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BackTable / ENT / Podcast / Transcript #35
Podcast Transcript: Thyroid Nodules
with Dr. David Goldenberg
Dr. David Goldenberg talks with us about the management of thyroid nodules, including workup, imaging and patient counseling. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Evolution of Thyroid Nodule Treatment
(2) Ultrasound for Thyroid Imaging
(3) Criteria for the Use of Fine Needle Aspiration
(4) Addressing Indeterminate FNA Test Results
(5) Dealing with Discrepancies Between Ultrasound and FNA Results
(6) Working Up Numerous Nodules
(7) The Role of Non-Ultrasound Imaging in Thyroid Nodules
(8) Strategies for Surgical Decision-Making in Various Cases
(9) Care Management for a Patient Undergoing Thyroid Surgery
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[Ashley Agan MD]
Hey everybody. Welcome to the BackTable ENT podcast. Our mission here is to bring you high quality otolaryngology content that enhances your medical education and gives you answers to those burning questions that pop up in your day to day work. We accomplished this through thought provoking conversations with experts in the field.
And we hope that you can take this information and apply it to your practice. Quick introductions; my name is Ashley Agan, and I'm a general ENT practicing in Dallas, Texas.
[Gopi Shah MD]
And my name is Gopi Shah. I'm a pediatric ENT in Dallas, Texas at UT Southwestern. So excited to be here today. Ash, how are you doing this morning?
[Ashley Agan MD]
I'm here Gopi, I'm a little bit nasally, little allergy ragweed going on down here in Texas. But excited to be here, excited for our guests today.
[Gopi Shah MD]
Yes. So let's get to it. We have Dr. David Goldenberg. He's a professor and chair of the department of otolaryngology at Pennsylvania State University in Hershey, Pennsylvania. He's a head and neck surgical oncologist. He was educated at the Ben Gurion University in Israel. After completing his residency in otolaryngology head-neck surgery at Rumba Medical Center in Haifa, Israel, he went on to do a three-year fellowship in head-neck surgery and oncology at John Hopkins. The hospital in Baltimore, Dr. Goldenberg just published a comprehensive textbook, Head and Neck Endocrine Surgery. And he's here today to talk to us about evaluation and management of thyroid nodules in adults.
Welcome to the show Dr. Goldenberg.
[David Goldenberg MD]
Thank you so much Gopi.
[Gopi Shah MD]
So Dr. Goldenberg, can you just first tell us a little bit about yourself and your practice.
[David Goldenberg MD]
Sure. So I'm a head-neck oncologist and I've been at Penn State for maybe 16 years. I guess my practice has evolved into primarily endocrine, so, thyroid and a lot of parathyroid disease. And we have a very robust practice. We're the only academic institution in central Pennsylvania.
So all comers from New York down to West Virginia come to us. We see all manners of pathology and I'm excited to talk to your listeners about thyroid nodules because there has been an evolution.
(1) The Evolution of Thyroid Nodule Treatment
[Ashley Agan MD]
Yeah, I think that's one of the things I'm most looking forward to hearing from you about because I think, you know, when we think about thyroid nodules, historically we were, we were maybe over-treating them. Right? And then now maybe there's some newer ways to make more conservative... how do I say? There's ways to, you know, do some more active surveillance or other things where maybe we aren't taking out as many, you know, maybe not every thyroid nodule needs to come out.
Can we get into kind of how these patients present to you and what that looks like?
[David Goldenberg MD]
Ashley, that's a really good point. And when I mentioned that I've been here for 16 years, I can tell you that the way we looked at and treated thyroid nodules and thyroid cancer back then was very different than we do now. And you're right. We are more conservative. We are doing less, what I guess we can call now in retrospect, unnecessary surgery, which is certainly good for the patient. The vast majority of patients present with an incidentally found thyroid nodule. They fell off a ladder. They had an accident. Their place of business sent them for a free screening, a Doppler of the carotid system. Vast majority. Every now and again, you have a patient who comes in because their gynecologist did a really thorough exam and found a nodule.
But, the overwhelming majority of these are incidentally found, which is kind of important because that scares patients. It really scares them to know that there is something. Now, thyroid nodule is very common. I wouldn't even call it a pathology, but that's not the way a lot of patients see it. So, yeah, that's the way the vast majority come, I'd say 90, 95% of the patients come in with an incidentally found thyroid nodule.
[Gopi Shah MD]
Of the patients that you see Dr. Goldenberg and Ash, how often can y'all palpate them? Like, is this something you're like, “oh yeah, I feel this.” Or it's truly the screen and when you examine the neck, you don't really feel much. Is that common?
