Questions and Answers
for the Patient with Thyroid Cancer:
What are the indications for
thyroid surgery?
The indications for thyroid surgery include suspicion or diagnosis of
thyroid tumor, compression symptoms on trachea and/or esophagus secondary
to thyroid enlargement, progressive thyroid enlargement on medical therapy,
uncontrolled hyperthyroidism in spite of medical management or hyperthyroidism
during pregnancy, substernal goiter, cosmetic concerns with large goiter/neck
mass, and uncontrolled hyperthyroidism.
Who should do thyroid surgery?
A qualified and experienced thyroid surgeon (general, endocrine, ENT)
working in hospital with considerable caseload should do surgery.
What are the risks of thyroid surgery?
The risks of surgery of the thyroid include but are not limited to recurrent
nerve injury (vocal cord paralysis), parathyroid gland deficiency (low
blood calcium), wound infection and bleeding and anesthetic risks. The
overall risk is very low.
How much thyroid should be removed?
The extent of thyroid removal should be sufficient to adequately remove
the disease. This is controversial and varies from partial to total thyroidectomy
depending upon multiple patient, tumor, and surgeon factors. Treatment
must be individualized!
Will surgery be required on the
neck lymph nodes?
Many, but not all thyroid cancers can and do metastasize to lymph nodes
in the neck and upper chest. If such involvement is suspected or present
then the lymph nodes should be removed by adequate surgery, the extent
of which is dictated by the location and extent of the tumor metastases.
What symptoms can I anticipate
postoperatively?
Moderate sore throat, which lasts 1 to 2 days, will occur, not precluding
drinking and swallowing. Some minor incisional pain is expected with some
neck tightness later, all of which resolve with time. Hoarseness is uncommon
and generally transient. Wound healing is brisk and generally complete
in a week or two.
How long will I be hospitalized for
the thyroid surgery?
The length of hospitalization depends upon the nature and extent of the
thyroid pathology and the surgery necessary to remove it, and may extend
from less than one day to a week or more. Poor general health, increased
operative risk and postoperative complications may prolong the hospitalization.
Will I have any cosmetic deformity after
my surgery?
Most thyroid operations do not require radical removal of neck tissues.
If the neck lymph nodes are removed some loss of soft tissue contour in
the low neck may result. Only if very extensive surgery is required will
more deficit be produced. Simple removal of part or all of the thyroid
gland generally results in no cosmetic deficit and an insignificant almost
invisible scar.
Will I need further treatment
after my thyroid surgery?
Depending upon the nature and extent of the disease, radioiodine treatment,
less commonly external radiation treatment, rarely chemotherapy or combinations
may be recommended.
Will I need to take medicine
often after my thyroid surgery?
Usually yes, depending upon the nature of the disease process and the
extent of thyroid removal. Total removal of the thyroid mandates life
long replacement medicine.
What are the goals of thyroid
surgery?
The goals are the documentation of precise diagnosis of the nature and
extent of the thyroid disease and, if possible, its complete removal.
Many but not all patients will know the nature of the disease from results
of preoperative investigation including imaging studies and fine needle
aspiration biopsy. Based upon his knowledge of the natural history of
the disease and its known-or-suspected-extent, the surgeon will recommend
a procedure to remove all the disease from the thyroid bed and the neck.
In those patients whose tumor has already spread beyond the confines of
the neck and is thus not surgically curable, the surgeon may recommend
total removal of the thyroid gland and the adjacent central lymph nodes
to facilitate and expedite other treatment, usually radioactive iodine,
and to assure local control of the tumor around the larynx (voice box)
and the esophagus (gullet). Rarely, adequate tumor resection may necessitate
a more radical resection including muscle, soft tissues, nerves and other
structures in those very few patients with more extensive neck disease
already invading those structures.
Do all thyroid cancers need to be treated
with extensive surgery and radiation?
Some thyroid cancers, if they are small and totally confined to the thyroid,
can be successfully treated by surgery alone. Other patients are at "high
risk" for recurrence or other complications, and require more extensive
treatment to reduce the chance that the tumor will come back or that it
will spread outside the thyroid gland.
