Question 1: What are the features of thyroid cancer? How does this nosology differ from other malignant tumors?
Answer: If you take the classic idea of oncology, then the prevalence of the disease is always taken into account. If we take in the structure of the incidence of oncology in general, this is not a very serious problem. But if we take the frequency among the endocrine organs from the position, then the thyroid cancer is the most common tumor of the endocrine organs. And the situation, which is now, is significantly different from that which was in my student years. If at the lecture the professor said that not all doctors know where the thyroid gland is located, today every resident of our country knows about it.
Why such attention is paid to this problem? Surely pushed serious knowledge about the thyroid gland problem of Chernobyl. The studies that were conducted and the information that appeared agitated people. The medical community was not very prepared to examine and control this situation. But I must admit that international cooperation in this regard played such a good role, and the Japanese, Europeans, and Americans participated in the problem of eliminating the consequences of the Chernobyl accident. Conducted colossal studies in the areas in order to maximize the detection of thyroid cancer. This was the most painful point after the accident, which manifested itself, and most of all it touched the children's age.
Question 1: Has the incidence of thyroid cancer increased?
Answer: The peak of the incidence, especially in children who were in the territory of Belarus, clearly exceeds all previous indicators that were. This whole situation is very clear with the epidemic of thyroid cancer. At this time, technologies appeared that allow to reliably detect changes in the thyroid gland itself. This ability to detect minimal changes in the thyroid gland with the help of ultrasound led to the fact that an enormous number of ordinary people who had never suspected that they had any problems became informed that they have something to do. .
Question 1: But is mortality not growing?
Answer: At the same time, the mortality rate remains approximately the same as in the past century.
Question 1: Maybe the incidence did not increase, but the diagnostic capabilities did improve with the advent of the ultrasound method? Or we can say that with globalization, industrialization there really is a growth due to various factors.
Answer: This is not so significant in comparison with those figures that have appeared in the scientific literature now. The moments that are now associated with screening are rethought by specialists, and not any education in the thyroid gland requires today to study it in detail using the same puncture biopsy that 10–15 years was not even considered, that is, any education in the thyroid gland, there are suspicious signs that must be investigated.
The story that is currently developing in an international research project is related to the fact that microcarcinomas do not always require treatment. As you know, thyroid cancer is almost 80-90% - it is papillary cancers, slowly growing. By itself, the diagnosis of cancer of an ordinary person is out of balance, and the need for the most radical actions is considered as a necessary attribute. Several studies have been conducted that show that between 10 and 30% of people who died for other reasons had thyroid cancer.
Question 1: We divide thyroid cancer into highly differentiated forms with a good prognosis, and there are morphological options, such as anaplastic cancer, poorly differentiated, in which the prognosis is insignificant. And when we talk about such situations, we mean highly differentiated tumors - this is papillary cancer, follicular tumors. Now the question is being raised by both Americans and our professors that it may not be worth treating some tumors, which can sometimes be quite unexpected information for patients. If a highly specialized professional tells him that he doesn’t need to do this, the patient will go to the next hospital, where another specialist will read this diagnosis and say: "You that, you should urgently have an operation." This is really a very unusual thing, a unique tumor with a unique biology. What is its uniqueness? After all, it is, on the one hand, cancer, and on the other hand, patients live for decades, and we are now talking about how to observe them for both 20 and 30 years, and not 5, as with other localizations.
Answer: A very important note is that among the histological options for thyroid cancer there are different options, while distinguishing a favorable prognosis and an unfavorable prognosis is the lot of specialists who know this problem and know it so much that they can send the patient under observation, while situations require not only surgical methods, but also the use of combined treatment.
