Each year, thyroid cancer affects about 23,600 people in the United States, with other conditions such as hyperthyroidism and hypothyroidism afflicting thousands more. The good news is that most thyroid cancers are treatable and have a high success rate; the bad news is that most thyroid cancer patients show no symptoms of the disease.

TREATING THYROID CANCER

A Team Approach at UPMC Passavant and UPMC Passavant Cranberry

The thyroid, a small, butterfly shaped endocrine gland underneath the Adam's apple of the neck, secretes hormones that regulate the body's metabolism, or the speed at which bodily functions proceed. When this gland malfunctions, due to various reasons such as nodules or growths, it can cause a number of problems that affect the body's ability to perform.

UPMC Passavant and UPMC Passavant Cranberry have recently established a Thyroid Center, part of the hospital-wide Cancer Center of Excellence, to help patients suffering from thyroid disease. Utilizing a team approach, consisting of various health care workers including different disciplines of physicians, Center staff work together to diagnose thyroid problems, determine the best course of treatment, and follow up with patients to ensure their long-term health.

"Our goal in establishing the Thyroid Center is not only to provide the clinical excellence needed, but to provide coordination of care," said Donna Jasko, vice president of Ancillary Services. "We worked with everyone from primary care physicians, to radiologists and pathologists, to endocrinologists and surgeons on a plan to have all of the services that patients need in one place-providing well-coordinated care for the benefit of patients and the physicians who are guiding them through the process."
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Diagnosing Thyroid Disorders

When the thyroid gland begins to malfunction, some people experience symptoms that can range from physical and mental fatigue and weight gain, in the case of hypothyroidism, to anxiety, weight loss and heat sensitivity in the case of hyperthyroidism. Ninety percent of thyroid disease occurs in women.

"Some patients come to us because they are losing hair, have irregular periods, are unusually tired or are suffering from depression," explained Shailaja Parepally, MD, FACE. "They may also have brittle nails, dry skin or weight gain, which can be a sign of hypothyroidism." Hypothyroidism is caused when the thyroid becomes inactive, and can be treated using different forms of thyroid replacement hormones.

Hyperthyroidism is caused by an overactive thyroid, which causes patients to be anxious and irritable, to lose weight, and can even cause heart palpitations. Left untreated, this condition can lead to atrial fibrillation and stroke. "Hyperthyroidism can be treated by radiation as well as surgery for those patients who are not candidates for radiation," said Dr. Parepally. "After the thyroid is removed, a patient will be put on Synthroid to regulate the levels of thyroid hormone in the body."

While these thyroid conditions can cause obvious symptoms, patients with thyroid cancer may never experience any symptoms at all. "While few people are aware of it, thyroid cancer actually occurs a lot more often than breast cancer," explained endocrinologist Elisabeth Bergman, MD. "Yet many patients with thyroid cancer have no clue that they have the disease until their physician feels nodules during a physical exam, or while being checked for swollen glands."

Patients who are suspected of having thyroid cancer undergo an ultrasound scan, which can help doctors determine the size of the gland and if there are masses or nodules present. "If there are nodules, the ultrasound can tell us how many there might be and what size they are," said Arthur Nussbaum, MD, chief of Imaging Services at UPMC Passavant and UPMC Passavant Cranberry. "From the ultrasound, we can identify nodules that could be targeted for biopsy to determine if the lesions are benign or malignant.

Using ultrasound guidance, radiologists use a needle to remove cells from the nodule for study. "This is a minimally invasive procedure that takes less than 30 minutes," explained Karen Barkey, MD, vice-chairman, Imaging Services. "We the sample to the pathologist while the patient is still here in order to determine if there is enough tissue to make a diagnosis. That way, the patient doesn't have to come back for another biopsy if we need another sample."

"Our goal is to get the patient in quickly, make the diagnosis as fast and as accurately as possible, and to use the immediate cytologist evaluation to ensure that they do not have to return for a repeat biopsy," she added.