How does my doctor determine
that I have "high risk" thyroid cancer?
In the same way that you are an unique individual, so is your cancer,
in terms of its tendency to cause serious complications like spread to
other organs, local invasion, or a tendency to come back after apparently
successful initial treatment. By studying many thyroid cancers in a number
of patients, doctors have noticed features of individual cancers which
are more likely to be associated with these complications. Some of these
features include a large size of the tumor, an aggressive appearance under
the microscope, invasion of the cancer into the tissues surrounding the
thyroid, tumors arising at multiple sites in the thyroid.
Patient characteristics may also be important, especially
your age at the time of diagnosis. Older patients tend to have more problems
than younger patients.
How does the radioactive testing
and treatment of thyroid cancer work?
These procedures take advantage of a special form of energy, which is
given to you either for diagnosis or for therapy. The energy is trapped
and concentrated in your tumor, much like a fisherman traps fish and concentrates
them in his net.
This "trapping"depends on the natural ability
of your thyroid and thyroid cancer to trap the chemical element iodine.
Special proteins on the surface of thyroid cells, take up iodine atoms
and concentrate them in large amounts. Most of the iodine atoms in your
body are not radioactive. However, elements that are radioactive, like
I-131, discharge radiant energy, in the form of gamma rays and beta rays.
I-131âs gamma ray, can detected by sensitive instruments in nuclear
medicine. When radioiodine I-131 is given, it is trapped in tissue like
other forms of iodine. The radioactivity detector (the gamma camera),
scans over your body, and an image is created by detecting gamma rays,
based on the contrast between the I-131 uptake in cancer and normal tissues.
An increase in intensity shows up on the image as a black spot, wherever
there is a site of thyroid cancer, taking up the radioactivity.
For the diagnostic purpose, a tiny (tracer) amount of I-131
is given, and the "whole body" is scanned. This test is the
most sensitive way that we have to determine if there has been spread
of cancer anywhere in your body outside your thyroid gland.
For the therapy purpose, I-131 is given in larger (therapeutic)
amounts, and the trapped radioactivity discharges enough energy to kill
the cancer cell. The more atoms which are trapped in the tumor, the greater
the amount of beneficial energy that is discharged to kill the tumor.
Will I ever be cured of my cancer?
Many patients, even with aggressive thyroid cancers that have spread outside
the thyroid, can be cured. Early spread to the lymph nodes and lungs are
common, in "high-risk" patients. Fortunately, a variety of treatments
have proven to be curative. These include surgery, which is often the
first form of therapy given to the patient with thyroid cancer. This form
of treatment is most effective when the cancer is confined to the thyroid
gland, but we have identified patients whose only known tumor sites have
been removed by surgery, when it was detected by other testing. Radioactive
iodine is also a curative therapy for many patients, even when the tumor
has spread to distant sites. Although we cannot promise that all patients
will be cured, early treatment helps.
What if the treatment does not totally
eradicate my thyroid cancer?
Thyroid cancer which has spread outside the thyroid gland is a serious
condition which can be life threatening. Nonetheless, some patients, will
have a normal life expectancy, even when their thyroid cancer is not totally
eradicated by treatments. This is because there are effective treatments
which tend to stop the growth of the thyroid cancer. One such treatment
is thyroid hormone, which reduces the rate of growth for most thyroid
cancer. This is one important reason why you should take your thyroid
pill every day, without fail, unless your doctor has instructed you to
stop your thyroid medication as a preparation for diagnostic testing or
treatment with radioactive iodine.
Also, if new worrisome symptoms develop, we would like you
to tell us about them right away, so that additional local treatments
may be given which will reduce their negative effects.
What are the side effects of
not having the thyroid pill?
When the body does not have enough thyroid hormone, you will be "hypothyroid."
