Chapters Transcript Video Reframing Thyroid Cancer: Precision, Progress & Personalized Care Thyroid cancers are a group of diseases often misunderstood in both their behavior and prognosis. Unlike many other cancers, the cure rates for most thyroid cancers are remarkably high, especially when caught early, but that doesn't mean the journey is simple. From active surveillance to advanced surgical and molecular approaches, managing thyroid cancer requires precision and nuance. Today we'll explore what makes these cancers unique and why outcomes are so often different than what patients might expect. Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Megan Crawley, head and next surgical oncologist at Miami Cancer Institute, part of Baptist Health South Florida, and. Joining us for our discussion is Doctor Rachel Slotkavage, a board certified fellowship trained endocrine surgeon at the Eugene M. Christine E Lynn Cancer Institute, part of Baptist Health at Boca Raton Regional Hospital. Uh, so I wanted to get started with um. Kind of how we start the workup for a thyroid cancer or even a thyroid nodule, um, I know I get referred patients sometimes even at the beginning when they think oh I this patient has thyroid nodules what do I do? you know, so I kinda wanted to know what's been your experience with that and kind of where do you start? I certainly, you know, one thing that I'd like. To make sure everyone knows is that it can be very hard to get any nuances of anatomic thyroid disease on imaging studies like CAT scan or MRI. So if an incidental finding is picked up on one of those studies, the single most important study to obtain is going to be a thyroid ultrasound. And you're going to want to ensure that includes lymph node mapping of both the central neck and the lateral compartments that is going to be the single best study to give us not only accurate size information but also accurate qualities of the nodule that will help um your thyroid cancer teams determine if something looks more benign if something looks very alarming for potential malignancy if something needs any intervention at all. Very small disease as you had talked about earlier in our conversations before we started today often doesn't need any attention mhm yeah especially even if it has a high uh score high tirade score which is the the rating system the radiologist uses for ultrasound to determine which ultra which nodules uh look more suspicious or have concerning features if it's super tiny, you know, if you did an autopsy on everyone that was over 75, you'd find that a lot of those patients have microcarcinomas that you don't. Even need to bother with, you know, they can just not grow and just live there for however long they wanna live there absolutely and I, I think something that we run into in initial work up to, you know, many of our physicians will try so hard to ensure that everything is done before a patient is sent to the surgeon, which naturally we very much appreciate. But when patients are dealing with a potential diagnosis of cancer. Um, their anxiety can sometimes allow the workup to get carried away. So for example, a PET scan, there's no indication for a preoperative PET scan in thyroid cancer, and I often have patients coming to my office insisting upon it because they're so familiar nowadays with that terminology from the care of other cancers. And a marker that physicians will often order thyroglobulin thyroglobulin antibodies, you know, those are things that we use in post operative surveillance, but they don't really help us guide treatment at all in the workup in the preoperative setting and you know I hate to have patients waste time and copays um on studies that aren't going to be beneficial to help them out in the setting of a potential thyroid cancer or I have a lot of patients that get referred to me for a micro. You know, less than 1 centimeter nodule, some suspicious features, and then they insist on a biopsy or I've even had them be referred to me with the referring provider saying that they need the thyroid removed and that's been really frustrating and um you know it's it's really difficult because I feel bad because the patient wasted their time to see me, you know, and they feel like I didn't do anything for them and it's really upsetting for me but I know it's also frustrating for the patient that we're both feel like we're, uh, this could have been a better use of both of our times, um. So that's one of the things, what is your stance on a chest CT or evaluating for metastatic disease? Yeah so typically I would utilize that in the preoperative setting when there is clinical concern for more advanced disease. So in a setting where a patient, for example, has a new obvious change to their voice that's concerning for vocal cord paralysis, um, you know, obviously very scary signs like hemoptysis, um. New onset shortness of breath with activity associated with a palpable visible mass, um, things that would suggest I, I would be negligent if I didn't mention palpable lymphadenopathy. Things that would suggest more advanced disease is what's going to tell me that we need to pursue that cross sectional imaging and contrasted CT scan is really going to be the best study. Obviously if patients have contraindications to the iodinated contrast. Kidney disease things like that. MRI is a good substitute, but for that true anatomic delineation when you're worried about advanced disease, contrasted CT is the way to go, yeah, because I was curious as far as like the, I don't often