Thyroid Nodule Management

August 10, 2020

Information

August 9, 2020

Yale Cancer Center

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00:00Support for Yale Cancer Answers
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00:05eliminate cancer as a cause of death.
00:08Learn more at astrazeneca-us.com.
00:12Welcome to Yale Cancer
00:13Answers with your host
00:15Doctor Anees Chagpar.
00:18Yale Cancer Answers features the
00:20latest information on cancer care by
00:22welcoming oncologists and specialists
00:24who are on the forefront of the
00:27battle to fight cancer. This week,
00:28it's a conversation about thyroid
00:30cancer and the management of
00:32thyroid nodules with Doctor Grace Lee.
00:34Doctor Lee is an assistant professor
00:36in the section of endocrinology and
00:38metabolism at the Yale School of
00:40Medicine where Doctor Schwartz is the
00:42John Slade Eli Professor of obstetrics,
00:44gynecology and Reproductive Sciences.
00:48Doctor Lee, my first question is
00:50can you tell us a little bit about
00:52yourself and your area of expertise?
00:54What cancers do you treat?
00:56What's your role at the Veterans
00:58Administration Hospital?
01:00So as you mentioned,
01:02I'm assistant professor of Medicine in
01:04the section of endocrinology at Yale.
01:06There I teach Endocrinology Fellows,
01:08medical residents as well
01:10as medical students.
01:11I'm also a clinical endocrinologist
01:13at the Veterans Affairs Connecticut
01:15healthcare system for the VA.
01:16I serve veterans at both the West Haven,
01:19and Newington locations.
01:21My areas of expertise include
01:22thyroid nodules, thyroid cancer,
01:25along with other metabolic bone diseases.
01:28I also practice general endocrinology.
01:32How common is thyroid cancer,
01:34especially in veterans?
01:35And how is it typically diagnosed?
01:37Are there any symptoms that
01:39people should be aware of?
01:41In general, I can tell you
01:43about the thyroid itself.
01:44Not a lot of people know where
01:47the thyroid is, so let's start
01:49off by saying where that is.
01:51It's a gland that's very
01:53important to the body.
01:54It's in the front of the neck and
01:57is right on top of your windpipe.
02:01You know when you ask about
02:03how common thyroid cancer is,
02:05it really depends on the type of
02:07thyroid cancer that we're talking about.
02:09And mainly there's about four
02:11different types of thyroid cancer,
02:13the most common being
02:15papillary thyroid cancer,
02:16and that's about 15 in every 100,000
02:18people an this being the most common
02:21type of cancer is actually also the
02:23most benign type of thyroid cancer.
02:26I shouldn't say benign,
02:27the least aggressive of all
02:29different types of thyroid cancer.
02:31The more aggressive type would
02:33be considered something called
02:34anaplastic thyroid cancer,
02:35which Fortunately is only less
02:37than 3% of the different types
02:39of thyroid cancer that exists.
02:41You asked about symptoms that people
02:43should be aware of and how it's diagnosed.
02:45Typically somebody may notice
02:47a lump in their neck,
02:48which can be either from a
02:50Mass in the thyroid or from an
02:53abnormal lymph node in the neck,
02:55or an enlarged lymph node.
02:57Another way it's typically diagnoses,
02:58actually, incidentally,
02:59for example,
03:00if somebody has a.
03:01Car accident and has a
03:03cat scan for their neck.
03:04They might be surprised to find
03:06out that they have thyroid nodules,
03:08but actually they are very common and
03:10thyroid cancer is actually a very
03:12small percentage of thyroid nodules.
03:14But those are the main different
03:16types of thyroid cancer and chances
03:18are if you're diagnosed with thyroid
03:20cancer it is probably going to
03:22be papillary thyroid cancer.
03:26I was very interested to see a
03:29difference between women and men in
03:31terms of the incidence of thyroid cancer.
03:33My impression is that women now have
03:35about 3 times as many cancers as men,
03:38but it seems to be less deadly in women.
