Guatr

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Thyroid: Surgery over the weekend, back to work on Monday.

 Scar-Free Thyroid Surgery

 

Genetic Testing Can Detect Thyroid Cancer

Goiter is the enlargement of the thyroid gland due to various causes. The thyroid is a butterfly-shaped gland located at the front of the neck that produces hormones essential for the body's metabolism. The hormones produced by the thyroid act like the body's battery, providing energy and regulating many vital functions.

When the thyroid produces excessive amounts of hormones, the condition is called hyperthyroidism. When it produces insufficient hormones, it is called hypothyroidism. Patients with hyperthyroidism commonly experience symptoms such as increased activity, heart palpitations, rapid heartbeat, weight loss despite an increased appetite, nervousness, tremors, and excessive sweating. In contrast, patients with hypothyroidism often experience slowed movements, weight gain, fluid retention, dry skin, and constipation.

In addition to these functional disorders, the thyroid gland can also develop structural abnormalities. Conditions characterized by the enlargement of all or part of the thyroid gland, often due to the presence of nodules, are commonly referred to as nodular goiter.

In Türkiye, approximately 40% of the population is affected by some form of thyroid disease, meaning an estimated 20–30 million people have a thyroid-related condition. Although various factors contribute to the development of goiter, the primary...

 

1. Iodine deficiency and other environmental factors

2. Hereditary factors

3. Constitutional factors play a role.

 

Among these, special emphasis needs to be placed on the iodine deficiency factor. Research shows that people in Turkey consume on average about a quarter of the iodine they need to take daily. In Central European countries with iodine deficiency, the problem of iodine deficiency and the resulting goiter has been largely resolved by adding iodine to bread baked in bakeries and to table salt used at home. An important issue for Turkey is that this iodine should be consumed by people who do not have a goiter for prevention purposes. Otherwise, if a patient who already has a goiter takes iodine to get rid of it, this does more harm than good.

 

Thyroid nodules started to be seen more frequently, especially after ultrasonography began to be used widely on the neck. In patients with nodules seen on thyroid US, a method called scintigraphy is used to create a functional map of the thyroid gland, and it is understood accordingly whether the nodules are functioning or not. Non-functioning nodules are called cold nodules, and the probability of cancer developing in these nodules increases. While cancer is found in 5 to 15 out of 100 nodules, in order to prevent every patient from being operated on out of a fear of cancer, we can make an accurate diagnosis in 95% of cancer patients using a method called fine-needle aspiration biopsy (FNAB). Therefore, the remaining patients can be safely monitored by taking thyroid hormone and are only operated on when their nodules are shown to grow via US. However, it should be emphasized that there is a 5% margin of error in FNAB.

 

Making the cancer diagnosis before surgery is important for the following reason. If a certain volume of thyroid tissue is left behind and cancer is seen in the removed specimen, the patient needs to undergo a second surgery and have the remaining thyroid gland removed. Since this surgery is quite difficult compared to the first one, we as surgeons desire the work that needs to be done to be finished in the first surgery.

 

Besides all this information, it must also be emphasized that the vast majority of thyroid cancers are very benign-natured cancers. A patient dying from thyroid cancer is equated with the survival chance of a patient who has undergone bypass surgery in the U.S. In our country, the probability of a patient losing their life to traffic accidents is considered higher.

 

One of the very important developments recorded in thyroid cancer in recent years is that through a genetic test performed on the blood of a mother or father with medullary type thyroid cancer, it can be understood whether this disease will be transmitted to their child. If this test also turns out positive in their children, since there is a 100% probability that the child will contract thyroid cancer by the age of 25-30, the thyroid gland is completely removed protectively in these children and a 100% cure is achieved. This is considered one of the most important contributions that genetics has made to the field of medicine. We also have such patients and their families, but it seems quite difficult to convince mothers to have their children operated on when their children have no illness at all. An important difference of thyroid surgeries from other surgeries is that the patient interacts not only with surgery regarding their disease, but with more than one specialist physician, because surgeons do not treat thyroid diseases alone, and as a team: endocrinologist, nuclear medicine specialist, pathologist, radiologist, and surgeon must work together, evaluate each patient together, and decide together on the most beneficial method for the patient.

