Endocrinologist Dr. Hyesoo Lowe and endocrine surgeons Dr. Jennifer H. Kuo and Dr. Katie McManus discuss current trends and practices in thyroid surgery, including the growing importance of personalized medicine
January is Thyroid Awareness Month, and this year, 2022, endocrinologist Dr. Hyesoo Lowe and endocrine surgeons Dr. Jennifer H. Kuo and Dr. Katie McManus discussed some of the most important topics in thyroid surgery and thyroid medicine.
The three colleagues emphasized the growing importance of individualized or personalized medicine and the essential role that clear and proactive communication—not only between doctor and patient, but also between endocrinologist, surgeon, and patient—plays in giving the best care.
Other covered topics included the non-surgical intervention Radiofrequency Ablation (RFA), the safety of thyroid surgery during pregnancy, and an overview of compressive symptoms that result from enlarged thyroid nodules. [The discussion below is transcribed and lightly edited for text].
Dr. Hyesoo Lowe:
Okay, welcome. Today I have Dr. Jennifer Kuo and Dr. Katie McManus, and we are delighted to have a conversation, more formally, I guess—we see each other informally all the time because we work in the same hallway—but thank you for joining us to talk about Thyroid Awareness Month. So, welcome.
Dr. Katie McManus:
Thank you so much for having us. We are honored to be here, chatting about this. Always a pleasure.
Dr. Jennifer Kuo:
Happy New Year to everyone.
Dr. Hyesoo Lowe:
Happy New Year, everyone. Okay. Well, let's launch ahead. This happens to be Thyroid Awareness Month. So can you tell us a little bit about maybe an aspect of thyroid surgery that has changed in the last year?
PERSONALIZED MEDICINE
Dr. Jennifer Kuo:
Well, I would say that I think we are finally embracing a concept that's been around for a few years, kind of percolating, but we're really now embracing this idea that less is more when it comes to thyroid disease and surgical management of thyroid diseases. We have a greater understanding of thyroid cancer. We have a greater understanding of how it behaves and the fact that it actually doesn't behave the same in everyone. And that sometimes for the majority of thyroid cancer, where it's a somewhat indolent disease, more surgery is not good for patients and can actually hurt them.
So I think we are fully understanding of that. It is being more embraced and more widely practiced. And there's greater exploration for alternatives to surgery. Active surveillance for small, well-differentiated papillary thyroid cancers, as well as some interventional treatment options, intervention-guided treatment options for benign disease.
Dr. Katie McManus:
I think that's a great point, Jen. And I would just like to add in this topic that has also been percolating just in medicine in general, which is just the idea of individualization of medical treatment. I think that is very, very applicable to the patients that we see for thyroid.
And we really have noticed, I think in the last couple of years as our technology has advanced with being able to do special molecular testing for thyroid nodules, and with the advent of different approaches to treating thyroid disease, that we really take in a lot of the patient's unique story to decide and discuss the evidence and what is going to be the best path for them. Because it may be very different from somebody who has another type of thyroid problem. And their preferences and their concept of what thyroid disease means to them, how it impacts their lives, is going to help us pick the best treatment for them.
Dr. Hyesoo Lowe:
That's a really great point. And I think due to technology, an explosion in genomic medicine, this whole idea of personalized medicine is finding its way to all kinds of aspects of medical care. And definitely thyroid is included. Along with that is a generalized push in general medicine toward shared decision making, where maybe two or three decades ago the patient-doctor interaction was a little bit, I would say, slightly paternalistic. Where the doctor would make a recommendation and the patient would follow it.
The patient felt like, okay, well, that sounds fine. And they would either agree to do that, or maybe not. And now there are so many more decisions to be made together. And a lot of this has to do with exactly what you were saying, Katie, about how a certain kind of surgery might impact your life? Do you want surgery? Is there an option of medical treatment? Is there an option of safe monitoring? So there's so many different things that are now involved, which certainly makes for more involved conversations in the office.