03:41Can you talk to us a little bit
03:44about how this phenomenon may occur
03:46and what should women be aware of,
03:49particularly during
03:50reproductive age?
03:52It's not exactly known why that's true.
03:55Some people think that women
03:56come under the care
03:59of providers more than men do,
04:01and it's true that in men it seems to be
04:04more of an aggressive
04:07cancer, however,
04:08it's all individual based on
04:11the patient and that doesn't necessarily
04:13mean that all men are going to have
04:15poor prognoses.
04:18I forgot to mention earlier,
04:20you mentioned what other
04:23symptoms that women should watch out
04:25for and men should watch out for.
04:27In addition to looking for lumps in the neck,
04:30which you may just find by feeling your neck
04:32you can actually, as the disease progresses,
04:35have compressive symptoms.
04:38So symptoms where in the neck
04:40the mass in the thyroid is large,
04:43it can push on different structures.
04:45For example, it can make it difficult
04:47to swallow or breathe.
04:48It can also actually cause a horse voice.
04:51There's an important nerve that
04:53travels near the thyroid called the
04:54recurrent laryngeal nerve, and if that
04:57is somehow invaded or pushed upon,
04:59that can cause a horse voice.
05:00In addition to that, when it's very large,
05:03if you're lying flat,
05:04people actually feel like
05:06they're choking, but again,
05:07these are more advanced forms
05:09of the cancer and
05:10not typically in the very early stages.
05:14I noticed that during pregnancy,
05:16especially thyroid nodules in
05:18thyroid cancer can present in women
05:23yet they seem to be very low grade.
05:26Can you tell us a little bit
05:29about that phenomenon?
05:30Thyroid cancer in pregnancy does happen.
05:33I would say that in most cases when
05:36this occurs, as long as it's what we
05:39think is papillary thyroid cancer,
05:41we typically do not like to
05:43operate on pregnant women.
05:45An OB I'm sure would feel the same
05:48and we will monitor the nodule
05:50and recommend surgery
05:51ideally after the birth of the child.
05:54However, I would say in rare cases if
05:57something like anaplastic is found,
05:59which I've never had happened
06:00to me or my patients,
06:02but if that were to happen, management,
06:05I assume would be different,
06:06but typically because the cancers
06:08tend to be less aggressive,
06:10we try to put off surgery for
06:12the thyroid in someone who's
06:14pregnant.
06:17And for veterans in the Vietnam War,
06:19of course, Agent Orange became an issue
06:21and I know that there's one recent
06:24study that suggested that there was
06:27a 24 % relative risk measure
06:29or increased risk of thyroid cancers,
06:32and those exposed to Agent Orange.
06:34Is this still a problem for our
06:37Vietnam Veterans today and are
06:39veterans from the Middle East exposed
06:42to increased risk for thyroid cancer?
06:44So those are all
06:46great questions.
06:47I can't tell you the exact
06:49answer to that, although I can say that if
06:52there's any type of radiation exposure,
06:54especially at a younger age,
06:57that does increase
06:58someone's risk of thyroid cancer,
07:00and typically we think of incidents
07:03like Chernobyl or
07:04nuclear accidents that occur.
07:05So any agents that are used that
07:08potentially could have radioactivity.
07:10There are also certain explosive devices
07:12that may have involved radiation.
07:15Anything like that.
07:16If you're in contact with that it
07:18can certainly increase your
07:19risk of thyroid cancer, yes.
07:23And what are the treatment
07:26options available to patients?
07:29So in terms of treatment in
07:31patients who have what's called the
07:33differentiated thyroid cancers,
07:34which are the very well developed cancers
07:37we mentioned, papillary thyroid cancer,
07:39follicular thyroid cancer is another type.
07:41The main treatment actually is
07:43surgery to remove the thyroid
07:45cancer that's present and luckily
07:47we have specialist surgeons who
07:49can provide this kind of surgery.