[David Goldenberg MD]
Typically, if the nodule is about a centimeter or large you can palpate it. Sometimes patients are now sent to us because of the high-resolution imaging techniques that we have. Sometimes patients are sent in with a very small nodule and admittedly, I can’t palpate it, but to the patient it's still there. Oftentimes they don't really care what the size is.
[Ashley Agan MD]
Yeah. That's what I see a lot too. Sometimes I'll just be like, you know, I really, I don't feel it, but you know, it's there, it's this big, you know, so then what's next? What imaging do you like do patients already come in? I mean, let's say they came in with the cervical MRI, you know, looking at their neck pain and it happened to pick up maybe a nodule.
Is that good enough? Or do you, what's your imaging modality of choice?
(2) Ultrasound for Thyroid Imaging
[David Goldenberg MD]
Well, the imaging modality of choice for anything thyroid, whether it's in the thyroid or in the neck is the ultrasound, the good old-fashioned, inexpensive, non-radiating ultrasound. And it's an interesting point. If they come in with their MRI, that's wonderful. I don't really like it when they were sent specifically for an MRI for a five-millimeter nodule, but it happens sometimes again, you know, when patients are referred into our practice specifically for this, oftentimes they come in with all kinds of imaging, but ultrasound is the tried, true, tested imaging modality.
[Ashley Agan MD]
Do you do any ultrasound, in your clinic or are most of your ultrasounds done in your radiology department?
[David Goldenberg MD]
I am fully credentialed to do ultrasounds and I'll do them every now and again myself, if I think it will add something. A lot of times the patients are sent to radiology, just because of timing. Just takes a while and sometimes patients will come in with an ultrasound already performed.
So there's really, it's a whole bag of, but certainly in our offices, we'll do an ultrasound if we think that it will add something, yeah. Labs typically TSH, if it hasn't been done, is the only thing you really need. And that's just to rule out a, you know, a toxic nodular goiter, incredibly rare in this day and age.
[Gopi Shah MD]
I assume that usually if there's a concern for a thyroid nodule, and you send them for an ultrasound thyroid you also have them scan the neck, both sides, one side?
[David Goldenberg MD]
Gopi. That's a really interesting point. I teach my residents that a thyroid ultrasound must include both sides of the neck. Because regardless of the nodule size, regardless of how benign it looks, if the patient has abnormal-looking lymphadenopathy that trumps everything. Ultrasound is excellent for looking for abnormal lymph nodes in the lateral neck.
It is not sensitive for looking for lymph nodes in the central compartment while the thyroid gland is in situ. So, you know, if they see something, that's also suspicious, but if they don't see something, it doesn't mean that it's not there. Ultrasounds are so good nowadays that we can get an inkling of the suspicion for malignancy in a thyroid nodule based on findings on ultrasound. So if someone comes in with a cystic lesion, purely cystic, the chances of this being malignant are very, very low. On the other hand, if a patient comes in with a nodule, which has, oh, microcalcifications, a hypoechoic irregular margins, taller rather than wide, mixed cystic solid component. All of these things say to me that the chances that this nodule regardless of size may be malignant. And, we'll probably take that to the next diagnostic level.
[Gopi Shah MD]
In terms of just purely cystic, is there ever a size criteria or you still need to consider taking it to the next level?
[David Goldenberg MD]
If it's purely cystic, it doesn't mean that I won't do a fine needle aspiration biopsy, it oftentimes you just get a, you know, gooey thyroid juice with no cells, for lack of a better term.
[Gopi Shah MD]
It's very, it's right on. The description was good. I could see it.
[David Goldenberg MD]
Well, that's what it typically is. And, if it's really, really large and cystic, I mean, I remember an elderly lady who came to me who had a 13-centimeter cyst and it was causing compressive symptoms.
And eventually, she went to surgery to get rid of it. In that case, you know, I aspirated on under ultrasound in clinic and just, you know, took out 20, 40 ccs of this goo, just to give her some relief, telling her this is absolutely going to come back, but this will make you feel a little bit better, but cystic lesions, purely cystic lesions are rarely anything to be concerned about when it comes to malignancy.
However, sometimes they can be bothersome.
(3) Criteria for the Use of Fine Needle Aspiration
[Ashley Agan MD]
So, moving on to FNA. What's your criteria for FNA? Does every nodule get an FNA? Is there a size where it maybe it's too small to get? And then how does the work-up proceed from there?
