass, Doctor, does that mean cancer?

Doctor:    It is too soon to tell, and I certainly can’t predict that right now.  We need to gather more information to determine exactly what the mass in your thyroid gland is.

Patient:    Then what does the word “mass” mean?

Doctor:    “Mass” just means a growth; it is a very generic, non-descript term.

Patient:    So what do we do now?

Doctor:    I would like to do a couple of things.  The first thing I would like to do is called a “fine needle aspiration” biopsy, and that is something I can do here in clinic. I will pass a needle into the mass in an attempt to obtain a cell sample. This will be looked at under the microscope, to see if we can determine whether or not it is cancer.

Patient:    Do you use any local anesthesia, like they do at the dentist?

Doctor:    No, the procedure is well tolerated. I just pass the needle into the mass. You certainly will feel the needle stick, but it is brief and quite tolerable.

Patient:    What happens then?

Doctor:    We will send this off to the pathologist, who will take a look at it under the microscope.  I will see you back next week to discuss the results of the biopsy. Also, in order to check the function of your thyroid gland and the level of your thyroid hormone, some blood will be drawn today.

Patient:    What test are you going to order?

Doctor:    One test is called TSH, or thyroid stimulating hormone.  The other test is called T4, or thyroid hormone.

Patient:    Somebody was telling me something about parathyroid. Do you check that?

Doctor:    The parathyroids are glands that lie near the thyroid gland. They have a different function within the body. At this point, I don’t think that this mass is originating from the parathyroid gland, but from your thyroid gland, instead.
   
Patient:    If you were checking for that, what blood tests would you order?

Doctor:    We would order a different test, called the parathyroid hormone, and we’d also check the levels of calcium and phosphorous in your blood.

Patient:    When do I see you again?

Doctor:    I will perform the fine needle aspiration biopsy today and see you back next week.

Patient:    Great. Thank you, Doctor.

The patient returns the following week.

Doctor:    Good afternoon; good to see you back. How are you doing?

Patient:    I am a little nervous about this, but otherwise I am fine.

Doctor:    I understand. Your blood test results regarding your thyroid function were normal. We did get the results of your biopsy back, and unfortunately, it revealed some suspicious cells that are concerning for thyroid cancer.

Patient:    Cancer, Doctor?

Doctor:    Yes. I am sorry to say that the cells revealed what is called papillary thyroid cancer, which is the most common type of cancer we see in the thyroid gland.

Patient:    Is that bad?

Doctor:    On the surface, having any cancer is bad.  This type of thyroid cancer, which we call well-differentiated thyroid cancer, actually has a very high success rate with regard to ultimate cure, but it does need to be treated, just like any cancer does.

Patient:    How did I get this?

Doctor:    It is difficult to know. There certainly are some risk factors for thyroid cancer, and you actually have one of them. You did tell me that in your adolescence, you were exposed to some ionizing radiation to your neck for some acne.  That is a documented risk factor for thyroid cancer.

Patient:    And that caused this cancer?

Doctor:    It is difficult to know that with certainty, but it is a known risk factor.

Patient:    What are other risk factors?

Doctor:    There are certainly familial types of thyroid cancer.  Having a family history of certain types of thyroid cancer can be a risk factor.

Patient:    Do you think my grandfather’s cancer caused this?

Doctor:    I don’t believe so, based on the type of cancer that the needle biopsy showed.

Patient:    So what do we do now?

Doctor:    There is a standard approach to the treatment of this type of thyroid cancer.  As I mentioned earlier, it ultimately leads to a very high cure rate.  There are two parts to the treatment, the first being surgery, and the second being what we call iodine ablation of the thyroid. The surgery calls for removal of your thyroid gland in its entirety, and any surrounding lymph nodes that appear to be enlarged, through an incision low on your neck.

Patient:    Will you do this in the office like you did the needle biopsy?

Doctor:    No. This procedure is done under a general anesthetic in the operating room. It is an inpatient procedure, and you would stay in the hospital for a day or two afterward.

Patient:    Is there going to be a scar on my neck?

Doctor:    Yes, there will be a short scar, low on your neck.

Patient:    I will be in the hospital for two days?

Doctor:    One or two days after the surgery; that is correct.

Patient:    Is it going to hurt?

Doctor:    As in any surgery, you certainly will have some discomfort in the neck, where we were working.  We will manage that appropriately with pain medication after the surgery.