07:51People who have high volumes of
07:53these types of patients to work on,
07:56they tend to have minimal complications.
07:58So really surgery is the mainstay
08:02treatment for thyroid cancer.
08:03In terms of types of thyroid surgeries,
08:05you can either do a total thyroidectomy
08:07which is to take out the entire thyroid
08:10gland or a thyroidectomy
08:12to remove just half the gland
08:15depending on where and how large the
08:17tumor is will determine the surgeons
08:19approach in whether they'll take out
08:22the entire gland or half the gland
08:24and then in addition to that there can
08:26be extra surgery called a dissection
08:28to take out any affected lymph nodes,
08:31typically in the neck area
08:33in the middle of the neck
08:35where the thyroid is,
08:36but then also on the sides of the neck.
08:39So actually one of the things that's
08:41really important before somebody
08:42has surgery for thyroid cancer is to
08:44have a neck ultrasound looking at
08:46all the lymph nodes including the
08:48sides of the neck so that the surgeon
08:50can plan the appropriate operation
08:52and really have the best outcome and
08:54not have to go again
08:55for surgery.
08:56I understand that there is some
08:59controversy about how extensive
09:00the surgery should be.
09:01What would be the difference between
09:04a partial thyroidectomy versus the
09:06complete removal of a gland in terms
09:07of the patient and her side affects?
09:10So that's a good question. In
09:12terms of total thyroidectomy which
09:13is taking up the entire gland,
09:15actually in both cases I should probably
09:18talk about what the risks are in
09:20both and then kind of separate them.
09:22So a risk of course in any procedure
09:24would be infection or bleeding,
09:26but in particular to thyroid surgery is that
09:29there could be damage to that
09:32nerve that we mentioned earlier,
09:34the recurrent laryngeal nerve which could
09:36actually cause a permanent or temporary
09:39hoarse voice for someone.
09:41Actually, that can be a big change
09:43in their life, especially someone
09:45who's a singer or their vocation
09:47includes speaking and giving lectures,
09:49for example.
09:51In terms of other side effects,
09:54right behind the thyroid gland
09:55are tiny little rice grain sized
09:57glands called parathyroid glands.
09:59And
10:00even though they're very small,
10:02they are very important in
10:03controlling the body's calcium level,
10:05and as you know,
10:06things like really like the heart,
10:08for example,
10:09rely on important calcium
10:10concentration so you know those
10:12glands are essential to the body.
10:14And it takes a very skilled surgeon
10:16to make sure that those are not
10:18harmed or the blood supply to those
10:21glands are not harmed as well.
10:23So one of the complications can
10:24be an under active parathyroid
10:25gland or parathyroid glands
10:27that aren't functioning properly.
10:29So I would say that
10:31in particular,
10:31that parathyroid effect would be
10:33a higher risk in patients with a
10:36total thyroidectomy versus only
10:37half of the thyroid being removed.
10:39But even then the risk is actually very
10:42quite low in patients who have both
10:45these procedures in experienced hands.
10:47So I really don't worry
10:49about that for my patients.
10:50It sounds like experience is
10:53a major issue and you really want
10:55to be sure to have a surgeon who
10:58does a lot of these surgeries on a
11:01routine basis
11:04if a total thyroidectomy is
11:07performed. What additional
11:08replacement therapies are necessary
11:10for the patient versus the
11:12partial thyroidectomy.
11:13Good question, in
11:14patients who have only part
11:16of their thyroid removed,
11:17which is usually going to
11:19be half of the thyroid,
11:20they actually have a chance of not
11:22needing thyroid hormone after surgery.
11:24It's interesting the other half of
11:26the thyroid gland can build enough
11:28response that they can make extra
11:30thyroid hormone so you don't have
11:31to take the pills after the surgery,
11:33but that's not always the case and
11:35so I would say if you're going in
11:38and you know that you're going to
11:40have half your thyroid removed,
11:42I would expect that you may need
11:44to take a pill afterwards with
11:46the whole thyroid being removed.