[David Goldenberg MD]
So, no, not everything gets an FNA, and not every nodule is FNA-able. And often we have a conversation with the radiologist, if they're doing the FNA as to whether this is justified or not. And I absolutely encourage a very good working relationship between the otolaryngologist, the pathologist, and the radiologist.
And we have that here, open dialogue, you know, is it why, why not et cetera? So certainly anything larger than a centimeter that has suspicious features, we'll get a fine needle aspiration biopsy. The issue of below centimeters, which is a microcarcinoma. And remember a centimeter is relatively arbitrary.
0.9 is not a centimeter. Is it a microcarcinoma? If there are highly suspicious features, I will have this, undergo fine needle aspiration biopsy. And I know that there is some discrepancy amongst those who say, well, if it's very small, it's not going to do anything anyway. That being said, I'm old enough to have seen many, a microcarcinoma send cervical metastases. So I also, in my neck of the woods, and this is just where I, where I practice, patients are not willing to hear, “Yes, it may be a cancer, but let's just watch it.” They're just not. So typically a centimeter, I guess we have to ask ourselves, what about the opposite side?
Are you going to get a biopsy if it's larger than four centimeters? Because there are those who say that larger than four centimeters, the fine needle aspiration biopsy is, and I quote, “wildly inaccurate.” And I don't agree with that. First of all, your fine needle aspiration biopsies are typically as good as the person doing them.
They are operator dependent and my institution, they're excellent doing this and they can get a nice diagnosis. You throw in molecular testing, it already becomes more accurate. So, I do not believe that the size of a nodule in and of itself is a criteria for surgery, unless it's bothering the patient.
So if you say to me, I feel fullness when I lie down or I have a swallowing difficulty that I believe is attributable to this thyroid nodule, then maybe. If the patient doesn't know about it and it's four and a half centimeters, I'm still gonna send her for a fine needle aspiration biopsy.
[Gopi Shah MD]
And you just made the point of it's operator dependent. So that is why a radiologist, IR, whoever, that does a lot of these, is doing these FNAs. This is not, is this something that ENTs are doing in their clinics?
[David Goldenberg]
Absolutely.
[Gopi Shah MD]
Okay.
[David Goldenberg MD]
And when I had more time, I was doing these in my clinic and, you know, we'd have to do smears and, in my institution it just flows better for them to do, they do pathology and radiology together. And what they have that I don't have is they can take the aspirate and look for adequacy of cells.
And I, I can't do that myself. So in my institution, we found it to be the best in the patient's best interest to do it that way. Certainly, if it's urgent, I have no problem putting a probe on, making smears in clinic, et cetera, et cetera.
[Gopi Shah MD]
And then talking about cytology FNA, what are we looking for?
[David Goldenberg MD]
Typically what the cytopathologist is looking for is papillary thyroid cancer. Now, why do I say that? First of all, the overwhelming majority of these are going to be papillary thyroid cancer, if they're going to be a cancer. Okay? The second, most common follicular thyroid cancer, as well as its cousin Herthel cell cancer, you cannot make the diagnosis by fine needle aspiration biopsy because the criteria that differentiates malignant from benign are invasion of the thyroid capsule, the capsule of the tumor and invasion or invasion of vasculature. And neither of those things can be seen on FNA.
Medullary thyroid cancer. Very rare. I recently had a lady who, you know, she had a biopsy, which was indeterminate and it turned out to be medullary thyroid cancer, so that certainly can happen. And, you know, usually obviously, the more horrific thyroid cancers such as anaplastic and lymphoma are not subtle in their presentation.
But, you know, if we're looking for papillary thyroid cancer, they look for a nuclear inclusions, and nuclear grooves, and nuclear enlargement, that kind of thing.
[Ashley Agan MD]
And then, know when you get your FNA report back, you're going to see, the more straightforward results are usually going to be your benign or malignant, right? And we know that if it's malignant, we start talking about treatment. If it's benign then, you know, and the characteristics fit, then we say, okay, maybe we don't need it.
It's I think it's the indeterminate, the atypia of undetermined significance, you know, things that are in the middle that can be more nuanced in the further management. Can we talk about that a little bit?
(4) Addressing Indeterminate FNA Test Results
[David Goldenberg MD]
That's a really good point because that's a concept that is a little bit more complex to explain to patients. Patients want to know, is it good? Is it bad? Is it cancer? Is it not cancer? So what happens is really interesting. Patients are often referred by an outside physician with a diagnosis of cancer that they don't have.