The problem of monitoring thyroid cancer is now viewed as unrealistic from the standpoint of the knowledge of most specialists and patients. Any recommendations on this topic are prepared on the accumulation of material. Now such studies are underway in Japan and the USA, and they represent a cohort of more than 1,000 patients who have undergone surgical treatment and have not. A very important note in terms of how to leave the patient under observation when he has a diagnosis. Indeed, this situation is possible only if we obtain the informed consent of the patient. And I must admit that patients, when they have a problem, use the Internet to know about the disease sometimes more than a general practitioner. And the problem itself, which is further solved, goes into the legal plane, is it possible to leave the patient under observation if he has been diagnosed with cancer. We have not solved this problem at the legislative level, but as an option, when a patient has a serious concomitant disease, then we can explain that this problem is leading, and we can leave this patient under observation to reveal the potential possibilities of this tumor. to rapid growth and time to do so, as is done today in most cases, that is, using combined methods of treatment, primarily surgically, and then applied radiotherapy, radiation therapy, life thyroxin replacement therapy.
The uniqueness of the tumor is that it is an endocrine organ. Without the thyroid hormone, thyroxine, which then turns into triiodothyronine, the body cannot exist.
The uniqueness of a thyroid tumor is that it is an endocrine organ. Without the thyroid hormone, the body can not exist.
Question 1: Very often, especially for women, being examined for gynecological pathology, during pregnancy, immunological problems, an ultrasound of the thyroid gland is performed. Found in man nodular formation of the thyroid gland. Where should he go: to an endocrinologist or an oncologist? After all, we are well aware that often patients with malignant tumors are observed for a long time by other specialists who do not perform a fine-needle inspiration biopsy, they say that nothing needs to be done. And people walk with this knot for years, which is a tumor. Do we all need to punctuate the nodules at once?
Question 2: How is thyroid cancer detected? I wonder how the primary receptions take place and how does the person finally get to you, before radiotherapy?
Answer: Most often there is discomfort in the neck or visible presence of a node, or ultrasound is done for other diseases and it is revealed that there are changes. Then the situation becomes a problem, which is successfully solved if this case is handled by a specialist who has the skill of working with cancer patients. But this is the ideal situation that a person immediately goes to an oncologist. And if he gets to a general practitioner, the task that they solve is to find a place where it is possible to deal with this node using an ultrasound or puncture biopsy.
If atypia is confirmed or tumor cells are detected, further tactics with this patient are clear, he goes for surgical treatment. Previously, any node more than three centimeters required surgical treatment. Today, surgical treatment can be shown only if this site has signs of a tumor, confirmed cytologically. It is not enough to understand the borderline conditions that occur during puncture biopsy of these nodes. A way out of this situation may be to refer such a patient to a specialized medical institution.
Cytological diagnosis - the lot of narrow specialists. The specialists who deal with this problem and purposefully study the endocrine organs, including the thyroid gland, are more likely to understand the nuances that the cell undergoes, turning into a tumor. Here it must be said that if earlier the need for surgical treatment in the presence of a node was related to the fact that each node was potentially reborn into a tumor, today research and observations suggest that the tumor node most often does not degenerate from benign nodule, and this immediately represents a tumor that may develop over time.
Question 1: We, as people involved in this pathology, know whether to puncture every nodal formation. After all, there is a classification of iterations that says whether to do it or not. But, let's say, it does not suit us very much, because it is quite mechanistic and remains at the discretion of the doctor of ultrasound diagnostics, as he interprets what he sees. There are tumors and 5 millimeters that can go beyond the capsule of the thyroid gland and go from T1 to T3, even with the invasion of fiber. And more often in such situations there are young patients, whom we have observed for a year or two, they have a small education of 5 millimeters, which was found during accidental puncture. How to define, puncture, observe? If we are talking about papillary carcinoma, it will not affect the patient’s life in such a way, but if we have a different form of tumor, a more aggressive formation, which is already malignant, this is not an easy thing, especially in countries where, economically, medicine is on other levels and there it’s calculated every action.
Answer: Do I need to puncture each node?
Question 1: Relatively speaking, centimeter. It happens because cancer is less, but it is much more.
Answer: I have been dealing with this problem for 30 years, it has always stood in such a way that it is still difficult to reconstruct the fact that some kind of cancer can be not diagnosed or operated on. But the recommendations that are now being written, and what is accepted in the American association of thyroidologists, imply that the nodules up to one centimeter do not require puncture biopsy. In itself, the presence of signs of a tumor supposedly should not move us to cytologically examine the patient. True, there are always reservations that there are prognostically unfavorable signs that require intervention, prior irradiation in the neck, or a family history of thyroid tumors. Such subtleties lead to the fact that in this situation the presence of a node up to one centimeter requires puncture.