11:48You'll definitely need to have
11:49thyroid hormone therapy afterwards,
11:51and that's usually in the form of
11:53something called Levothyroxine.
11:54This thyroid hormone would be
11:56a life long treatment because,
11:58as we mentioned earlier,
11:59the thyroid has lots of effects
12:01in the body and you really can't
12:03live without thyroid hormone.
12:05Well, you mentioned earlier also that
12:07most of the thyroid cancers that
12:09we're seeing are low grade cancers.
12:11Are additional treatments necessary
12:12for high grade cancers or for
12:15cancers that have spread to
12:17local lymph nodes or beyond
12:19that?
12:21Yes, for those types of cancers we also offer
12:24something called radioactive iodine
12:26therapy and I think that this is
12:28very what we would call a
12:31targeted therapy because a thyroid
12:33gland is really good at absorbing
12:36iodine and we take advantage of that.
12:38That's
12:40radioactive and what can happen is
12:42the patient when they take radioactive
12:45iodine that iodine can go to
12:47all parts of the body that
12:49have thyroid tissue,
12:50whether it be in your lungs or other parts,
12:52where it may have spread all
12:54they have to do is take the pill
12:56and it will go to both the neck
12:59area where there is probably little
13:01bits of thyroid cells left behind
13:03and then also to the lungs
13:05if there is spread
13:06of the cancer to the lungs,
13:08so instead of
13:10a general chemotherapy,
13:11it's really a targeted therapy
13:12to that thyroid tissue and that
13:14is sort of the beauty of
13:16the treatment.
13:16Are there any additional side
13:18effects that would be expected with
13:20radioactive iodine being
13:21injected?
13:22We think at low doses,
13:25really patients tolerate it very well
13:27an the biggest complaint that I usually get
13:30about it is fatigue or the fact that
13:32they have to actually be on something
13:34called a low iodine diet beforehand and
13:37the reasoning for the low iodine diet
13:39is to make your body hungry for iodine,
13:42so that will take up the
13:44iodine to the thyroid
13:47tissue where it's widespread
13:49in terms of side effects.
13:51Some people do get dry mouth,
13:53you can get watery eyes.
13:55Some people get sort of this
13:57inflammation of the stomach and these
13:59can be either temporary or permanent,
14:02but typically the stomach effect
14:04is very limited and goes away.
14:07And in rare cases, at higher doses,
14:10there is a concern for other
14:11malignancies occurring such as leukemia.
14:13But again,
14:14those risks are minimal and typically
14:16with higher doses of radioactive iodine.
14:18So all in all,
14:19patients really usually tolerate
14:21radioactive iodine rather well,
14:22and if patients are complaining
14:24most about the low iodine diet,
14:26it tells you that the effects
14:28usually are not that bad.
14:30We're going to take a
14:32short break for a medical minute.
14:35Please stay tuned to learn
14:36more about thyroid cancer
14:38and the management of thyroid
14:40nodules with Doctor Grace Lee.
14:42Support for Yale Cancer Answers
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14:49various types and stages of cancer.
14:52More information at astrazeneca-us.com.
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15:35You're listening to Connecticut public radio.
15:40Welcome back to Yale Cancer Answers.
15:42This is doctor Peter Schwartz
15:44and I'm joined tonight by
15:46my guest Doctor Grace Lee
15:48and we are discussing thyroid
15:51cancer and the management of thyroid nodules.
15:54So doctor Lee, what are thyroid nodules?
15:56How are they managed?
15:58Can they be cancerous?
15:59What causes them?
16:01Thyroid nodules are actually nodularity of
16:03the thyroid tissue so I describe it
16:07as little balls within your thyroid.
16:09They're very common and actually can
16:11be president in up to 68% of
16:14adults, if you look at adults with ultrasound
16:16and they actually increase with age,
16:18they are often found
16:20incidentally most of the time.
16:22How I see patients as referrals is that
16:24they were found for another reason.