So I get to tell them, hold on. It's not the chance of this being cancerous 30%. Let's talk about it. Sometimes patients will be sent in and they understand it as “well, it's not cancer, but it's not right anyway.” So I have to go and this is really important to explain to patients. And what I typically say is, “There's about six categories that this could be, two of them are very straightforward. If it's cancer, we'll talk about treatment and you'll be fine. If it's benign, then depending on what it is, you'll either go home and we say goodbye to you or, you'll be watched every year, every two years, or referred to endo or something like that.”
And then we talk about other things. So nondiagnostic, what I tell the patient is sometimes the nodule doesn't give up cells. Okay. And again, it could be operator-dependent, but sometimes it's actually the nodule that doesn't give up.
It happens. And our choices to either watch it or to repeat it, depending on the patient, the specific points of this patient or their ability or inability to sleep at night. Then you come in with the atypia and follicular neoplasm or suspicious for follicular neoplasm. And for the last, ooh, it's gotta be almost a decade, maybe a little less, we've been sending these out for molecular testing.
We use ThyroSeq, and another one is Afirma. Those are the two big boys in town. And what this does is it helps us rule in or out cancer, more accurately than cytopathology alone. And I explained that to the patients. Bethesda V is called suspicious for malignancy.
And theoretically, you can send that out for molecular testing too. In my experience, I have never seen a case that was suspicious for malignancy that was not in fact malignant. And I treat it as such, and I explain this to the patients. We see a lot of thyroids, a lot of thyroid nodules, and we send out a lot of these for molecular testing.
And, in the vast majority of cases, it saves the patient an unnecessary surgery. So before molecular testing, if someone came in with a Hurthle cell neoplasm, the implied risk of malignancy, right, is up to 30%. And I tell the patient, we recommend that you take out half the thyroid gland just to make sure, it's a grand biopsy.
Nowadays, we're doing a lot less than a lot, a lot less than those. Another interesting thing that we've been learning, you know, if someone has a BRAF mutation, we know that they have a thyroid cancer. But now we're learning about co-mutation. So if someone comes in and they have a BRAF mutation together with a TERT mutation, well, you know, not only do they have thyroid cancer, but there's a good chance they have a very aggressive thyroid cancer and you have to speak to them about that and let them know. So, that's a conversation that has to be, you know, like you said, I think Ashley, it is nuanced. It's, you know, it's in the patient's best interest.
[Ashley Agan MD]
Yeah. And I think, you know, another one that I find that can be difficult are, a larger size nodule. So, you know, maybe two to three centimeters and you, you get a benign FNA, and maybe there's some radi, the radiology features for the ultrasound are not perfectly cystic.
You know, there's some suspicious features. And then having that conversation with the patient about, you know, are we, do we feel like we got a good enough biopsy to really say this has benign and not worry about it? Or, I would be curious which one worries you more the FNA results or the radiology, you know, ultrasound features.
(5) Dealing with Discrepancies Between Ultrasound and FNA Results
[David Goldenberg MD]
So that's a great question, Ashley. So what do you do about discrepancies? What do you do when things don't line up? So in this day and age, this is a conversation that you have with a patient. And although they taught us in medical school to speak with patients, I don't think maybe they're teaching it now, but not all patients are created equal. Some of them have an understanding. Some of them don't, some of them don't want to have an understanding. “You're the doctor, you decide.” To which I usually answer, “It's your neck, you decide.” But it's a conversation and we do it together. So we have to ascertain the patient's risk aversion. We have to ascertain, whether they can sleep at night, whether they're an upstanding citizen, who's going to come back for another ultrasound or a biopsy or disappear in the wind only to come back five years later with an anaplastic thyroid cancer. These are things I've all seen. So all of these things, it's, it's not just the FNA.
It's not just that conversation has to be had. I think you'll never go wrong if you bring the patient back for an ultrasound in six months. Never. I also don't think that you're wrong if you do a lobectomy on a patient like that, because they can't sleep at night, thinking that there's a chance that maybe it's a cancer.
Certainly years ago, we did a lot more lobectomies. We know how to do that. We know how to do it well. The patients will be great. It's not the wrong answer either. Last week I had a patient who came in with a biopsy in an outside institution that was, sent out for Afirma, 50% chance of malignancy suspicious.
I always bring the path in to our institution. I have a patient who came in with a fine needle aspiration biopsy, an outside institution that was Afirma suspicious, 50% chance of malignancy sent to me for a lobectomy.
I always ask that pathology be brought to our institution because I always think a second opinion by people who experienced it. It's not never a bad idea. Well, our people said there's insufficient cells to call it anything. So I sent her for another biopsy. My new biopsy came back completely benign. So what do we do?