Once the sample is given to the pathology department and it is determined to be of an adequate size, a diagnosis is made, usually within one to two days. "We help determine what modality of treatment is appropriate for the patient; our diagnosis guides the clinician in determining what is more appropriate- surgical or nonsurgical means," said Rajnikant Amin, MD, chief of Pathology.

"Because all of our departments work as a team, we are able to more quickly respond to patient needs, and to refer for the appropriate treatment."
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One Patient’s Story

When patients come to UPMC Passavant for thyroid surgery, they often have the opportunity to speak with someone who has undergone the procedure before - their anesthesiologist, Irene Zervos, MD underwent a partial thyroidectomy in 1997, and is happy to share her experience with patients who have questions or concerns.

"I just need to remember not to wear turtlenecks on those days so that patients can look at my neck, because they often ask to see the scar," Dr. Zervos said. "I usually have to point it out - most people can't even see it because it's barely visible."

Dr. Zervos had been told by her primary care physician (PCP) that she had an enlarged thyroid, but had never had any problems.  It wasn't until a physician's assistant remarked that he could see a nodule on her thyroid, three years after that first diagnosis, that she decided to have the thyroid examined.

"I never had any symptoms, and tests on my thyroid had always come back normal," said Dr. Zervos.  After undergoing ultrasound imaging and a needle biopsy, Dr. Zervos was found to have a 2.5-cm nodule on her left thyroid.

"There was no way to tell if it was cancerous unless it was removed," said Dr. Zervos. "I tried thyroid suppression drugs for a year to see if the nodule would change in size, but when it didn't, I decided to go ahead with the surgery."

Scott Celin, MD, and Philip Pollice, MD, performed the partial thyroidectomy, and Dr. Zervos went home the same day, and was back at work the next week.  "UPMC Passavant is blessed to have such excellent surgeons - they really do superior work," said Dr. Zervos, who now acts as the anesthesiologist at many similar procedures.

Dr. Zervos' nodule turned out to be nonmalignant, and because her right thyroid is still intact, she doesn't need to take medications to regulate her body's metabolism.  She still has yearly scans, however, to ensure that she remains healthy.
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Treating Thyroid Disorders

This team approach is taken even further in the operating room. For the past 10 years, Philip Pollice, MD, and Scott Celin, MD, have worked together on each patient's thyroid surgery. "Two surgeons working together is unique and highly beneficial to the patient," explained Dr. Pollice. "The patient receives the skills of two fully trained and fellowship trained surgeons, which allows for a safer, faster, more accurate surgery.

"I believe that our dual-surgeon approach elevates the level of care the patient receives," he added. "This approach marries the skill sets of two surgeons in the same specialty, doubling the surgical expertise applied to the patient's disease."

Each year, Dr. Celin and Dr. Pollice perform hundreds of thyroid surgeries together. "This has allowed us to become very intuitive and to anticipate the surgical maneuvers of one another," said Dr. Celin. "One of the main advantages to this is that it minimizes the length of the operation, which minimizes anesthesia time, and the postoperative recovery for the patient.

"By having two surgeons, instead of one assisted by a nurse or resident, the operations take less than half the time that they used to take each of us to perform separately," he added. "Thyroid and parathyroid operations are technically demanding-visualization is through tiny incisions to minimize scarring. By having a highly trained surgeon stand on each side, we are able to make smaller, less invasive incisions."

Depending on a patient's situation, thyroid surgery can be done as either an inpatient or an outpatient procedure. Patients who have certain types of thyroid cancer may be treated with radioactive iodine approximately six weeks after the surgery. "There is always the chance that there are microscopic cells left in the neck after surgery," said Dr. Barkey. "Radioactive iodine destroys any functioning thyroid tissue."

If caught early, most types of thyroid cancer can be treated, with cure rates topping 90 percent, according to Dr. Pollice. This is especially important, as cases of thyroid cancer have increased four-fold in the last decade. "This isn't because there is more cancer out there-it's because we are catching these cancers at earlier stages," he said. "And the earlier we catch them, the better the chance of a cure."

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