Thyroid Disease

Thyroid disease is the leading endocrine disorder in the United States. While there are several different health issues that can result from either an overactive or underactive thyroid, thyroid cancer is the most prominent. The rate of thyroid cancer has tripled in the past three decades, likely due to better detection methods. Here, Atlanta Medicine shares the thoughts of two Atlanta area endocrinologists about recent strides in the detection and treatment of thyroid cancer, along with findings from a recent study on how thyroid disease affects pregnancy.

New Methods Reduce Need for Treatment

Nodules are abnormal growths on the thyroid that can be a warning sign of cancer. They can cause visible or palpable symptoms like a lump in the neck, hoarseness or trouble swallowing. or the person may experience no symptoms at all. Kate Wheeler, M.D.,

an endocrinologist with Laureate Medical Group, says that the latest methods for detection and evaluation of thyroid nodules have resulted in fewer people being treated for thyroid cancer.

“Whereas we used to put people through biopsies, sometimes unnecessarily, we now have ultrasound to help us get a better look at thyroid nodules,” she said. “The ultrasound helps us define the type of nodules that tend to be malignant and the characteristics of those that usually tend to be benign”

Dr. Wheeler says that improvements in the technology in recent years have given physicians the ability to judge the malignancy potential of thyroid nodules.

“The resolution of the ultrasound has gotten much better and allows us to see much finer detail,” she said. “Now, we’re able to look at margins, texture and blood flow, which are the characteristics by which we judge the malignant potential of a nodule. We’ve learned that, for some nodules, the chance of them ever becoming malignant is so unlikely that it would be totally unnecessary to put the patient through a biopsy.”

Dr. Wheeler adds that monitoring patients who have had thyroid cancer has also improved due to another method of evaluation — thyroglobulin level testing.

“The tests performed on someone who’s had thyroid cancer depend on the type of cancer he or she had. If the person received radioactive iodine therapy after a thyroidectomy, their doctor will test thyroglobulin level every year,” she explained. “Thyroglobulin assay has become so precise, you can get a lot of information just from that one test. If the thyroglobulin level is zero, it probably means the patient does not have cancer.”

Genetic Testing Can Help Patients Avoid Unnecessary Surgery

According to John H. (Chip) Reed, III, M.D., a specialist in Internal Medicine, Endocrinology and Diabetes with Southeastern Endocrine & Diabetes, P.C., one of the biggest problems in the past for determining whether thyroid nodules are malignant or benign were biopsies that yielded indeterminate results. He says that advances in testing methods have made great improvements for both physicians and patients.

“When biopsy results of nodules were indeterminate, we were presented with a dilemma about how to treat the patient,” he said. “Ultrasound can tell us a lot about nodules, but we now have the ability to do genetic testing that can predict cancer.”

These genetics tests use thyroid cells obtained at the time of biopsy to screen for molecular markers for malignancy such as BRAF and RAS mutational states, mRNA classifier and high-density genomic data.  These tests are commercially available through a variety of laboratory companies.

“Previously, we often would end up surgically removing part or all of the person’s thyroid when biopsy results were indeterminate,” Dr. Reed said. “Gene expression testing gives us more definitive results that help prevent unnecessary surgeries when nodules are actually benign.”

When asked why the incidence of thyroid cancer has risen so dramatically in recent years, Dr. Reed says he believes it’s due to improved methods of detection.

“The big question about thyroid cancer is whether it’s becoming more common or if we’re simply finding it more than we used to,” he said. “In the past, patients and doctors had to actually feel something in the neck that would lead to testing. But now, routine carotid ultrasounds and neck CTs are detecting the nodules. I think the answer is that we’re just finding it more.”

Thyroid Disease in the News: New Guidelines for Management during Pregnancy

New evidence-based recommendations from the American Thyroid Association (ATA) provide guidance to clinicians in diagnosing and managing thyroid disease during pregnancy and the postpartum period. Pregnancy has a profound effect on thyroid gland function, and thyroid disease is common in pregnancy. The 97 recommendations presented in the new Guidelines help define current best practices for thyroid function testing, iodine nutrition, pregnancy complications, and treatment of thyroid disease during pregnancy and lactation.

The “2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease during Pregnancy and the Postpartum” were coauthored by an international task force of expert clinicians and researchers in the field of thyroidology. Led by Co-chairs Erik Alexander MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA and Elizabeth Pearce, MD, MSc, Boston University School of Medicine, the task force provides a solid foundation of knowledge on the assessment and treatment of thyroid disease in women during pregnancy, preconception, and the postpartum period. The Guidelines include recommendations related to the diagnosis and management of hypothyroidism, thyrotoxicosis, thyroid nodules, and thyroid cancer, as well as thyroid considerations in infertile women, fetal and neonatal considerations, and directions for future research.

“With an estimated 300,000 pregnancies impacted by thyroid disease in the United States annually, these guidelines coalesce the best available evidence into clear clinical recommendations, and will improve the health of many, many mothers and newborns alike,” say Dr. Alexander and Dr. Pearce.