order chest CTs on patients, you know, and so I was just curious what your experience is with using that definitely not a common thing, but it's nice to know that we can get very good, very clear images about what's going on in the settings where it's needed, right? Uh, so then I also want to know, um, as part of part of the workup sometimes we use molecular testing, especially with Bethesda 3 and Bethesda 4 category biopsies which are indeterminate or atyp of undetermined significance so we're trying to figure out, OK, well what do we do with that? So one of the things you can do is just kind of wait, see what the clinical behavior of the lymph of the nodule is and then re-biopsy it which people typically aren't very satisfied with which it could be a little uncomfortable for the patients believe me I'm not happy with it either, but um. And then one of the things that we have in our little tool kit is to use molecular testing so curious how, you know, in my practice I've used it as, you know, if it's something very definitive or really concerning, you know, as far as if it's above, you know, 50% as far as the risk for it being invasive or um a carcinoma, then that'll kind of push me to counsel the patient to say, hey, we still have the option of watching it and re-biopsying it but you know I think you also meet indications for having a low back. Me, um, to kind of get an idea of what this is and you know lay your fears to rest and it's also the treatment but I you know I wanted to know if that's also kind of what you've experienced in your practice as well I think um I've been using it in a very similar way in my practice um I find it most useful in a setting where a patient maybe is not an ideal surgical candidate maybe there's someone who really couldn't tolerate an operation due to bad heart disease, other comorbidities. Um, I find that using it to enable a patient to not have surgery. Is a little more helpful than necessarily an indication for surgery because I think many patients have a level of anxiety and apprehensive apprehension excuse me, associated with these diagnoses or even potential diagnosis. I have a lump I want it out yeah and so I tend to move towards surgical option a little bit more with the Bethesda 4 nodules, but for the 3s. You know, if we can use that to avert a repeat biopsy, I think that is a fantastic use of that tool. And the way I describe it to my patients, I, I think it helps to break it down a little bit intellectually for them, is that Well, we can quote based on a Bethesda categorization, the average risk of malignancy for a type of nodule like they have, the molecular testing gives us their personal risk of malignancy. And so I tell them it's not precise, you know, if a nodule appears very benign on ultrasound, it's behaving indolently, um. Then maybe a 95% risk of malignancy that might be gotten from molecular testing may not tell the whole story because those nodules can certainly be benign, um, but it will help drive our surgical decision in one direction or another. Another piece of the puzzle is really helpful to have, yeah, because well I've even read that uh the Bref even having one that's Bref positive, I've seen data that writes, oh it's the worst it's associated with a bunch of metastasis and a high recurrence rate and increased mortality. However, then they say oh but it's also been positive and less aggressive cancers soenomas as well. Like, well, this seems like very useful, great, but I do know that the BRF has been um quite useful also for immunotherapy so in some cases like anaplastic thyroid cancer or undifferentiated cancers or something that's not resectable or the patient's extremely uh frail to undergo surgery, then the immunotherapy targeted towards Bref has been. Really quite game changing and helpful in that population certainly and thankfully those more aggressive cancers are a small population so I think the majority of the utility at this point is coming in the preoperative planning setting yeah uh I think also the preoperative imaging and everything kind of helps plan our surgeries so you know it helps me determine and I tend to get FNA's before I decide on. If I'm doing bilateral necks or just one side of the neck, you know, I like to get confirmation that there's disease there, um, so you know we can end up being a, um, doing bilateral neck dissections unilateral neck dissections, but also determining if there's involvement of the trachea, you know, I've had a couple where you know we've had to do. Very rarely, but had to do tracular sections uh as part of the surgery or knowing that you're gonna leave some disease behind and then considering leaving it up to radioactive iodine or even considering external beam in the future um so as far as uh radioactive iodine, uh, you know, I know that at least in my institution we tend to have a heavy hand with radioactive iodine we offer it to a lot of our patients. So in your experience, what, uh, you know what has been your experience with offering radioactive iodine so we. We are now 10 years into the most recent American Thyroid Association guidelines for handling differentiated thyroid cancers, and I understand from a colleague who got to attend the ICA meeting that there's going to be new set coming out in the near future. Um, I do not have details on that just yet, but we know that the overwhelming majority of patients with low or intermediate risk thyroid cancers pathologically. Um, are considered or let me, let me say it this way, we know that patients who have