 

Frequently Asked Questions About the Thyroid

 

What is the thyroid gland, what are its functions, and with what complaints are its diseases noticed?

 

The thyroid gland is a gland located right in front of the windpipe in the neck, which regulates the functioning of almost all systems and organs in the body—from the nervous system to the digestive system—by secreting thyroid hormone. Such glands are called endocrine glands. The internal medicine branch dealing with the diseases of such glands is called endocrinology, and the surgery of these glands is called endocrine surgery. The enlargement of the thyroid gland is called goiter. Patients presenting to the physician with very large swellings in the neck in the 60s are now very rarely seen; instead, thyroid nodules, which are accidentally noticed during a check-up via ultrasound or palpation, have become the most common disease seen in thyroid patients today. In addition to these, there are hormone production disorders.

 

How are hormone disorders of the thyroid noticed? The uncontrolled increase in hormone production by the thyroid gland, which we call hyperthyroidism, causes complaints of weight loss (despite increased appetite) especially in young patients, and heart palpitations, hand tremors, sweating, heat intolerance, nervousness, menstrual irregularities in women, hair thinning with hair loss, and diarrhea in elderly patients. In the case of hypothyroidism, which is seen more frequently—meaning the production of less hormone than required—there will be swelling in the body and especially in the face, water retention, weight gain, constipation, menstrual irregularities, hair thickening with hair loss, skin dryness, cold intolerance, and slowing of movements, and in advanced cases, mental functions.

 

How frequently are thyroid diseases seen in Turkey? Thyroid nodules of various sizes are found in 40% of the public and 60% of women. While 95% of these nodules are usually benign, thyroid cancer is virtually hidden among these nodules in 5%. Hypothyroidism, which is seen more frequently than hyperthyroidism, has reached up to 20% of women around the age of 40 due to the rapid increase in thyroid inflammation in recent years.

 

What is the cause of thyroid inflammation? With the iodization of our salts starting from the year 2000, a very important step was taken to protect future generations from goiter. However, as in all countries where such programs are implemented (Argentina, Switzerland), in the 20 years following iodization, the frequency of inflammation—namely thyroiditis, and specifically Hashimoto's thyroiditis as a special form thereof, and thyroid cancer developing on this background—increases 4-5 times. The situation is around this level in our country as well. Therefore, it would be more appropriate for iodized salt to be used in babies and children of developmental age, while adults, especially thyroid patients, should use non-iodized salt. Consequently, food in the kitchen should be cooked without salt, and there should be two salt shakers at the table; children should use iodized salt, and adults should use non-iodized salt.

 

What should be done for the early detection of thyroid disease?

 

All check-up programs should include the TSH hormone, which is the most sensitive indicator of thyroid hormone levels, and thyroid ultrasonography. In addition, just as mammography is done for breast cancer or a smear test for uterine cancer in public health screenings, thyroid US and needle biopsy should also be included in a public health program.

 

What do the latest figures regarding thyroid cancer say?

 

The year 2005 was declared the year of thyroid cancer in the U.S. Because the figures related to this in the April issue of the journal Thyroid published in the U.S. (www.thyroid.org) are as follows:

 

• Approximately 25,000 thyroid cancer patients to be diagnosed in 2005 have doubled the number of patients diagnosed every year since 1995.

• Thyroid cancer, which ranked 14th among all body cancers in the 90s, rapidly rose to 7th place in the 2000s.

• With an annual increase rate of 4% in women and 2% in men, thyroid cancer became the fastest-growing cancer among all cancers.

• Although it is seen more frequently in women, it was revealed that thyroid cancer shows the fastest increase among cancers causing loss of life in men.