16:26For example,
16:27they had a carotid ultrasound to
16:29look at their arteries and
16:31happen to find a thyroid nodule,
16:33and then I end up seeing those patients.
16:35And we mentioned earlier another
16:38time is when people have CAT scans
16:40for other reasons of their neck
16:42and they find the thyroid nodules.
16:44And typically,
16:45the way to best evaluate them is
16:48actually a thyroid ultrasound.
16:50Most of these nodules are benign and
16:52I think that's the biggest message I
16:54want to say is that if somebody tells
16:57you that you have a thyroid nodule,
17:00the first thing is not to panic.
17:02There actually very common and only
17:05about four to 6 1/2% of these thyroid
17:07nodules are cancerous in terms of who
17:10is at risk for these thyroid
17:12cancers they are usually people who have had
17:15radiation to the head or neck area,
17:17especially as a child,
17:19or have had radiation exposure.
17:20And who another risk factor would be
17:23having a family history of thyroid
17:25cancer in a first degree relative.
17:30So I guess the next
17:31question that people ask me,
17:33what do I do when I find a thyroid nodule?
17:36What does the doctor do or what
17:37should they do?
17:39The first thing to do is a blood test,
17:42and in addition to the thyroid
17:43ultrasound that I mentioned and the
17:45blood test is really to see whether
17:47you have a normal amount of thyroid
17:49hormone in your body and that's
17:51done through a test called thyroid
17:53stimulating hormone called TSH.
17:54And so the reason we do that
17:56is that thyroid nodules,
17:57actually some of them can make
17:59thyroid hormone and those
18:00are called hot nodules.
18:02On the other hand,
18:03there are thyroid nodules that
18:04don't make extra thyroid hormone,
18:06and those are the ones that
18:08typically need to be more evaluated
18:10for whether they are cancerous or not.
18:13So if somebody has a test that
18:15shows that their thyroid
18:17hormone levels are very high,
18:19then it's very unlikely for that
18:20thyroid nodule to be cancer,
18:22and in that case
18:24it's not something that's biopsied.
18:25However, if you find a cold nodule,
18:28what we do is a thyroid ultrasound.
18:30We look at the ultrasound to see
18:32what does this nodule look like.
18:34Are there things in the nodule
18:36that are more concerning?
18:37For example,
18:38sometimes tiny bits of calcium can
18:40be seen in the nodule and that can be
18:42very classic for papillary thyroid cancer.
18:44So in those cases we're more
18:47concerned will offer the patient a
18:48biopsy which is done with a very
18:50fine needle where only cells are
18:52removed from the thyroid nodule and
18:54then looked at under the microscope.
18:58You mentioned some of the risk factors
19:01are radiation,
19:03especially and
19:05other inherited susceptibilities.
19:06I guess what I'm really asking
19:08is who should be screened?
19:11Or should screening be done on a
19:13routine basis for thyroid nodules?
19:15So I would
19:16say that screening just doing ultrasounds
19:19on everybody should not be done.
19:21I believe that if that's done there would
19:24be a lot of patients who would have
19:28unnecessary biopsies
19:28potentially and tiny tiny
19:30thyroid cancers being found that really
19:32may not have caused the patient any trouble.
19:35So generally speaking,
19:36if a nodule is palpated on exam,
19:39so having good physical exams at
19:41your annual physical is important.
19:42If something is found there, then yes,
19:45thyroid ultrasound should be performed.
19:47Or if one of the thyroid cancers that we
19:49didn't really talk about much today but
19:52is called medullary thyroid cancer,
19:54and that one can run in families,
19:56meaning that it can be passed
19:58on from parent to child.
20:00And
20:01is often due to a genetic mutation
20:03that can be checked for in
20:05those types of families, yes,
20:07thyroid ultrasound would be indicated,
20:09but in the general public,
20:10I wouldn't say at a specific age
20:12that people should
20:14just generally be screened.
