MANAGEMENT OF THYROID LUMPS
Dr Sandeep Uppal and his team at The ENT Clinic understand that a thorough diagnostic process is crucial for addressing thyroid lumps effectively and follow the following steps for effective management of this condition.
DIAGNOSTIC METHODS
DETAILED PATIENT HISTORY
Before any physical examinations or tests, a detailed history is taken to understand the patient’s symptoms, lifestyle, and any potential risk factors.
Questions may include when the lump was first noticed, any changes in size or texture, associated symptoms, family history of thyroid disorders or cancers, and any previous radiation exposure.
CLINICAL EXAMINATION
A comprehensive clinical examination involves palpating the neck area to assess the size, texture, and location of the lump.
Dr Sandeep will also check for enlarged lymph nodes in the neck and other signs that could indicate a more systemic issue.
An endoscopic examination of the larynx (voice box) will also be performed to rule out any abnormality of the nerve supplying the muscles that help to produce voice.
ULTRASOUND IMAGING
An ultrasound is typically the first-line imaging study used to visualize the thyroid gland and any nodules present.
This technique can discern whether the lump is solid, cystic, or a mixture of both, and can also identify suspicious characteristics like irregular borders or internal calcifications.
FINE-NEEDLE ASPIRATION (FNA) BIOPSY
An FNA biopsy is often crucial for determining the nature of the thyroid lump.
A thin, hollow needle is used to extract a small sample of cells from the nodule. Local anaesthesia may be used to numb the area.
The extracted cells are then examined under a microscope for characteristics that may indicate cancer or other thyroid conditions.
BLOOD TESTS
Thyroid-Stimulating Hormone (TSH), Free T4 and sometimes Free T3 levels are checked, and in some cases, additional tests like thyroid antibodies may be done to rule out autoimmune conditions.
ADDITIONAL IMAGING
For complex cases, further imaging studies like CT scans or MRIs may be performed. These additional imaging studies can provide a more detailed view of the thyroid gland and surrounding structures.
MOLECULAR TESTING
Molecular testing looks at the cellular makeup of the thyroid nodule, specifically focusing on the genes and proteins that are expressed.
This kind of testing is particularly useful for nodules where the Fine-Needle Aspiration (FNA) biopsy results are indeterminate or suspicious but not definitively cancerous.
By examining the molecular markers, our team can better understand the behaviour of the nodule, such as its potential for malignancy or aggressiveness.
Types of molecular tests for thyroid nodules include ThyroSeq, Afirma, and RosettaGX Reveal, among others.
These tests analyse the presence or absence of various gene mutations and rearrangements to offer a more nuanced diagnosis.
GENETIC TESTING
Genetic testing takes a broader look at an individual’s genetic makeup to understand the risk factors for developing thyroid nodules or thyroid cancer. With his background of research and PhD in ‘Genetic Studies on Inherited Diseases Presenting with Unusual ENT Problems’ Dr Sandeep in well placed to recommend genetic tests for patients with a strong family history of thyroid disorders or other endocrine cancers.
Types of Genetic Tests
- Germline Testing: This test examines a blood or saliva sample to identify inherited mutations that increase the risk of developing thyroid nodules or cancer. This is especially useful for individuals with a strong family history of thyroid or other endocrine disorders.
- Somatic Mutation Testing: Conducted on the tissue sample obtained from the thyroid nodule, this test looks for mutations that have occurred after birth and may contribute to the nodule’s growth or malignancy.
Commonly Tested Genes
- RET Gene: Mutations in this gene are often associated with medullary thyroid cancer and are a cornerstone of genetic testing for individuals with a family history of this condition.
- BRAF and RAS Genes: These are often tested in somatic mutation panels to identify the likelihood of papillary or follicular thyroid cancer.
- PTC and FTC Genes: Sometimes, tests may include genes specifically associated with papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC).
When is Genetic Testing Recommended?
- Family History: When multiple family members have had thyroid nodules or cancer, genetic testing may be advised.
- Multiple Endocrine Neoplasia (MEN) Syndromes: For families with a history of MEN syndromes, which involve tumours in multiple endocrine glands, genetic testing is highly recommended.