Patient:    How long will I be out of work?

Doctor:    It is difficult to predict. I tell most people to plan on taking at least a full week off from work after this type of surgery.  Depending on how you feel and what you do, it might take more then a week to resume your normal energy level.

Patient:    Can I go to the gym?

Doctor:    I recommend avoiding strenuous exercise for about two to three weeks after surgery.

Patient:    Are there risks to the operation?

Doctor:    Yes, there are risks to any surgery. The general risks in any operation include the risk of a general anesthetic, along with the risks of bleeding, infection, and damage to nearby structures.  There are two important structures at risk during any thyroid surgery.  The first is called the recurrent laryngeal nerve, and that is the nerve to the vocal cord.  There is one on each side, and anytime we operate on the thyroid gland, that is at risk. We do everything we can in the operating room to identify and preserve this nerve, but there is a risk of temporary or permanent voice change after surgery.

Patient:    When you say voice change, what are we talking about?

Doctor:    You would experience a hoarse voice, a weak voice.

Patient:    In the end, does that recover?

Doctor:    It depends on whether the nerve was just injured to give it temporary deficit, or whether it was injured significantly, so that the function did not return.

Patient:    Does it ever happen that you cut it on both sides?

Doctor:    That has been described, and that could result in you having significant breathing difficulty.

Patient:    Are there other problems?

Doctor:    The second main risk in any thyroid surgery is the risk of injury to the parathyroid glands. There are four glands, usually two on each side, that help regulate your body’s calcium metabolism.  If for some reason all four are damaged during surgery, you would have a risk of either temporary or permanent low blood calcium that would require that you take calcium supplements.

Patient:    My husband and I were reading about thyroid cancer. We read there are other kinds of thyroid cancers. What are they?

Doctor:    There is another type of well-differentiated cancer like yours, but that one is called follicular carcinoma.

Patient:    How is that different; is it better or worse?

Doctor:    It is treated the same way, and has a very high cure rate, as well.

Patient:    If the cancer only involves half of my thyroid, mainly the lobe on the right side, why are you taking out the whole thing?

Doctor:    That relates to the second stage of treatment after surgery, the radioactive iodine ablation. This involves taking a dose of radioactive iodine, also called iodine 131 or I131. You will take a pill of radioactive iodine, and if there are any thyroid cells left in your body, especially thyroid cancer cells, they would take up this radioactive iodine and be destroyed.

Patient:    I don’t understand why that is necessary. When you do the operation, aren’t you going to take the cancer out?

Doctor:    I certainly will do my best to take all the cancer out by removing your entire gland, but if you can imagine, there may be just single cells, or very small clusters of cancer cells in the area, that I can’t see.  Essentially, the iodine 131 acts to mop up any cancer cells that may still reside in your body.

Patient:    Does this cancer ever spread elsewhere?

Doctor:    It can. It primarily spreads to the lymph nodes in your neck first, and then it can spread to your lungs. At this point you show no indication that it has spread anywhere in your body. I don’t feel any enlarged nodes in your neck, but again, if there were any spread on a level that I could not detect, the iodine 131 would treat that, as well.

Patient:    Is this going to change how long I live?

Doctor:    It is unlikely, given your age. With appropriate and timely treatment, I believe we have a greater than 90% chance of this being cured.

Patient:    Is there anything else I should be asking you?

Doctor:    No. I believe we have covered everything I wanted to relate to you and your husband.

Patient:     What is my next step?  We have talked about this, and I would like to proceed with the surgery as soon as possible.

Doctor:    I understand. I will have my nurse come in and discuss it with you further. We will get to work scheduling the surgery.

Patient:    Thank you.

Doctor:    You are welcome.

Patient:    If you take out the thyroid gland, does that affect your daily life, or does it do anything?

Doctor:    That is a great question. As a caveat of us doing the surgery and removing the thyroid gland, you will need to be on lifelong thyroid hormone replacement. You will take a pill, a thyroid hormone supplement, every day for the rest of your life. Thyroid hormone is essential to life and your daily activities.

Patient:    One of my friends took a thyroid pill and lost weight. Do you think that will help me?

Doctor:    If that was the case, she was probably not on the correct dose. The appropriate dose will maintain your weight. If the dose is too high, you could lose weight inappropriately.

Patient:  Thank you.

Doctor:  You’re welcome.