Still very high hopes are connected with the fact that an ultrasound study, correctly conducted and evaluated, can with high probability say that this node is a tumor or not. But I understand that the question was when it was already found out by ultrasonic criteria that the node was malignant, whether it was necessary to puncture it. It is necessary to do, because in order to confirm the need for surgical intervention, we need a cytological conclusion.
Nodules up to one centimeter do not require puncture biopsy.
Question 1: Many patients have such a myth that if a puncture is made, it will worsen the course of the disease. What do you say to that?
Answer: The idea is interesting in the sense that if we assume that surgical treatment should not be performed for all nodes, then maybe there really is a situation so that small nodes should not be disturbed in order not to create conditions for dissemination. Although if the question is that this patient after a puncture is undergoing surgical treatment, no prognostically unfavorable moment is considered. That is, if it is punctured and operated, then there can be no dissemination, spread of this tumor.
But another thing is that if we puncture and then leave it under observation. Here we need details to study whether everything is really going well in this situation.
Question 2: I think we have many patients insist on puncture. When confronted with cancer, you want to know more about your illness, get ready, and the doctor says: "Observe, we will observe, come another time." Is this a common situation?
Answer: Yes, this is a very uncomfortable situation for the specialist himself. To take the responsibility not to conduct a patient biopsy, you need to be very confident and competently consider this situation.
Question 2: When can we refuse treatment and when we immediately put a person on the surgical table, then we irradiate, and so on?
Question 1: Here the question is being discussed by world experts. If a person comes to an oncologist in our specialized unit of head and neck tumors and he has a cancer diagnosis, we will offer surgical treatment. Men older than 55 years old, used to be 45 years old, who have a T3 tumor, that is, more than 4 centimeters, there are metastases, regional lymph nodes, there is a way beyond the capsule, this is a group of patients requiring the most aggressive treatment.
There is a position that you can not touch, observe. These are people of a certain age with a certain planned survival and with small-sized tumors that are not life threatening. But this is still a theory, discussion.
Answer: The situation really looks like this, that only low-risk groups, not the second stage, that is, it is always only the initial stages are considered in order to be observed.
Question 2: But after all, small tumors can also give metastases?
Question 1: Exactly. I had an operation in our department, a young girl, 31 years old, education 5 millimeters, long-existing, accidentally punctured, papillary cancer confirmed. And according to all the criteria that we have, we performed the organ-saving treatment for her, removed half of the thyroid gland and captured the surrounding fiber, which already had micrometastases, which required performing a second operation and removing the entire thyroid gland.
Answer: Now, regarding micrometastases, which are located near the thyroid gland, it turns out that they do not worsen the prognosis for the patient, and this situation can be considered if it is from the side where part of the gland was removed as a completely favorable prognosis.
Question 2: Or an organ-sparing surgery, thyroidectomy?
Answer: If we perform an organ-preserving operation, then our range of possibilities to investigate the spread of this tumor in the body is limited by the fact that we can only use ultrasound methods and, to a small extent, tumor markers may indicate a situation that proceeds favorably or unfavorably. To make it clear that the removal of the entire thyroid gland leads to the fact that there is no thyroglobulin protein in the blood, which is synthesized by the thyroid cell. Actually, this protein tireoglobulin is the marker that allows us to monitor the patient after the removal of the entire gland. The presence of this protein in the blood suggests that there are some cells that synthesize it. And this is a reason to explore the whole body with the help of the same iodine, but iodine is no longer ordinary, but radioactive. This may be an advantage of specialists who deal with the problem of the thyroid gland, because they have a method that has long been used to detect the spread of tumor cells throughout the body.
Removal of the entire thyroid gland leads to the fact that thyroglobulin is absent in the blood.
Question 1: For many years the topic has been discussed that it is necessary to remove the entire thyroid gland or to leave a part. Then there were at-risk groups, many endocrinologists in our country began to build their tactics on this until literally 2014. They denied the possibility of performing hemithyroid octomies, although in 2014, oncologists made a sensational statement by leading experts of endocrine surgery that this could be done.