those lower intermediate breast cancers. That lobectomy is considered a curative procedure. And in the setting of lobectomy, there is no indication for ablating the remnant, virtually no indication. And so knowing that the majority of patients with thyroid cancer can have only lobectomy and be considered cured. Means that radioactive iodine has really fallen out of favor um if in the ATI guidelines, the only indication the only hard indication for radioactive iodine is for the highest risk tumors, those are that are very large, those with extra thyroidal extension, um, those that have obvious lymph node metastasis and so even amongst endocrinologists. There's still a big push as as you're seeing in your practice, um, to use a lot of radioactive iodine, and the data is not really supporting that as strongly as it used to. We now know that we were giving a radioactive therapy that requires patients to isolate from their loved ones for a few days to a lot of people who truly didn't need it. And, you know, be able to tell someone that has cancer that. Yes, I need you to take to take you to the operating room. Yes, of course, there's going to be a recovery period afterwards. Yes, of course there are risks, but that's going to be the end of your thyroid cancer treatment journey and the beginning of your surveillance journey. That's a pretty incredible piece of news to be able to share. Absolutely. That would be great. I mean. I know people do stress about the radioactive iodine and it is a little bit scary you have to do counseling regarding your fertility uh reservation you need to discuss dry mouth, you know, these, so it's not a completely benign treatment even though it's a one time pill and it's easy peasy, but you know there are some consequences from giving it for sure absolutely and you know since we're starting to see thyroid cancer in a much broader range of patients I was speaking to someone just today whose daughter was diagnosed right before high school graduation. And you know, knowing that Young women, especially this being a more common disease in women, um, that their fertility is at risk is a really alarming thing we don't tend to see that in the gentleman until they've used very high therapeutic doses for multiple recurrences somewhere around, you know, 400 milies or so um but just being able to avoid. Not only from from an anxiety standpoint that treatment for patients but also from a time off work, a, you know, travel, all of these things that many of our patients require to get additional therapies, knowing that that's not going to be needed, I think can be a huge reassurance for patients as sort of a harbinger of their future quality of life, which we often expect to be phenomenal. Yeah, absolutely. And then what is your stance on when someone has like a 1 to 4 centimeter uh differentiated thyroid cancer but then they have nodules in the contralateral lobe. This one's a good one. I knew I just thought of that, but I, I always counsel patients like look, you have this. I can treat that side with a lobectomy you do have nodules on the other side. I was like we're gonna have to keep watching those, you know, because they've been biopsy they don't meet criteria for, uh, thyroidectomy, so. I, um, so I always say, look, you're gonna have to keep an eye on it. You're gonna have to ultrasound it. There's a high chance you don't need thyroid hormone, but you might if I do a thyroid lobectomy. So then I offer them in that case, if you want a total, we can do that and explain the rest of the surgery, of course. But I find that majority of my patients when I go through the spiel are like just take the whole thing out. So I don't know what your experience has been or if you're in the same boat or if you're pretty hardcore about being like, I'm only gonna do a low. I think I'm pretty much in the same boat, yeah, I, I think. You know anything that could even potentially be cancer is very anxiety provoking and I think that can overrule the very rationalized context that you set this disease in and I think a lot of patients. Just do say take the whole thing out. I rarely do lobes. I only because the patient insists I do the total because I'm like, OK, what I'm gonna do is remove the lobe. There's a possibility once the pathology comes back that I may have to go back in or remove the other path and then I'm like it's unlikely even if I explain and I don't think that's gonna happen, but I have to explain to you that it's a possibility. People just say absolutely not I'm not gonna do this more than once, which and I always break it down and I say. It depends on your own personal risk tolerance and what I mean by that is, are you somebody who says, Doc, don't do anything to me I don't absolutely need in which case lobectomy is the answer if you are someone who's going to be constantly palpating your neck looking in the mirror worried thinking about the possibility that something could happen to the other side. Then total thyroidectomy is the answer and I find very much as you do that most patients there in that direction. Yeah, I was gonna say I was like I never usually do the lobes mainly because of that conversation so I just was wondering what your experience with that is um one of the other things that's been coming up um lately or you hear a lot of buzz about the meetings is RFA, which is the radio frequency ablation. Uh, you know, that's the hot new thing or patients ask me about it, um, personally we don't have it in my practice, uh, offered, but I know where we can