But there's certainly a lot more awareness and patients can be much more informed and happy with the decision they make because they're making these decisions along with us. And to highlight the idea that there's no one right answer for a lot of things. There are many right answers, and there is a better answer for each person individually. And so that's what we're really learning. So that's great.
So Jen, on the topic, we're actually really happy that you're here to talk to us about certain, less invasive thyroid treatments. We're happy to have Jennifer Kuo because she has one of the highest volume radio frequency ablation practices here, in the country. So can you describe what radio frequency ablation is? We call it RFA, those are the initials, but what is it exactly? Is it kind of like a laser procedure? Can you describe it pretty briefly?
RADIOFREQUENCY ABLATION (RFA)
Dr. Jennifer Kuo:
Yeah. So radio frequency ablation is really just one of these more image-guided thermal ablation techniques. So it's really using different sorts of energy. So laser is one of them, for sure. Radio frequency is another, and there is microwave as well. Basically, we are targeting individual nodules and using heat, the application of heat, to destroy the cells within that nodule.
And usually the main objective is to destroy the cells, let the body reabsorb those destroyed cells, in order to shrink the overall size of the thyroid nodules. So it's really to address benign disease, because as we all know, even benign thyroid nodules grow. And a lot of patients, at some point, will have some compressive symptoms from these benign nodules.
Dr. Hyesoo Lowe:
So what kind of compression symptoms are patients mainly talking about?
Dr. Katie McManus:
Yeah. So oftentimes, patients will come in and say that when it's large enough or in a position where it's by the airway or the esophagus, they'll say “I'm having trouble sleeping. When I lay flat, or even when I recline, I feel like I'm choking or like I can't catch my breath.” And it's just because of this heaviness that they have at the front of their neck, that's causing them that sensation.
Oftentimes, people will say that they're having difficulty swallowing. And it's not so much a pain with swallowing, but it's almost like an extra effort has to be made. So people will say, when I swallow something, or especially if I swallow pills, I find that I have to swallow multiple times to get things to go down. And so that's a very common thing that people will report.
And also in terms of just changes in voice. That's another thing that people can have if they have any sort of compression on the nerves that control the vocal cords and voice projection. People can also have hoarseness or difficulty projecting as symptoms as well.
Dr. Jennifer Kuo:
Traditionally, we've only been able to offer surgery. But now when patients ask, “Can't you just zap it?” I can actually say, yes, I can zap it. But the key to understanding what all these thermal ablation techniques are able to offer is really just understanding that it's volume reduction, and not complete disappearance of the thyroid nodule. And I think that is a concept that needs to be clear, and is not as clear to patients, I think, as would be ideal.
So you're still going to have a nodule. You're still going to need ultrasound surveillance. You may need biopsies, and you may need future ablation sessions down the road. So it's still a commitment, as compared to surgery. With a surgical resection, that nodule comes out and you never really have to worry about that nodule again.
Dr. Hyesoo Lowe:
That sounds great. So it seems that RFA would be great for a person who's got a nodule that's benign, it's not cancer, but it's growing and growing. And every time it gets re-imaged, it seems to be a little bit bigger. And the patient maybe is thinking about whether to have it removed or whether they'd be happy enough to just, as you say, just zap it and make it smaller. And that would be the decision point to make. Obviously, being able to avoid surgery for a less-than-one-hour procedure, down the hall, could be very, very appealing to a lot of people.
So how have people been doing? You've done a whole bunch of these in the last year. Are people pretty happy with the procedure?
Dr. Jennifer Kuo:
Yeah. Dr. McManus and I have done a total of, I would say over 150 patients at this point, for RFA alone. And for more cystic thyroid nodules, we prefer to use ethanol ablation when appropriate. So combined, we have over 200 patients in our series. And patients love it. I would say for the most part, their biggest driver, what they're happiest about is the fact that the nodule is smaller and their compressive symptoms are resolved and they don't need thyroid hormone medication, and they were able to hold on to their thyroid gland. That I think is an increasingly important concept for a lot of patients.