20:16I think that would be finding too many
20:18and there would be too many
20:20unnecessary procedures.
20:21I'm aware
20:21of a Korean study,
20:23and apparently the conclusion
20:24was they went through the roof with
20:26finding so many thyroid nodules,
20:28so we don't need to do that.
20:30I think that's a
20:31perfect example of what you just said.
20:34Another controversy seems to be
20:36regarding these indeterminant fine
20:38needle aspiration biopsies. Can you
20:40discuss that for us? It seems like
20:42it's around 25% or so of biopsy is
20:45a significant number of patients so
20:47so let me walk you through a biopsy.
20:49If I send you for a biopsy and you
20:52had this aspiration biopsy
20:54the results can be one of the following
20:58so they can come back and say
21:01this is most likely benign.
21:04Two, they can come back and
21:05say, this is most likely cancer.
21:07And then there's this whole gray
21:09area in between of what you've
21:11described called indeterminate.
21:13It's very frustrating both
21:14for patients and providers.
21:15What does that mean?
21:16How much percentage risk of cancer is that?
21:19It's a large range and so
21:21management can be difficult if you
21:23just get this intermediate result.
21:25So over the past couple of years,
21:27what's been developed is called
21:29molecular testing,
21:29where they take the RNA or the ribo
21:32nucleic acid from these cells that
21:34you have taken from the biopsy.
21:36And actually test that for different
21:38mutations or changes that
21:40are typically seen in thyroid cancer.
21:42If those are seen than the results
21:44can come back and say,
21:46you actually have, for example,
21:48of 40% risk of cancer,
21:50not a 15% risk of cancer in
21:52that indeterminate category,
21:53and that can sway you and say,
21:56you know what?
21:57This makes more sense to take the patient
22:00to surgery or offer them a thyroid surgery,
22:02at least for that side of the thyroid
22:05as opposed to watching that nodule, so
22:08this molecular testing has been
22:10very helpful in guiding us in
22:12managing these patients,
22:13but yes,
22:13a very frustrating result
22:15when you get that gray,
22:16area result.
22:18Do you find the patients tend to
22:20lean more towards surgery
22:22then follow up because of this
22:25uncertainty about the
22:26nature of the nodules.
22:29It varies. I've had both ends of the
22:31spectrum more so I would say more of
22:34my patients would be more
22:36proactive.
22:38I don't want to categorize people,
22:40but there are patients also who are
22:43very conservative and maybe with more
22:45advanced age with other risk factors for
22:47surgery they may want to just watch it
22:50and I think that makes sense
22:51if you have other reasons,
22:53severe heart disease or heart failure.
22:55Other things that may increase your
22:57risk of complications post operatively,
22:59then it would make sense to watch them,
23:02especially if your risk
23:03ends up being low.
23:05Let's move on and let me ask
23:08you this, what is endocrinology?
23:10What is the role that hormones play and
23:14how is that managed and what does the
23:16thyroid do?
23:19You're an endocrinologist.
23:21What exactly do you do?
23:24Endocrinology is a study of the body's
23:26endocrine system, which is basically
23:28the system that controls your hormones,
23:30and this includes the pancreas,
23:32the thyroid, parathyroid,
23:33the parathyroid and thyroid in your neck.
23:36The hypothalamus and pituitary which are
23:38in your brain and adrenal glands
23:41I like to say sit on top of the
23:45kidneys are like little hats on the kidneys.
23:48In addition to that, sex hormones
23:50are made by the testes and ovaries.
23:53So as an endocrinologist I manage diseases
23:55that involve the endocrine system,
23:57including thyroid disorders,
23:58osteoporosis and bone diseases,
23:59diabetes, pituitary disease,
24:00and even transgender medicine.
24:03You mentioned a lot of
24:05organs that are now sometimes
24:07affected by our newer medications.
24:10We have targeted therapy and a lot
24:12of the new checkpoint inhibitors,
24:15for instance, affect these organs.
24:17Can you talk a little bit about that?