 

The Chernobyl accident has been talked about a lot regarding thyroid cancer; are its effects still seen? Since the leaked radioactive iodine at Chernobyl affected the thyroid especially and children of developmental age were heavily affected by this. Because the dose was very high, cancer appeared within 4-5 years, and with intensive screening, thousands of children were diagnosed at an early stage, operated on, and saved. Since the children of those ages are today's adults, if we encounter a thyroid cancer patient today who lived in the relevant regions in those years, unfortunately, since no screening was done in that period, we cannot understand whether the disease stems from those years or appeared later. The fact that all responsible parties of that era, unlike the whole world, did not care about this issue or even belittled caring about it is actually a very major crime against humanity committed by them.

 

What kind of diagnostic devices are used in thyroid patients? While thyroid hormones and thyroid scintigraphy were used in the past, today we use scintigraphy to see if the thyroid is working too much or too little, and we prefer ultrasonography, which is more sensitive for nodules and thyroid cancer.

 

What can be done to understand whether the mass in the thyroid is benign or malignant? We perform a needle biopsy on the mass, which has no side effects, and an experienced pathologist interprets it for us. When it says benign, it turns out 95% accurate; when it says malignant, it turns out 99% accurate. Therefore, we recommend everywhere that surgery should not be performed without a needle biopsy, especially so that less-experienced surgeons do not encounter surprise results at the end of surgery.

 

Can patients whose needle biopsy comes back clean be monitored? Despite a certain low risk, they can be safely monitored; if the nodule continues to grow and becomes large enough to create a sensation of pressure, it can always be operated on. But the goal of endocrine surgery should not be to find benign thyroid nodules, but rather thyroid cancer patients hidden among these nodules.

 

How is the surgical treatment of thyroid nodules or thyroid cancer performed? The treatment of thyroid diseases is entirely a team effort. The quintet consisting of the endocrine surgeon, endocrinologist, nuclear medicine specialist, radiologist, and pathologist can only make the most accurate decisions about the patient by speaking the same language and staying in constant communication. The complexity of thyroid diseases keeps individuals busy enough that they cannot deal with any field other than this branch within their specialty, and it is only possible in this way to concentrate on the patient and their disease. As for thyroid surgery, while all surgeries are a stitching process, thyroid surgery is an embroidery work, meaning it requires finesse, meticulousness, and precision. Especially since it requires very clean work in terms of the vocal cords and neighboring parathyroid glands, it is also necessary to reduce the risk of recurrence of the disease after the surgery to near zero. Since 2004, with the help of the latest technological tools, instead of the method traditionally used in the past which causes a necklace-shaped suture scar in front of the neck, the minimal closed approach method that we apply with a 2.5 cm incision from the side of the neck is becoming the preference of ladies as well as gentlemen, and is preferred due to factors such as cosmetics, the possibility of early post-operative neck movements, and the absence of edema.

 

What is the treatment known among the public as atom treatment, and who is it used for? Atom treatment, medically known as radioiodine treatment, is used in low doses to treat hyperthyroidism, and in high doses in thyroid cancer in addition to surgical treatment or to treat distant metastases. The substance leaked at Chernobyl was the exact same radioactive iodine used in this treatment.

 

Which hyperthyroid patient is suitable for atom treatment? There are different approaches to this issue in different countries. For example, while radioiodine is widely used in almost every age group and all kinds of hyperthyroidism in the U.S., the UK applies drug treatment that lasts 1-1.5 years and lowers hormone levels. Both methods are applied in Turkey, but in addition to hyperthyroidism, if the patient's thyroid gland is large—meaning they have a goiter, have a suspicious nodule, or have a contraindication for taking medication—surgical treatment is recommended.

 

Can the patient's preference also be important in the treatment of hyperthyroidism? When a patient sometimes desires pregnancy in a short time, they may prefer surgery, from which they can get a response in a shorter time, rather than losing a long time with drugs or postponing pregnancy for a while after radiation. Sometimes, when we as surgeons inform the patient who comes to us for surgery about methods other than surgery, they themselves prefer atom treatment or drug treatment.