But everywhere there are advantages and disadvantages. One of the advantages, as we now believe, is a reduction in the number of complications. There are parathyroid glands located near the thyroid gland, which are responsible for the exchange of calcium. And hypothyroidism is a rather difficult situation, especially after 10–20 years, serious complications arise. It also reduces the risk of damage to the recurrent laryngeal nerves that innervate the vocal folds. And one of these moments in favor of intact treatment is a reduction in the number of complications.
But there are completely different problems. It is easier for us to deal with the patient after the complete removal of the thyroid gland, and to monitor it by the level of thyroglobulin, and in the case of the appearance of distant metastases, the tactics here are simpler. What are the advantages and disadvantages and diagnostic capabilities of radioactive iodine, and what is it?
Answer: The situation associated with the volume of surgical intervention undergoes changes. If at the beginning of our activity we saw that it is possible to perform organ-preserving operations on the thyroid gland, this would be ostracized by people who read foreign literature well, and the tactics of total removal of the thyroid gland was perceived as a prerequisite for solving this problem.
It is extremely difficult to explain to both the patient and the insurance company why the patient at the initial stage received complications from the recurrent nerve, the parathyroid glands, is practically a disability for a person for life. And whether it was worth removing a tumor with a low potential for malignancy to completely remove the thyroid gland, which was accompanied by a high risk of complications. I say that the complete, total removal of the thyroid gland was often accompanied by such complications. And the accumulating material, it turns out that super-radical treatment, removal of the gland, radioiodine therapy of patients in low-risk groups do not create benefits for them in terms of survival, in terms of relapses. And then they came back to the idea that if it is a localized organ tumor, it does not go beyond its limits, does not grow into a capsule, there is no metastasis, young age, up to 45 years old, this prognosis is most favorable. Now it is allowed not only up to a centimeter, but also higher. If it does not extend beyond the capsule of the gland, it is limited to removing a part of the gland, as a rule, this is half. But further observation remains for life.
Question 1: No, they say: "But how are we going to watch?"
Answer: We must understand that the level of thyroglobulin has a normal background. If we have a spread of a tumor, then, as a rule, the level of thyroglobulin exceeds these values. It is necessary to be guided by it. On the other hand, the presence of high-class ultrasound equipment allows today to study the structure of the remaining gland tissue in as much detail as it was previously unavailable. The question of whether iodine can no longer be used is no longer relevant.
Here are two methods - residues of thyroglobulin and ultrasound are quite sufficient for us to say that everything proceeds favorably, given that the survival rate of such patients is 99%.
What do we achieve when we remove the entire gland? They live the same, but if we remove only a part of the gland, it allows some patients to use thyroxin and not have complications that are associated with complete removal of the gland, that is, a change in voice and impaired calcium metabolism.
Question 1: Radioactive iodine - what is it, what is the meaning of the method, its advantages, why is it necessary?
Answer: The unique situation that medicine has gained as a result of knowledge about the biology of the thyroid cell. The story at the beginning of the last century that radioactivity appeared, that any element from the chemical periodic table has isotopes. When I first started, iodine isotopes were 15, now they are being considered around 27. The Manhattan project, the creation of a nuclear bomb, led to the emergence of a group of people who were concerned with the use of isotopes for medicine. In 1942, when there was no time on our territory, there were reports that iodine isotopes can be used in medicine. And a lecture by a professor at the University of Massachusetts was about what physics can do for medicine. Already then it became clear that iodine isotopes have the same behavior as stable iodine, and this can be used further in treatment. Initially, it was thyrotoxicosis, then with thyroid tumors a unique situation was obtained, it was the first targeted drug that reached its target, but its biological features were used, that is, iodine accumulates in the thyroid cell against the concentration gradient and due to such accumulation and keeping it in the cell all this leads to the fact that the energy of the isotope that is in this cell allows it to be destroyed.
Question 1: Based on the fact that the thyroid cell captures iodine, which is needed for the further synthesis of hormones, and it accumulates only in the thyroid gland.