And so the ability to address a problem that's not cancer without surgery has been a very good option for a lot of these patients. And we've had outcomes, in terms of volume reduction, very similar and on par with what the international experience has been previous to us. And so it does appear, even with our own patients, to be a safe procedure. And patients really do, I think, value having that nonsurgical option.
Dr. Hyesoo Lowe:
I agree. When I bring that up as an option for peoples' nodules, when I see my patients with this condition of thyroid nodules, you're absolutely right that an increasing awareness and value is to “hold onto my healthy thyroid tissue. Is there a way I can just hold onto my thyroid, but just take care of the nodule?” And for many years I said, “Well, there's really no such thing as a lumpectomy for a thyroid nodule. Either the whole thyroid's got to come out, if it's all over the thyroid, or at least half of the thyroid that is housing the nodule would have to come out with the nodule.”
And that is a significant concern because patients want to hold onto their thyroid function, especially if it's normal, and they don't want to start a long term commitment with thyroid medication. So that is definitely one of the benefits of this non-invasive technique and this booming, or ever-growing field of interventional endocrinology. So we're very happy to continue to offer that.
Dr. Katie McManus:
It's funny, because it used to be that if a patient's nodule comes back as benign, we say, okay, that's it. And really, then they're like, “Well, wait a minute, though, I'm still having trouble with sleeping, laying flat, feeling like I can't breathe or I'm choking. I'm having trouble every time I swallow, I feel like I have to swallow extra times to get food to pass.” A lot of patients say that they've noticed when they compare pictures from the past to now, that their neck just looks asymmetrical or larger.
Dr. Hyesoo Lowe:
Especially on Zoom, now that everyone's on it.
Dr. Katie McManus:
Yeah. Especially on Zoom. Now that everyone is working from home and able to look at themselves 24-7, people are really noticing these changes. And we used to say, well, really the only thing that we can do in terms of treating this is to take it out. And if it was more of a fluid filled nodule or a cystic nodule, we could, of course, drain the fluid out with a needle, but that had a disadvantage of a high rate of recurrence. So thus, the beginnings of our ethanol ablation, where we actually inject ethanol into the cavity, the lining of the cyst to get it to stick together and prevent that refilling of the fluid.
But now I find that the conversation gets a lot more nuanced and complex with a benign nodule more than with a cancer. Because they really have to weigh their preferences about, “Well, how do I feel about having an operation?” and “Although complication rates are very low, how do I feel about undergoing surgery? How do I feel about having a scar?” And of course, now there are remote-access types of surgery that can take out the thyroid, part of the thyroid, the whole thyroid as well, and avoid a scar.
But, this is just another interventional endocrinology that can add to the list of options versus “How do I feel about,” as Jen had said, “this lifetime commitment of, ‘I may need to have another biopsy, I may need to have another ablation in the future.’ ” Because we're not actually taking out the tissue, we're not actually taking out the nodule.
I think it's funny how it's really transformed from a very brief conversation of, “Well, if it's bothering you enough…” and people responding, “What's enough? It's bothering me” into a longer discussion, in which we say, “Okay, well, there are several more options for you.”
Dr. Jennifer Kuo:
When you first asked the question, what's changed in the last year? In my head, I was thinking: “I'm doing a lot more talking and a lot less cutting!” In my thyroid surgery world. For sure, the conversations are so much more complex now.
Dr. Hyesoo Lowe:
A lot more talking. I would agree with that. And I agree that these conversations have really bloomed because there are just that many more options that are becoming more mainstream, especially here at Columbia. So yes, absolutely. A short conversation for benign nodules, which are very, very common, and way more common than thyroid cancer, previously would just end with, “Everything's okay, it's not cancer.” Now that is a much longer and nuanced conversation about, well, do we want to do anything about these nodules, and here are various options.
So ethanol ablation, injection of alcohol for those fluid-filled cysts, and then up to radio frequency ablation for the more solid nodules that are growing. All of which are being done here and very, very successfully. Just a question about RFA, how fast do people notice a difference? Is it instantaneous, does it take a couple of months, a couple of years?