 

Are there restrictions after atom treatment? This situation can also vary according to the radiation regulations of countries. In our country, after radiation given below a certain dose for hyperthyroidism, the patient goes home, but it is recommended not to take a baby in their lap for a week. After thyroid cancer treatment, however, the patient is kept in a room with lead-lined walls for 5 days because body wastes contain radiation, and there is a possibility of harming their relatives. Patients see this as an isolation room, but in certain hospitals, there are rooms for this that lack no luxury, and patients can spend this period perhaps without contacting their relatives, but without getting bored. Approaching babies is also restricted for a while after this treatment.

 

In which type is the condition where the eyes are affected seen? The protrusion of the eyes outward or the retraction of the eyelids upward is seen in a special form of hyperthyroidism (Basedow-Graves Disease). In this case, successful treatment of hyperthyroidism also has a positive effect on the eyes, but a group of patients' eye findings may persist or progress. At that time, some interventions targeting the eye may need to be made. Which patients undergo surgical treatment in thyroid diseases? Surgical treatment is applied to mainly three groups of patients with the thyroid. The first of these are patients known to have thyroid cancer via needle biopsy or patients with suspected thyroid cancer via biopsy; the second group are patients with nodules that are thought to be benign in character but are progressively increasing in diameter and causing pressure symptoms in the neck; and the third group are patients whose hyperthyroidism disease cannot be controlled with medication or radioactive iodine, or is foreseen from the beginning that it cannot be controlled.

 

What kind of path is followed for hyperthyroidism patients? In the surgical treatment of hyperthyroidism, the two main goals are to eliminate this disease of the patient and prevent it from recurring again. Therefore, especially in Basedow-Graves disease, which is seen at young ages and also affects the eyes, if surgery is to be applied, then 95% of the thyroid must be removed. As a result of this, although the patient will need to use thyroid hormone for life, two undesirable complications—such as inadequate treatment of the disease, meaning the continuation of hyperthyroidism after surgery or its recurrence in the future—are prevented. Trying to preserve too much tissue with the aim of avoiding medication usually results in failure, and a second surgery may be required for the patients.

 

What kind of treatment is applied to patients who have a growing but benign nodule in their thyroid? In these patients, if the character of the nodule has been determined to be benign by needle biopsy before surgery, then removing the entire side where the nodule is located is a leading surgical principle. If the opposite side, meaning the other side of the thyroid, is healthy and the patient is over 50 years of age, then there is no harm in preserving the healthy thyroid, as the risk of goiter formation decreases after this age. However, the iodine deficiency frequently seen in our country and the gradually increasing incidental thyroid cancer have pushed us in recent years towards the total removal of the thyroid in surgeries, and this situation has become a method accepted generally all over the world.

 

What should be done if thyroid cancer is diagnosed before or during surgery? The treatment of thyroid cancer starts with surgery, and this means the total removal of the thyroid. If less than 95% of the thyroid has been removed, then the effectiveness of the radioactive iodine treatment to be performed following the disease decreases, and therefore a second surgery becomes necessary before the treatment. Distinguishing thyroid cancer during surgery is possible visually by experienced surgeons at a rate of 90%. However, in suspicious cases or for the detection of very foci, it is possible through the pathologist called to the surgery examining the tissue by freezing it during the operation.

 

Why is thyroid cancer treatment complex? The treatment of thyroid diseases is entirely a team effort. The quintet consisting of the endocrine surgeon, endocrinologist, nuclear medicine specialist, radiologist, and pathologist can only make the most accurate decisions about the patient by speaking the same language and staying in constant communication. The complexity of thyroid diseases keeps individuals busy enough that they cannot deal with any field other than this branch within their specialty, and it is only possible in this way to concentrate on the patient and their disease. As for thyroid surgery, while all surgeries are a stitching process, thyroid surgery is an embroidery work, meaning it requires finesse, meticulousness, and precision. Especially since it requires very clean work in terms of the vocal cords and neighboring parathyroid glands, it is also necessary to reduce the risk of recurrence of the disease after surgery to near zero.