Do we believe the old one and give her a lobectomy, which is probably unnecessary. Or do we wait? So it's a discussion I had with a patient. I try not to push patients one way or another, but if they now, you know, I'll say, “Listen, if I think you're doing the wrong thing, I'll say to you, I think you're doing the wrong thing.”
In this case, we're going to get her ultrasound in six months. Even if this is a papillary, these are slow-growing cancers. We all know that. The main thing is not letting the patient get lost and having a follow-up system so that you keep an eye on it.
[Gopi Shah MD]
Does insurance cover the molecular testing for these patients? Or is there a criteria that you have to show for them to approve it?
[David Goldenberg MD]
So, this probably is different in every institution, but the way that we do it is that, and this was the agreement when we brought this molecular company on board and our institution was, if insurance does not cover it, the patient will never get a bill more than a couple of hundred. Which I think is reasonable.
Our endocrine surgeon has a long conversation with them about it. I typically don't, I've never had a complaint about it, but you know, insurance is a funny thing. It, uh, well I have nothing nice to say.
[Gopi Shah MD]
And then, can we maybe just go back for a second?
[David Goldenberg MD]
Sure.
[Gopi Shah MD]
Does having more than one nodule make a difference in those questionable cases? Or at all in your workup?
(6) Working Up Numerous Nodules
[David Goldenberg MD]
That's a great question. So, the old way of thinking was the more nodules you have, the less likely any one of them is to be cancerous. On the flip side, we've all seen multifocal, papillary, thyroid cancers. If someone comes in with a multinodular goiter, that looks like a multinodular goiter it typically is. If one or two of the nodules there are suspicious specifically, you know, certainly you can have a thyroid cancer and a multinodular goiter, but usually the patients who come in, usually, they have a solitary, thyroid nodule, which is, I guess, is more suspicious. But I certainly would not, you know, poo-poo it just because they had a couple of nodules and say, wow, this one is really suspicious, but since you have another two, it can't be cancer. I would never do that.
[Ashley Agan MD]
And it's appropriate to biopsy all, like anything suspicious. I would assume, right? If you're sending them for FNA and you have a couple suspicious nodules, go ahead and stick a needle in both of them.
[David Goldenberg MD]
Typically up to three. That's what I typically do. You know, if they have four, but, usually the idea is if someone has a multinodular goiter and we've all operated on these patients, it looks like a bag of grapes. They can have 20 of them, 30 of them. It's not reasonable to biopsy all of them. We typically biopsy the ones that may be suspicious up to three, typically.
(7) The Role of Non-Ultrasound Imaging in Thyroid Nodules
[Gopi Shah MD]
And then in terms of like workup for your nodules, you know, for some of the cases that aren't as clear cut, the example that Ash gave was a great one. Do you ever use a PET scan or is there a role for these other imaging modalities and how do you use them?
[David Goldenberg MD]
That's a wonderful question because we see this. So the vast majority of people with PET scans are people who come in with a PET scan for another malignancy and they find a solitary FDG avid nodule, and those are actually considered suspicious and need to be worked up and they are.
So the patients come in with a PET CT scan for another reason, if there's a solitary FDG avid nodule that needs to be worked up, usually they get a fine needle aspiration biopsy on the ultrasonic guidance.
In those cases, they don't need a neck CT because the neck is covered by the PET. And overwhelming, if the thyroid cancer is FDG avid, and it's a cancer, it's usually more aggressive because it means it's probably not iodine avid and the opposite. So I do remember a couple of patients who accidentally came in the young, you know, sometimes a patient will not be sent to us or to even endocrinology by a PCP because they hear the word cancer and they send it to oncology and they do a PET scan probably unnecessarily. And you see it. So this is kind of anecdotal if you will. So no, we don't send for, for our thyroid nodule for a PET scan. if I'm doing surgery on a patient that already has a thyroid cancer. Or if, a thyroid nodule, like if someone comes in with a thyroid nodule and they are complaining of compressive symptoms, my rule is that I have to be convinced that it is the thyroid nodule that is causing their compressive symptoms.
The reason being, there's an old saying, you break it, you buy it. So once you've operated on the patient, they're yours for life. And if you're taking out half their thyroid gland for no good reason, you're not going to make them happier because thyroidectomy doesn't typically cure reflux. so I'll get a CAT scan on someone who is complaining of compressive symptoms.