24:21Definitely,
24:21so we've had a lot of rules over
24:23the last few years as those
24:26immunotherapy's have been used and these
24:28immunotherapies are basically tricking
24:31your body's immune system to attacking
24:33the cancer and it works really well.
24:36But actually also tends to attack
24:38these glands that I treat so quite
24:40often I will see patients who are
24:42getting these treatments and will have
24:45what we call thyrotoxicosis or too
24:47much thyroid hormone because the
24:49thyroid gland is being attacked by
24:52the agents. In addition to that,
24:54you can actually see also
24:55inflammation of your pituitary gland,
24:57which is the gland which is a tiny
24:59gland in the middle of your brain
25:01and we call it actually the master
25:04gland because it sends out
25:06hormones to other parts of your
25:08body and glands to control those.
25:11The beauty though is that we never tell
25:13oncologists
25:15to stop their treatment.
25:16The beauty of it is that we
25:18have all the hormones to replace
25:20that in terms of treatment.
25:22So whatever needs to be done
25:24for their primary cancer,
25:25we say go on and do what you need
25:28to do and we will take care
25:30of this equality that happens with
25:32the hormones and we will replace
25:34whatever hormones needed to
25:36be replaced so the thyroid,
25:37in my experience, can be both
25:39overactive as you just mentioned,
25:41but also under active.
25:42So you need to be able to evaluate that.
25:47One of the reasons I love endocrinology
25:50is that we can check blood work
25:52and blood work can be very helpful
25:55in telling you what is going on.
25:58So one of the things
25:59that can happen is inflammation,
26:02or thyroiditis of the
26:03thyroid gland can happen with
26:05these immune checkpoint inhibitors.
26:07So initially what happens with them
26:09is inflammation of the gland and there
26:11is actually a thyroid hormone
26:13within the gland that as it's attacked is
26:16released and so because that happens,
26:18there's a lot of extra thyroid hormone
26:20in the body and patients can feel
26:23symptoms of too much thyroid hormone.
26:25What would those be?
26:27Feeling hot when no one else is hot.
26:30Almost like a hot flash feeling
26:32very hungry and actually having weight loss.
26:35You can have weight gain, just an
26:38imbalance in your thyroid
26:40hormone after that happens because
26:42the thyroid gland has been inflamed.
26:44It also can no longer make
26:47thyroid hormone,
26:48so a lot of
26:51thyroid hormone patients go through
26:52a state of
26:56very low thyroid hormone and so
26:58at that point the thyroid hormone
27:00needs to be replaced,
27:02and so that's a very typical
27:04picture that we see.
27:06We call immunotherapy related.
27:07It's like a thyroiditis and the
27:09symptoms of low thyroid.
27:12And you can see the opposite
27:14so you can feel very tired.
27:17Feel cold when no one else is cold,
27:19constipated. And you can
27:21also have a low heart rate.
27:24We're just about ready
27:25to finish. But let me ask you are there any
27:28recent advances that have been made or
27:30exciting research in the pipeline?
27:32You alluded to some of that.
27:34Actually, immunotherapy is being used now
27:36in trials to see whether that can help
27:38patients with advanced thyroid cancer.
27:40And at Yale, there is a trial
27:42now ongoing with cabozantinib,
27:44which is a tyrosine kinase inhibitor in
27:46patients who have failed another type of
27:48tyrosine kinase inhibitor called Lynn VAT,
27:50and if so, a lot of interesting
27:52research is going on in advanced
27:54thyroid cancer these days.
27:56Doctor Grace Lee is an assistant
27:58professor in the section of
28:00endocrinology and metabolism at
28:02the Yale School of Medicine.
28:04If you have questions,
28:05the address is canceranswers@yale.edu
28:07and past editions of the program
28:09are available in audio and written
28:11form at Yalecancercenter.org.
28:12We hope you'll join us next week to
28:14learn more about the fight against
28:17cancer here on Connecticut public radio.