Dr. Jennifer Kuo:
Very quick. It's actually quite surprising how quick those compressive symptoms really resolve. Patients have been reporting that they feel a difference in terms of the neck pressure, in terms of their swallowing, within a week of the procedure. And that was actually very surprising to me when we first started to do these, and seeing patients in follow up. So it can be, especially for those patients with pretty significant compressive symptoms at baseline, the difference is pretty quick.
Dr. Hyesoo Lowe:
Amazing stuff, amazing stuff. I'm going to switch gears now. We have been talking about thyroid nodules, things that are benign, that people will have some time to think about the options. But sometimes there is NOT a lot of time to think about particular options, such as when a patient is pregnant.
There are certain situations in pregnancy where we will find that a patient really may need to have thyroid surgery somewhat urgently, and possibly even during their pregnancy. This would involve things like large or invasive thyroid cancers, persistent hyperthyroidism, where they're allergic to medications or the medications really are not right for them in pregnancy. How safe is it, and when can a patient get operated on in pregnancy?
THYROID SURGERY DURING PREGNANCY
Dr. Jennifer Kuo:
You just hope that the patient's in their second trimester, because that's the safest time to perform an operation if one is really needed. I'd say that we try not to operate in pregnancy at all, but if absolutely necessary, the second trimester really is the safest time. In the first trimester, you risk that it's a high risk of miscarriage. Within the third trimester, there's a high risk of early labor.
Dr. Hyesoo Lowe:
Makes sense. So we try not to do it, but if we have to do it, mainly the best time is second trimester. And we certainly have had it safely done. Good.
And so I'm just going to wrap this up to say that as an endocrinologist, I work with both of you quite often, and we share a lot of patients and we get to have a lot of back-and-forth down the hallway about our patients. You also have a lot of other referring endocrinologists who are more remote and need to communicate with you in other ways.
What kind of things would you like your referring doctors, endocrinologists, other doctors to know about endocrine surgery or how best to collaborate with you?
BETTER COMMUNICATION & SHARED DECISION-MAKING
Dr. Jennifer Kuo:
I think for me, it is important to know that you guys are our partners, especially now that everything is so complex. And as you mentioned before, there is no right answer. It's a team effort. It's shared decision making, not only between the surgeon and the patient, but the surgeon, the patient, and the endocrinologist. And so I think we really do value your knowledge, your training, your expertise in all the areas that we really have none. And it's important that the decision, whatever decision is made, is made with all of our input in it.
Surgeons aren't known as warm, friendly types. But we do really, really value, I think, our partnerships with our medical endocrinology colleagues in the care of our patients. And so I guess I don't say it very often, but that's what I would want you guys to know.
Dr. Hyesoo Lowe:
Aww.
Dr. Jennifer Kuo:
We appreciate you. That's it, I guess.
Dr. Katie McManus:
We appreciate you, yes. That's absolutely true. I think we're a small part of providing care for the patient. We do a very specific nuanced part of their treatment plan, and we really value the endocrinologists who know them, and many times have been following them for years. And really have a good understanding of the patient's disease as well as the patient's preferences and how they want to proceed with their treatment.
I always think it's so important to communicate and be sure that everybody's on the same page as far as the decision-making and timing of things. That is one of the most important things that we do, and that we do as surgeons, is to be sure that we follow up and communicate and let you know our plan, make sure that you agree, and then go forward.
Dr. Hyesoo Lowe:
Do I work with the best team ever? This is just wonderful. Absolutely wonderful. And I have to tell you guys that, obviously, if I don't have the utmost confidence in sending my patients to the people that are going to get the job done in a reliable way and be smooth sailing all the way through, that we can't do our jobs properly.
So you're absolutely right. It's a team effort and we are privileged that we just have the best that there is out there and we can confidently tell our patients, I would send my own family to them. And so we are completely confident that you will be in good hands when we send you to our people. I'm happy that both of you are here.
Dr. Katie McManus:
Thank you for having us.