And I will go over the scan together with the patient, say to them, “You know what, you're right. Your massive thyroid nodule is compressing your esophagus or pushing on your trachea. Let's take out below.” or I'll say to them, “You know, your thyroid is really not that large. We have to look for another reason to explain your compressive symptoms.”
If it's a thyroid cancer, I reserve the right to do a CAT scan with contrast if I think it will help my surgical planning. Usually if there's extensive neck disease, I say I reserve the right, because in certain places, nuclear medicine, gets up in arms over the use of contrast. I think it's unwarranted personally.
We do what's right for the patient. If I think a cat scan will help, but it's not a routine thing that I'll do for any old thyroid nodule.
[Ashley Agan MD]
And the concern is timing for post-op radioactive iodine. Is that right? They're worried that that's going to delay that treatment if they need it.
[David Goldenberg MD]
Yeah. That's the concern. Yeah, I don't buy it. First of all, it takes awhile to get the nuclear scan or the iodine treatment, at least in our neck of the woods. I'm sure the iodine from the CAT scan has washed out long ago. But in any case, my ability to perform surgery is at that point, the more important thing. It's a surgically treated disease, right?
(8) Strategies for Surgical Decision-Making in Various Cases
[Ashley Agan MD]
Yeah, absolutely. So I think that's a good pivot point to kind of move on and talk about surgical decision-making. Once you've decided that, surgery is warranted and indicated. And so what are the different scenarios where it may be appropriate to do, you know, lobectomy versus total thyroidectomy? Adding in central compartment neck dissections and you know, versus lateral neck dissections, let's get into that part.
[David Goldenberg MD]
Great question. Like I said before, my decision making has matured over the years. I'm much more conservative about leaving someone half a gland, even in the face of cancer than I was. So, you know, when I finished my fellowship and when I came out here, every patient who had a malignant thyroid neoplasm got a comprehensive neck if they had neck disease, as well as a total thyroid, that was it, at plus minus, but more plus radio-iodine.
Certainly for an indeterminate nod, I don't think it's justified to take the whole gland. For a malignant neoplasm, you know, a papillary, it is justified to take the entire gland, except if it's a very small cancer, if it's a young woman, if it's an upstanding citizen who doesn't want it and they're going to come back and be watched, then I'm okay leaving half a gland and the patient, gets to keep their thyroid function at, but they can't get radio-iodine if needed. So regardless of what surgery a patient gets, if it's malignant, I tell them lifelong surveillance. Long after I'm in an old age home, I have seen people recur 35 years out.
So, for an indeterminate thyroid nodule, you know, I'm not going to take out the entire gland. Sometimes, you know, to keep things fun, there are, you know, what do you do if you have two indeterminate nodules, one on each side? It happens. What do you do if you have no clear sign of malignancy on th onset? But, you know, it's malignant.
So case in point, I had a lady who came to me, I operated on her maybe a week or two ago. She came to me with what they called on a scan. I didn't send for the scan, it was a CAT scan, a peri thyroidal mass. So I had it needled and it came back as, I don't know what it is. Nothing, no thyroid cells, none of that, just a very-
Well, there's a mass next to the thyroid, kind of looks like a met to me, but I, I don't know. So, you know, we went in there and we pulled this thing out and sent it for frozen. And the pathologist said, well, and I look, you know, I go over to the gross lab and there's obviously thyroid cells in this mass, this lymph node, but he can't call it cancer on frozen.
Now, what are the other reasons that you would have thyroid cells and. And then there's the old thing that we all learned in medical school. And well, maybe it's a rest of thyroid tissue outside the thyroid. What do we do? Uh, she had another rest of thyroid tissue, huge one in the mediastinum. And I took out half the thyroid.
And I did a central compartment. I took out this node, which was sitting and it's interesting, this node was, and I really don't blame the radiologist. It wasn't, it was more central compartment than lateral, but it was sitting in between the great vessels and the vagus. So it was kind of splaying the vessels.
So it wasn't lateral to it. Wasn't really medial to, it was kind of in between to. So in this case, I took out half her gland. I took out all the nodes. I spoke with her mom who was waiting downstairs and I said, you know, this is probably, if it were at cancer, she probably will need a completion, but I'll come back and do it another day because I'm not going to rob this young lady of her entire gland with no clear diagnosis of thyroid cancer.
Even though it was screaming thyroid cancer to me. But you know, these are judgment calls. You really gotta- It's not always simple. Sorry if I digressed from your question.
[Ashley Agan MD]
No, it's so true. It's like most of them aren't the straightforward, simple ones. I feel like, like, these are the conversations I’m having all the time. Do you have a cutoff, for your, you know, the size wise, if you're deciding you want to do just a lobectomy only, or it just depends?