- Young Age: The presence of thyroid nodules or cancer at a young age can also be an indicator for genetic testing.
Pre- and Post-Test Counselling
- Pre-test Counselling: Before undergoing genetic testing, it’s often recommended to speak with a genetic counsellor to understand what the test can and cannot tell you.
- Post-test Counselling: After the results are available, another session with a genetic counsellor helps interpret the results, understand the implications for treatment and future screening, and discuss the potential impact on family members.
Genetic testing can provide valuable insights into the diagnosis and management of thyroid conditions, but it’s important to interpret the results in the context of each patient’s unique medical history and symptoms. Dr Sandeep Uppal and his team at The ENT Clinic offer a thorough, evidence-based approach, incorporating genetic testing as part of their comprehensive care for thyroid disorders.
TREATMENT AND PROGNOSIS IN THYROID CANCERS
Dr Sandeep Uppal and his team at The ENT Clinic emphasize the importance of a comprehensive approach to understanding the prognosis of thyroid cancer, which can be influenced by several factors such as the stage of the cancer, the patient’s age, and any relevant genetic markers.
It’s worth noting that survival rates are general estimates, and the prognosis can vary from patient to patient based on a variety of factors, including overall health, response to treatment, and other individual characteristics. In general, younger patients (<45 years) often have a better prognosis across all types of thyroid cancer.
PAPILLARY THYROID CANCER
Stage I
Younger than 45: Almost 100% 5-year survival.
45 Years and Older: 80-90% 5-year survival if localized.
Stage II
Younger than 45: Almost 100% 5-year survival.
45 Years and Older: 70-80% 5-year survival if localized.
Stages III & IV
Younger than 45: 90-95% 5-year survival.
45 Years and Older: Reduced 5-year survival, often below 50% for stage IV.
Genetic Factors:
Genetic Markers: BRAF V600E, RET/PTC rearrangements.
Prognostic Significance: The presence of a BRAF V600E mutation is often associated with a more aggressive disease course, including higher rates of recurrence and decreased overall survival.
Reference: Xing M., et al., J Clin Oncol, 2013.
Reference: American Joint Committee on Cancer (AJCC), 8th edition.
FOLLICULAR THYROID CANCER
Stage I
Younger than 45: Nearly 100% 5-year survival.
45 Years and Older: The 5-year survival rate is also generally excellent, although slightly lower than in younger patients. It ranges from 80-95%.
Stage II
Younger than 45: Nearly 100% 5-year survival.
45 Years and Older: Approximately 70% 5-year survival.
Stages III & IV
All Ages: 50-60% 5-year survival.
Genetic Factors:
Genetic Markers: RAS mutations, PAX8/PPARγ rearrangements.
Prognostic Significance: RAS mutations are generally associated with a more indolent course, whereas PAX8/PPARγ rearrangements can be seen in both benign and malignant follicular lesions but may suggest a higher potential for metastasis.
Reference: Nikiforova MN, et al., Endocr Relat Cancer, 2012.
Reference: American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 8th Edition; National Comprehensive Cancer Network (NCCN) Guidelines for Thyroid Carcinoma.
MEDULLARY THYROID CANCER
Stage I
All ages: Around 95% 5-year survival if localized.
Genetic Factors: Presence of RET mutations, especially in familial cases, can significantly influence prognosis and may necessitate more aggressive treatment.
Stages II to IV
All Ages: 5-year survival rates range from 81% for stage II to below 50% for stage IV.
Genetic Factors:
Genetic Markers: RET mutations.
Prognostic Significance: Presence of certain RET mutations, especially in familial cases, often necessitates more aggressive treatment and surveillance due to a higher risk of metastasis and recurrence.
Reference: AJCC Cancer Staging Manual, 8th Edition; Wells et al., Thyroid, 2015.
ANAPLASTIC THYROID CANCER
Stages IVA & IVB
All Ages: Generally poor, often less than a year of survival.
Stage IVC
All Ages: Extremely poor, often just a few months of survival.
Genetic Factors
Genetic Markers: TP53 mutations, TERT promoter mutations.