Patients who are hypothyroid feel weaker, slower, and cold despite normal
or warm room temperatures. You may also experience constipation, and changes
in mood, especially depression. This is because your body depends on thyroid
hormone, as a basis for the natural metabolism which is the basis for
most normal functions of life. Also, you may find that your reflexes will
be slowed, particularly just before you undergo the diagnostic testing
which we call "dosimetry". Its important that you recognize
this, and we recommend that you have someone else drive your car when
you are not taking the thyroid hormone, particularly in the last week
prior to dosimetry testing. In addition, the ability to think may be impaired.
My wife and I have not started our
family. Will this treatment have any effect on our ability to have children?
High dose radioiodine therapy can cause the sperm count to drop in the
year immediately after treatment. For this reason, many male patients
who desire to have children will bank their sperm, in order to facilitate
later conception.
What is the purpose of the radioactive
iodine therapy? How will this therapy be adminstered?
This therapy is intended to target thyroid-like tissue, whether normal
residual thyroid that remains after surgery, or thyroid cancer deposits.
You will drink a saline solution that contains the therapeutic dose of
radioactive iodine, and over the next few hours, the radioactivity will
be absorbed from your stomach, and will enter your blood stream. The radioactive
Iodine 131 will be trapped in thyroid like tissue, in sufficient amounts
to destroy the cancer cells.
Will the radioactive Iodine-131
therapy make me feel sick?
In the first few days after oral treatment, there can be side effects
of nausea, salivary gland pain and swelling and redness and irriation
in the mouth. Normally these effects are mild, and we will treat you with
an anti-nausea pill before therapy to counteract this effect. Analgesics
and local treatment is normally effective to reduce salivary gland swelling
pain. If there is a very major discomfort and swelling, a short course
of steroids is very effective to reduce pain and discomfort. These side
effects occur because some normal tissues, like the stomach and salivary
glands will also trap radioactive iodine, and although this trapping is
much less than the target cancer cells, there is the potential for some
damage to these normal tissues.
I am allergic to shellfish and iodine
containing contrast materials. Will the radioactive Iodine treatment cause
me to have allergic symptoms?
The chemical concentration of radioactive iodine is too low to have any
effect on your body at all. Also, allergies such as this, are caused by
iodinated proteins, rather than inorganic iodine. During the course of
normal living, you take in about 100 micrograms of inorganic iodine per
day, and in the long run, your body requires a certain amount of inorganic
iodine to survive.
Will I feel anything from the "test" dose or dosimetry dose
of radioactive iodine?
You will not feel any side effects from the radioiodine used in dosimetry.
This is because the chemical dose of iodine, is extremely tiny, only a
"trace".
Why do I have to be on a "low
iodine" diet, prior to diagnostic testing or therapy with radioactive
iodine?
Iodine is a natural chemical element that is essential for life. In patients
with a thyroid gland, the iodine is taken up by the thyroid and used as
a building block to make a key hormone, thyroid hormone, which is important
to the bodies normal functioning. Thyroid cancer, also takes up iodine,
not as efficiently as the normal thyroid, but sufficient that the uptake
can be traced with a radioactive iodine, the most commonly used form is
Iodine-131. (Also called a radioisotope). What happens is that the tracer
dose of radioactive iodine mixes with the naturally occurring, non-radioactive
iodine, and together, the radioactive and the non-radioactive iodines
are taken up in your thyroid gland and thyroid cancer.
How different is the therapy
from the dosimetry dose?
You will get a more concentrated solution but the procedure of "drinking"
the dose is identical.
I am contemplating having children
in the future? Can I get pregnant again?
Yes, but you should not get pregnant until a year after your last therapy
because this is the time period we need in order to repeat the testing
to confirm if you have no evidence of disease.
Acknowledgments
The Light of Life Foundation gratefully acknowledges and wishes to thank
the following medical professionals for the generous donation of their
time and knowledge in the preparation of the educational material for
this pamphlet.
Steven M. Larson, M.D.
Chief, Nuclear Medicine Service
Attending Physician, Department of Radiology
MSKCC
Richard J. Robbins, M.D.
Chief, Endocrinology Service
Attending Physician, Department of Radiology
MSKCC
Elliott Strong, M.D.
Attending Surgeon
Head and Neck Surgeon
MSKCC
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