[David Goldenberg MD]
No, I'm very careful not to use size as a criteria for half a gland, or a whole gland. I've seen too many where people take out the whole gland needlessly and something goes awry. I will say this. obviously the most common cause of litigation over thyroid surgery is damage the recurrent nerve, right?
We all know that, but amongst that, most of the cases and most of the successful cases, patients or doctors who go over to the opposite side and trash both nerves when in retrospect it should not have been done. And that's very, very hard to defend. So you got to do the right operation for the right reason, knowing full well that even if it's thyroid cancer, but certainly in benign disease, you can always go back and fight another day, use the same incision and you take out the other side when needed.
(9) Care Management for a Patient Undergoing Thyroid Surgery
[Gopi Shah MD]
That's a great segue into your peri-op, intra-op, post-op. What do you do for the nerve? Are you scoping everybody before surgery, after surgery? Do you use a NIMS? Do you not use a NIMS?
[David Goldenberg MD]
Yes, and yes. I scoped patients all the time. That's one of the things that we as otolaryngologists can do, and we do do it. And that's the way to evaluate the vocal cords. I mean, uh, so, yes. And, we use a neuromonitoring, every case, every time, for every thyroid, every parathyroid and every parotid.
We have a neuromonitoring service. We have our dude or dudette sitting in the corner, and they have oversight of a neurologist and they monitor the recurrent laryngeal nerve. I would be remiss in not mentioning the fact that this is an adjunct, and that the gold standard for thyroid surgery is anatomically finding and preserving the recurrent laryngeal nerve.
And it's really fascinating if you look at the literature, the more, the higher the volume a thyroid surgeon is the more likely they are to use intraoperative neuromonitoring, which is counter-intuitive. It's a good teaching tool. It's also very important not to let your trainees become dependent on it, you know, so I don't let them do anything until they've found and shown me the nerve, trace it up and traced it down a little bit so that we're sure it's the nerve.
And, so I use intraoperative neuromonitoring. We find the parathyroids every time. You know, I guess, standard, hopefully, good practice, you know, a capsular dissection and a thyroidectomy.
[Ashley Agan MD]
And then when patients come out of surgery, do you scope them post-op, you know, in the immediate post-op period or wait until you see them in clinic, or just, if you're worried about them kind of following them clinically.
[David Goldenberg MD]
If I'm worried about, them, then obviously I'll scope them. But thankfully that's not, typically it's in clinic a week or so later.
[Gopi Shah MD]
What's your protocol for managing calcium for totals?
[David Goldenberg MD]
Well, typically we measure their calcium in the AM and if it's sustainable or improving, they go home. I personally am, like I said, a little bit more conservative. So all my thyroids stay overnight, 23 hour stay. The reason being that, as I stated in the very beginning, we have a large catchment area, and first of all, I try very hard to treat all the patients the same.
And, if someone lives four or five, six hours away, I don't want to send them home right after surgery. And I don't want them finding their way to a small emergency room in the middle of the night when something goes awry either for real or not. And the vast majority of patients are okay with that.
They stay 23 hours. And we do, as we measure their calcium and patients are sent home in my practice with, if their calcium is above eight, they go home with a calcium carbonate 500 tid. And if they start, you know, dropping and so-and-so forth, we'll add on calcitriol, obviously, not including, postpartum, which are treated a little bit differently.
And if we have any inkling that something is not right, I have a very low threshold for consulting our endocrinology colleagues. This typically occurs when you're doing bilateral central compartment lymph node dissections, because if the disease is bulky, sometimes you must sacrifice two lower parathyroid.
I really try very hard to preserve the upper ones. I like to preserve them in situ. Although I will take it out and chop it up if it's impossible. That's about it. I guess.
[Ashley Agan MD]
Question just popped in my brain. What about drains? Do you, do you routinely leave drains in your patients or never, or sometimes?
[David Goldenberg MD]
I don't leave routinely. I don't use drains routinely. I haven't for many, many years. The only time I'll put a drain in is if I am, doing an extensive dissection, a massive goiter, anything that's going to leave a dead space. If like, if I'm doing two necks and bilateral central compartment, and a thyroid, person is going to get at least one drain, two drains, but they're also going to stay a couple of days.
[Ashley Agan MD]
Yeah, that makes sense.
[David Goldenberg MD]
But no, I don't routinely use it for every thyroid. And by the way, the patients really hate drains. I don't know why.
[Ashley Agan MD]
I know.