Prognostic Significance: These mutations are often associated with an extremely aggressive disease course and poor response to therapy.
Reference: Landa I, et al., J Clin Endocrinol Metab, 2016.
Reference: AJCC Cancer Staging Manual, 8th Edition; Smallridge et al., Thyroid, 2012.
Reference: National Comprehensive Cancer Network (NCCN) Guidelines for Thyroid Carcinoma.
TREATMENT OF THYROID CANCERS
Dr Sandeep Uppal and his team at The ENT Clinic understand that a nuanced approach to thyroid cancer treatment is vital. Treatment decisions are based on several factors, such as stage, size of nodules, presence of cervical lymphadenopathy, distant metastasis, and whether to opt for hemithyroidectomy or total thyroidectomy.
Dr. Sandeep Uppal and his team at The ENT Clinic are dedicated to providing a personalized, evidence-based approach to the management of thyroid cancers. They collaborate closely with genetic counsellors, radiologists, and other specialists to offer patients the most comprehensive care, from diagnosis through to treatment and ongoing monitoring.
Below is a more detailed guide:
PAPILLARY THYROID CANCER
We are committed to providing the most comprehensive and tailored treatments for patients with papillary thyroid cancer. Recognising that each case presents unique challenges, they adhere to the most recent guidelines for evidence-based care. Below is a more detailed exploration of treatment options based on various scenarios:
Small Nodules (<1 cm), Stage I, No Lymphadenopathy, No Metastasis:
- Hemithyroidectomy: Removal of the half of the thyroid containing the nodule is often sufficient. The advantage of this approach is that it may preserve some thyroid function, possibly eliminating the need for lifelong thyroid hormone replacement.
- Postoperative Monitoring: Regular ultrasounds and measurement of thyroglobulin levels are typically advised to monitor for recurrence.
Reference: Haugen et al., Thyroid, 2016; NCCN Guidelines.
Large Nodules (>1 cm), Stage I-II, No Lymphadenopathy, No Metastasis:
- Total Thyroidectomy: Complete removal of the thyroid gland is recommended to eliminate all potential sources of cancer.
- Radioactive Iodine Treatment (RAI): Often administered postoperatively to destroy any microscopic areas of thyroid tissue that may be left behind.
- TSH Suppression: Patients are often placed on levothyroxine to suppress TSH, which could potentially stimulate any remaining cancer cells.
Reference: Haugen et al., Thyroid, 2016; NCCN Guidelines.
Any Size, Stage III-IV, With Lymphadenopathy or Metastasis:
- Total Thyroidectomy and Lymph Node Dissection: In addition to removing the thyroid, affected lymph nodes in the neck are also surgically removed.
- Radioactive Iodine (RAI): Higher doses are usually administered postoperatively.
- External Beam Radiation or Targeted Therapy: For very advanced or aggressive cases, external beam radiation or targeted therapies like sorafenib may be considered.
- Follow-Up and Monitoring: More frequent monitoring, including advanced imaging like PET scans, may be required.
- TSH Suppression: Patients are often placed on levothyroxine, a synthetic form of thyroid hormone, to replace the hormones that the removed thyroid gland would normally produce. The dosage of levothyroxine is adjusted to suppress the level of thyroid-stimulating hormone (TSH) in the body. Elevated TSH levels could potentially stimulate the growth of any remaining cancer cells.
- Monitoring: Periodic blood tests are done to ensure that TSH levels are adequately suppressed while avoiding overtreatment that could lead to hyperthyroid symptoms.
- Long-term Follow-Up: In addition to TSH, other markers like thyroglobulin and imaging studies will be used to monitor for recurrence or metastasis.
Reference: NCCN Guidelines for Thyroid Carcinoma; AJCC 8th Edition.
By adhering to these guidelines and tailoring treatments to individual needs, we aim to provide the most effective and personalized care for each patient, enhancing the likelihood of successful outcomes.
FOLLICULAR THYROID CANCER
Low-Risk Patients (Stage I & II)
- Surgical Removal: Lobectomy or total thyroidectomy is recommended, depending on various factors like multifocality and patient age.