 

Can the closed method be applied in thyroid surgeries? Since 2004, with the help of the latest technological tools, instead of the method traditionally used in the past which causes a 6-7 cm long necklace-shaped suture scar in front of the neck, the minimal approach method that we apply with a 2 cm incision from the side of the neck is becoming the preference of ladies as well as gentlemen, and is preferred due to factors such as cosmetics, the possibility of early post-operative neck movements, and the absence of edema. However, in this surgery, the pathologist must definitely examine the specimen during the operation, and in a suspicious case, the entire thyroid should be able to be removed if necessary. See surgical technique page

 

How long do patients stay in the hospital? Patients to whom we apply the minimal approach can return home the same day, while those we treat with the classic method stay in the hospital for 1 night and return home in less than 24 hours. Patients who start thyroid hormone medications after surgery are no different from any healthy person whose thyroid works normally.

 

GOITER WILL BE HISTORY IN TWENTY YEARS (Press)

 

Surgery on the weekend, back to work on Monday Stating that the surgical scar, which used to be likened to a necklace, now remains as a scratch in the form of a 'cat scratch', Dr. Mete Düren: Patients can return to work two days after surgery..

 

Prof. Dr. Mete Düren, Faculty Member at Cerrahpaşa Faculty of Medicine, Department of General Surgery, Endocrine Surgery Service, answered questions about when thyroid patients should be operated on:

 

LIKE A PING-PONG BALL...

 

• Which thyroid patients do you operate on? We operate on patients whose 'fine-needle aspiration biopsy' result used in the diagnosis of thyroid nodules comes back suspicious and patients diagnosed with cancer. During follow-up, we recommend surgery for patients whose nodules, known to be benign, grow large enough to cause discomfort in the neck. This size starts giving complaints from 3-3.5 cm onwards, meaning it reaches about the size of a ping-pong ball... It is difficult for the person to notice this. If the nodule is benign, it is possible to wait up to 3-3.5 centimeters.

• Hyperthyroidism patients can also be operated on, right? Yes, we can also recommend surgery for hyperthyroidism patients. Although most of these patients are treated with radioactive iodine or drug therapy, it is observed that these treatments do not yield results in some of them. As a result, when the result of the needle biopsy is negative, it falls to surgery.

• Is the news that there is a fivefold increase in thyroid cancers true? It has increased, yes. It is the fastest-growing type of cancer in America. It rose from 14th place to 7th place. It is the cancer with the fastest-increasing frequency of occurrence in women. In men as well, it is the only cancer among fatal cancers where survival time cannot be prolonged.

• Well, how is it understood whether the mass in the thyroid is benign or malignant? We perform a needle biopsy on the mass, which has no side effects. The pathologist interprets this. When it says benign, it is 95 percent accurate. When it says malignant, it is 99 percent accurate. Therefore, I do not recommend surgery to be performed without a needle biopsy. An inexperienced surgeon may encounter bad surprises at the end of surgery.

• How soon after surgery can patients return to work? They can return home a day later. The following day, they become able to return to work.

• Is the thyroid among very difficult surgeries? In every region of Turkey, the most up-to-date thyroid surgeries are successfully performed using the most modern technologies. According to needle biopsy results, the cancer risk of a patient whose result comes back clean is 1 percent, that of a suspicious one is 50 percent, and the probability of the result turning out to be cancer when it is diagnosed as cancer is 99 percent. There is also a 10 percent gray area; since it is not possible to speak definitively enough with a needle biopsy, it is not possible to diagnose these patients without operating on them. The probability of cancer is also 10 percent in these patients.

 

COMPLAINTS ARE TEMPORARY

 

• How is treatment performed after a thyroid cancer diagnosis is made? After a thyroid cancer diagnosis is made, all or almost all of the thyroid gland is surgically removed. We can endoscopically remove the entire thyroid with a 2.5 cm incision.