Answer: Yes, and then we have a unique opportunity - we can diagnose and treat with the same drug.
Question 2: Let's be easier. What problem can we solve with iodine, if we talk about treatment?
Answer: Treatment with radioactive iodine is not only oncology, primarily thyrotoxicosis, which can be unsuccessfully treated for a long time with the help of medicines, but can be radically cured with radioactive iodine. Oncology, differentiated tumors as well as normal gland tissue, most often have the ability to accumulate radioactive iodine. And due to this ability, we can use a dosed amount of iodine introduced into the body, which then destroys this cell.
Question 2: Cancer?
Answer: Cancer cell.
Question 1: If the tumor is removed, metastases in the neck or bone, which is often the case for thyroid cancer, then there must be surgical active tactics. With the impossibility of surgical removal of metastases, for example, in the lungs, multiple lesions, 15-20 metastatic nodules, of course, surgical treatment can no longer be. And here is just a salutary therapy with radioactive iodine. Moreover, it is introduced quite easily, it is oral administration, and highly differentiated metastatic cells, like the primary tissue of the thyroid gland itself, capture this iodine, which carbonizes these cells.
Question 2: Is it iodine water that goes where we already need?
Question 1: Yes, it is a solution.
Answer: It is taken in the same way as a mixture, but due to its selective accumulation in the cell, these unique properties are used to diagnose and treat.
Question 1: This is a unique opportunity to help the patient. And not something that even support, but ease, even with a metastatic common process.
Question 2: Is this a postoperative measure against the metastatic process? And where can I get such a mixture, and how widespread is treatment with radioactive iodine?
Answer: I have already mentioned that this story has been around for several decades.
Question 2: Are there many such specialists in this field?
Question 1: No, not a lot.
Answer: If we take it on a global scale, then any clinic dealing with the problem of thyroid cancer has the ability to immediately orient patients if there are indications. In our country, this technology has been underdeveloped for a very long time, and this was connected both with Chernobyl and with other problems. The fear of radioactivity led to the fact that it was inaccessible. The consciousness that this technology is in demand is now being restored, it is effective, safe, and at cost it is a way out in situations where there are serious problems for the patient and which may limit his life.
It is planned that this will be in every federal district. There are now at least three centers working in this area in Moscow, in Obninsk from the very beginning, which has been preserved, and other regions - Kazan, Chelyabinsk, Tyumen, Krasnoyarsk, Arkhangelsk, these are the places where these technologies already work.
Question 1: In principle, any citizen of our country — the Russian Federation and other countries — can contact our center, the radiological center, whose branch is the medical radiological center in Obninsk, where you can get qualified surgical treatment and any options for treatment with radioactive iodine.
Question 2: Who will not be shown such therapy and what side effects exist?
Answer: This therapy is not indicated in the presence of the thyroid gland. The presence of residues of the thyroid gland leads to the fact that this iodine will accumulate in the residues.
Contraindications may be severe concomitant diseases. This treatment is possible with proper preparation, you need to wait 3-4 weeks after the removal of the entire gland or cancellation of thyroxin, and only in this case create conditions of iodine deficiency in the body, eliminating iodine-containing products and medications. We have the opportunity to work effectively with this drug.
Question 2: And the side?
Answer: Side effects from a single dose are practically not critical for patients. And all the side effects occur in patients who have accumulated high activity. Salivary glands and tear glands may suffer. Now they are thinking about how potentially dangerous this is for the next generation, whether it affects the development of second tumors. This situation is studied on a large statistical material in great detail. There are conclusions that a single use of iodine is completely safe and comparable to a single examination of the same computed tomography of individual parts of the body or excretory urography. Large accumulated doses do not represent a danger, but this is a situation that occurs with repeated use of this radioactive iodine.
Question 2: With a clear introduction to the patient after thyroidectomy, is the procedure predictable and safe?
Answer: Yes, it is easily tolerated and the consequences are minimal. In a single examination, the inflammation of the salivary gland is the maximum that bothers the patient. If there are large residues, the inflammation occurs in the place where it has accumulated.