- TSH Suppression: Levothyroxine is administered postoperatively to suppress TSH levels.
- Follow-Up: Baseline neck ultrasound and serum thyroglobulin levels to be checked 6-12 weeks postoperatively.
Intermediate-Risk Patients (Stage III)
- Surgical Removal: Total thyroidectomy is generally recommended, especially if there are other risk factors.
- Radioactive Iodine Therapy: Postoperative RAI is considered for patients with risk factors like extrathyroidal extension.
- TSH Suppression: Continued Levothyroxine therapy to suppress TSH levels.
High-Risk Patients (Stage IV)
- Surgical Removal: Total thyroidectomy along with possible neck dissection for any involved lymph nodes.
- Radioactive Iodine Therapy: Postoperative RAI therapy is usually administered.
- TSH Suppression: High-dose Levothyroxine therapy to suppress TSH levels.
Follow-Up as per NCCN Criteria
- First 12 Months: Physical examination and neck ultrasound are typically performed every 3-6 months, along with serum thyroglobulin tests.
- After 1 Year: Annual visits including a neck ultrasound and serum thyroglobulin tests, particularly for intermediate and high-risk patients.
Reference: NCCN Guidelines for Thyroid Carcinoma; AJCC 8th Edition.
By adhering to NCCN guidelines, Dr Sandeep Uppal and his team ensure that each patient receives evidence-based, state-of-the-art care for Follicular Carcinoma of the thyroid.
MEDULLARY THYROID CANCER
Dr Sandeep Uppal and his team at The ENT Clinic adhere strictly to the NCCN guidelines for managing Medullary Thyroid Carcinoma (MTC). The NCCN guidelines provide a stage-wise approach to treatment, which Dr Sandeep and his team find invaluable for tailored patient care. Below is a more detailed look at treatment options based on the stage of the disease.
Stage I
- Surgical Treatment: Total thyroidectomy is recommended, and central compartment neck dissection may be considered based on risk factors.
- Follow-Up: Serum calcitonin and carcinoembryonic antigen (CEA) measurements at 3 and 6 months postoperatively.
Stage II
- Surgical Treatment: Total thyroidectomy along with central neck dissection is usually recommended.
- Follow-Up: Frequent monitoring with serum calcitonin and CEA, along with neck ultrasound, is advised every 3-6 months.
Stage III
- Surgical Treatment: Total thyroidectomy, central neck dissection, and possibly lateral neck dissection based on lymph node involvement.
- Adjuvant Radiation Therapy: Considered for patients with high-risk features, such as extrathyroidal extension.
- Follow-Up: More frequent follow-up with imaging and serum markers is recommended due to the higher risk of recurrence.
Stage IV
- Surgical Treatment: Surgery for debulking purposes may be considered, especially if there is compressive symptomatology.
- Systemic Therapy: Tyrosine kinase inhibitors like Vandetanib or Cabozantinib are usually recommended for metastatic or progressive disease.
- Radiation Therapy: May be used for palliative care in symptomatic metastatic sites.
- Follow-Up: Intensive follow-up with cross-sectional imaging and serum markers, typically every 3 months.
Follow-Up for All Stages
- First 6 Months: Physical examinations, neck ultrasounds, and serum calcitonin and CEA tests are usually performed every 3-6 months.
- 6-12 Months: Monitoring frequency may decrease to every 6-12 months, depending on risk factors and disease status.
- Long-Term: Annual check-ups, including imaging and serum marker tests, are generally recommended for all stages, with the frequency adjusted based on risk stratification.
Reference: NCCN Guidelines for Thyroid Carcinoma; AJCC 8th Edition.
By abiding by the NCCN guidelines, Dr Sandeep Uppal and his team at The ENT Clinic can provide the most current, comprehensive, and individualised care for patients with Medullary Thyroid Carcinoma at different stages.
ANAPLASTIC THYROID CANCER
Dr Sandeep Uppal and his team at The ENT Clinic adhere to the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of Anaplastic Thyroid Cancer (ATC), which is one of the most aggressive forms of thyroid cancer. Below is a stage-wise summary based on general NCCN guidelines up to January 2022. It’s crucial to consult the most current version of the guidelines for the most accurate and up-to-date information.