send people, um, so you know I've read that it's mainly used for benign nodules that are causing some symptoms, um, compressive symptoms or cosmetic or someone's bothered by it and they don't wanna keep watching it then they'll do the radio frequency ablation, but I've seen some new research showing that. Radio fix ablation can be used for um microcarcinoma so someone inadvertently biopsies FNA is one of those ones they're not supposed to um or incidentally found some other way then that's a possibility to use it. So I just wanted to know in your practice, have you had experience with RFA? Do you offer RFA? So we do not offer RFA in my practice, um, but. Essentially the data that comes to the thyroid cancer end of therapy from that, as you hinted at, comes from the benign disease end. So patients who have uncomfortable bulky disease that is benign with compressive symptoms, um. We know that the data for RFA or percutaneous ethanol ablation in that context is really quite strong at this point. But the patients need to be carefully selected, so anyone who has posterior disease, you know, they're not gonna be a great candidate because if that, you know, the RFA goes a little too far, the ethanol gets out a little bit, the recurrent laryngeal nerve is at jeopardy, right? So in the cancer setting we're seeing it mostly for metastatic lateral lymph node disease, as I'm sure you know. Um, in patients who have really maximized their surgical and radioactive iodine ablation options, um, so we know it's effective, we know it has a similar risk profile to that being done in the thyroid itself in that I mean the vagus nerve is right there, you know, there, there can be other issues with other nerves from that same therapy, um, the short term data is excellent. And that makes a lot of sense because most thyroid cancers are so indolent. The longer term data seems to be showing us more that patient selection is very important, right? It needs to be low volume lateral neck disease and it may only have a palliative effect because since the majority of these people are going to have already had a lateral neck dissection, have potentially already had RAI, probably already had RA. Um, and so it's only sort of those worst cases that it's really being used right now still pretty experimental, right? Well, also I was reading the technique of the RFA is to basically it's like burning the tissue right from the inside out so you put your probe in and then it's gonna radiate out so it makes a lot of sense what you're saying that you're not gonna get every cell so you know time will tell when it grows back or you know hitting one of those adjacent structures we definitely don't wanna do so that's been very. Helpful, not only could it potentially not get every cell, but you can't see the entire degree of spread with your own two eyes and your ultrasound equipment. You have a pretty good idea where that zone ends, but. Carefully selected patients, I think it's truly the answer definitely an imperfect science at this point indeed yeah so to summarize kind of the some of the key talking points that we brought up today, I think some of the things that I'm taking away from our conversation is that uh we know we need to be mindful of our work up and not overworking up these patients, doing unnecessary imaging and testing. Uh, but also, um, you know, maybe even considering treatment reduction or, you know, not over treating these patients, which is very important so as we've seen with the microcarcinomas, you know, now we're doing more of an active surveillance technique with them, uh, for nodules that don't meet size criteria, not biopsying every thyroid nodule, and then even you were saying that being a little bit more conservative with who we offer radioactive iodine. Uh, in the future will be really helpful, and I think the next step for thyroid cancer treatment is really seeing if, um, less invasive treatments will be used more can be offered to more patients, especially in the cancer setting um, so that will be something on the horizon that I think will change how we treat thyroid cancer if it's successful um so I think those are the main things that. I'm taking away from it. I agree and I think something to keep in mind is that. Surgery remains the mainstay of treatment for these diseases. But 95% of them are going to be curable. Only 5% are going to have that more aggressive presentation where we need to consider some of these alternative therapies. And so I think there's a lot of opportunity moving forward to really be able to tailor our therapy to the patient's exact disease presentation, being able to re reassure our patients that most of them. Will only need one operation and can be considered cured. But if that is not the case. We will be looking at their exact tumor and its behavior to be moving forward with the additional therapies that they need. Absolutely. Uh, as we look to the future, emerging technologies are reshaping thyroid cancer care from AI assisted diagnostics to genomic guided therapies and next generation radioisotopes. These advances promise not just better outcomes but more precise, less invasive. Treatment pathways. The era ahead is one of innovation where technology aligns with biology to refine how we detect, treat and ultimately cure thyroid cancers. The goal isn't just survival, it's smarter, tailored care for every patient. Thank you for your time. To find out more about the topics covered on Baptist Health to doc, please visit physiciansources.baptisthealth.net. Created by