[David Goldenberg MD]
But they hate drains. So they're, they're usually very happy when you say no drainage tube.
[Gopi Shah MD]
Yeah, children don't like drains either. Just that's my addition to this. Anyways, Dr. Goldberg. Thank you so much. I feel like we're kind of wrapping up. Is there any other final pearls, for our listeners, for thyroid nodules?
[David Goldenberg MD]
No, I think we've really covered it. Surgical judgment is the, I call it the cousin of common sense. you really have to know the literature, things change all the time. and have a frank discussion with your patient. I feel if you explain it to the patient, you're explaining it out loud so that everyone's clear as to what the goals are, why you're doing something.
Do you want to ask me about my book?
[Ashley Agan MD]
I was about to say, before we, before we let you go, we need to plug your book. Tell us about your new book. And so, where our listeners can check it out.
[David Goldenberg MD]
Thank you. Yeah, I just published a comprehensive textbook and surgical and video atlas on head-neck endocrine surgery. It's published by Thieme. Probably can get it at Thieme or at Amazon or wherever they sell books. This is, I guess, my seventh or eighth textbook and it's certainly the most important work I've done to date.
This is, I would say the most comprehensive book out there on thyroid and parathyroid surgery written by some of the most famous endocrine surgeons, endocrinologists in the world, from all over the world. I wrote this book as a dedication to my daughter who was killed in an accident, about four years ago.
I guess that was the impetus for this book. It's unique amongst textbooks because it is the first book written for the modern learner, if you will. I say that because, people of other generations learn differently than perhaps we did and what we, or when I say we, I mean me. You guys are obviously, far younger than me.
[Gopi Shah MD]
But I still, I get it.
[David Goldenberg MD]
What we did is we, every chapter, every chapter of this book has. bulleted points to open. Every chapter has a case report. Okay. To help illustrate what it looks like in real life. Every chapter has what we call points to ponder. These are a little blurb in between sections that force the reader to answer in their own mind a clinical question regarding the thing that they just read.
And finally, every chapter has between three and five of the Seminole landmark references in an annotated version, meaning each one of them has a small abstract, so I'm very proud of this. And, you know, hopefully people will learn, a little bit about thyroid and parathyroid surgery and disease.
[Ashley Agan MD]
That's wonderful. Congratulations. That sounds like, quite a work. I’m excited to check it out.
[David Goldenberg MD]
Thank you.
[Gopi Shah MD]
And you send this is the sixth or seventh textbook, correct? Dr. Goldenberg.
[David Goldenberg MD]
Seventh or eighth. I think I'm not. I'm trying to look. I don't know. We’re, uh, yeah.
[Gopi Shah MD]
Congratulations. That's a whole other podcast in itself on how to, how to write a textbook.
[David Goldenberg MD]
Sure.
[Gopi Shah MD]
You want to tell us a little bit about the EMT program at Penn State? How many residents do you guys have?
[David Goldenberg MD]
So we have two a year, hopefully to be augmented. And we have a, something actually very unique is we have a resident, research program whereby one resident, of the two we take a year, goes into the lab prior to their intern year, not after their intern year. And we are doing in our lab thyroid cancer and head and neck cancer genomics amongst other things.
It's an interesting group. You know, obviously, like any other otolaryngology program, we get the best of the best. It's very competitive, but, you know, we get great, great people, a very cohesive group. But from the department standpoint, you know, like I said, we're the only academic show in town. So we get anything that's weird and wonderful. Tons of trauma, tons of head-neck oncology. Yeah I’d say a case report walks in the door every day.
Yeah. So proud of the program. Very nice. We are in a beautiful rural setting in central Pennsylvania. But it's a growing health system. So, proud to work here. Great people.
[Ashley Agan MD]
Awesome. I guess that's a good place to put a pin in it. Thank you so much for your time today, Dr. Goldenberg. It was a really great talk. We appreciate, I think that our listeners will really get a lot out of it.
[David Goldenberg MD]
Well, thank you very much guys, for having me do this. I truly appreciate it.
[Gopi Shah MD]
You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter @_backtableENT. We love feedback. Reach out to us for topics, ideas, speakers, or if you ever want to come on a show.
[Ashley Agan MD]
And, don't forget to subscribe, rate, and share. That's a wrap. Thanks everybody.
Podcast Contributors
Dr. David Goldenberg
Dr. David Goldenberg is a professor and the chair of the department of otolaryngology - head and neck surgery at Penn State in Hershey, Pennsylvania.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 2). Ep. 35 – Thyroid Nodules [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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