Stage IVA (Locally Invasive)
- Surgery: Surgical debulking may be attempted if feasible, to relieve compressive symptoms.
- Chemoradiation: Concurrent chemoradiation therapy is typically recommended.
- Targeted Therapies: May be considered in certain cases.
Stage IVB (Locoregional Spread)
- Surgery: Surgical intervention mainly for palliative purposes.
- Chemoradiation: High-dose radiation along with chemotherapy is often recommended.
- Targeted Therapies: Tyrosine kinase inhibitors or immunotherapy may be considered.
Stage IVC (Distant Metastasis)
- Systemic Therapy: Chemotherapy along with targeted agents like kinase inhibitors.
- Palliative Care: Symptomatic relief measures such as radiation for bone metastasis.
- Clinical Trials: Given the poor prognosis, enrolment in clinical trials for new treatments is often considered.
Follow-Up for All Stages
- Short-Term: Given the aggressive nature of ATC, close monitoring is essential, often on a weekly to monthly basis initially.
- Medium-Term: Continued regular check-ups and imaging studies.
- Long-Term: Ongoing surveillance is generally determined by the individual patient’s response to treatment and overall health status.
Reference: NCCN Guidelines for Thyroid Carcinoma; AJCC 8th Edition.
PERSONALISED TREATMENT
Genomic profiling can guide targeted therapies, such as tyrosine kinase inhibitors for RET mutations in medullary thyroid cancer or BRAF inhibitors in papillary thyroid cancer with BRAF mutations.
Reference: National Comprehensive Cancer Network (NCCN) Guidelines for Thyroid Carcinoma.
HOW DOES DR SANDEEP ENSURE SAFETY IN THYROID SURGERY?
Dr Sandeep and his team is deeply committed to ensuring safe and effective thyroid surgery. With training from esteemed institutions around the world, Dr Sandeep has integrated a blend of technical expertise and evidence-based practice into his surgical approach.
TRAINING AND SKILLSET
Foundational Training
Dr Sandeep received his initial training in thyroid surgery at the York General Hospital, UK under Dr Andrea Nicolaides and Dr Andrew Coatesworth, and further honed his skills at the Leeds General Infirmary, UK under the tutelage of Dr J. Woodhead and ZG Makura. He received further advanced training in thyroid surgery under Professor N. Stafford and Dr J. England at Hull Royal Infirmary, a tertiary centre for head and Neck Cancer Treatment. In all these centres Dr Sandeep was involved in the Multidisciplinary Thyroid Tumour Board and honed his skills in managing thyroid cancer patients.
Evidence-Based Practice
Dr Sandeep strictly adheres to internationally accepted guidelines and norms, including the NCCN guidelines, to ensure that surgery is performed only when necessary.
Surgical Innovations for Safety
When surgery is indicated, he uses advanced tools like the Nerve Integrity Monitoring system and the Harmonic Focus™ scalpel, where indicated. These technologies aim to ensure optimal voice outcomes and minimal blood loss.
Safety First
Above all, Dr Sandeep places the highest priority on patient safety. His rigorous training and adherence to guidelines are geared towards minimizing risks and ensuring the best possible outcomes for his patients.
Through this unique blend of international training, advanced techniques, and strict adherence to evidence-based guidelines, Dr Sandeep Uppal and his team at The ENT Clinic ensure the highest standards of safety and effectiveness in thyroid surgery.
ASSERT CONTROL OVER YOUR WELLNESS: ADDRESS THYROID LUMPS PROMPTLY!
Are you noticing swelling in your neck, experiencing changes in your voice, or feeling discomfort when swallowing?
Thyroid lumps can be a sign of underlying issues that require immediate attention. Both adults and children could face the risks associated with these growths, which, if left unchecked, might lead to critical outcomes, including obstructive symptoms or the need for more invasive treatments.
Don’t let thyroid lumps go unchecked. It’s time for decisive action!
Team up with Dr Sandeep to discover the right approach for your thyroid health. Book your evaluation with Dr Sandeep for specialized insight and tailored management strategies.
