Keith Forwith
Innovative Thyroid Surgeon
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Innovative Thyroid Surgeon
I am very conservative in my recommendations for surgery. I follow this simple rule: would I encourage my wife, child, parent, or friend to have the surgery under the same conditions? I sleep well at night because I never forget this very simple guideline: treat patients as though they are family and everyone you care about is watching!
So, if I’m doing my job right, an expert second opinion will only make me look good and provide reassurance to the patient and family. If’ I’m offended by a second opinion – then I’m not following the simple rule stated above. I encourage my family and friends to get second opinions for major surgery.
As a high-volume thyroid surgeon at this point in my career, most cases seem routine to me. But surgery is never routine to the patient. Each surgery is likely the first for the patient and a lot is on the line! The best outcomes are with the first surgery. Complications and completeness of resection matter, especially to cancer outcomes. While I strive to reduce complications to the lowest possible rates, there is still risk with every surgery. A thorough and honest discussion is part of every pre-operative counseling visit. In my field of expertise, it’s literally the patient’s neck on the line!
When an FNA biopsy is done and a nondiagnostic biopsy is returned, the FNA should usually be repeated. If it was a clear indication for a biopsy the first time, then a nondiagnostic result would mean that the patient is still in need of an accurate fine needle aspiration. The process of obtaining an FNA does generate inflammation within the gland of the thyroid and so repeat FNA should be delayed for a time which allows for a resolution of the inflammation. This helps to avoid conflicting biopsy results and increases the accuracy of the subsequent biopsy.
The other situation where a repeat FNA is often considered is in the face of an indeterminant result. While some people advocate for repeat FNA, this should be done with caution. Not all nodules contain uniform and homogeneous populations of cells. It is possible for a repeat FNA to pull out benign cells that are unlike the unusual cells that were seen on the first sampling. While this may appear reassuring for the patient that benign cells were seen, there is still a concern about the abnormal cells that were sampled during the first FNA. The better reason to consider a repeat FNA for indeterminant results is if molecular testing could be used to help further stratify the risk of cancer in a particular lesion. Molecular testing has added a significant degree of certainty to the indeterminant category and can be reassuring for increased probability of benign disease. Its use has obviated the need for surgical biopsy in many cases. Molecular testing is certainly an evolving area within the thyroid nodule evaluation, and it is critical that the performing surgeon understand the nuances of molecular testing and when it is appropriate to be used. Not all indeterminant lesions should undergo molecular testing and not all patients require this expensive testing. New advances in this area are coming at a rapid pace, so make sure your doctor has extensive knowledge and has kept up with the available molecular tests.
The evaluation for a thyroid nodule in a pregnant patient is pretty much the same as that for nonpregnant women. If the pregnant woman has a normal TSH or is hypothyroid then a fine needle aspiration can be done in the routine way. Fine needle aspiration does not present any risk to the developing baby. If the TSH is below normal range, the fine needle aspiration is typically deferred until after pregnancy and sometimes even after the cessation of lactation. Thyroid uptake scans are not recommended for evaluation during pregnancy or lactation. If a nodule is proven to be thyroid cancer, then the decision making needs to be done in close conjunction with the surgeon. If the thyroid cancer does not appear to be aggressive, then waiting until after delivery for surgical removal is likely to be the recommendation. If surgery is required because of an aggressive growing thyroid cancer during pregnancy, the ideal time to perform that is in the second trimester. The first trimester induction of anesthesia puts the patient at risk for developmental abnormalities. These risks are much lower in the second trimester. Third trimester operations have the risk of inducing premature labor. So, second trimester is the ideal time if the surgery cannot be delayed until after delivery. If thyroid cancer treatment is delayed on the suspicion or confirmation of thyroid cancer, then the TSH should be kept at low range, typically .1 to 1.0 for the duration of the pregnancy. As with all thyroid surgery, an experienced thyroid surgeon can reduce the inherent risks. As time under anesthesia is an important risk factor in pregnant women, a high-volume thyroid surgeon can more efficiently perform a thyroidectomy and reduce anesthesia time for the operation. Higher risk thyroidectomies, such as in a pregnant patient, should not be done by anyone other than a high-volume, experienced thyroid surgeon! Check out this advice on choosing a thyroid surgeon!
If the FNA results indicate that your thyroid nodule is benign, then congratulations are in order! Benign results are not 100% accurate and so it is still important that the thyroid nodule be evaluated for unusual growth over time. It is not uncommon for thyroid nodules to grow by 1-2 mm per year, but more than this amount of growth should definitively be reevaluated. Follow up ultrasound is the easiest way to evaluate for unusual nodule growth. This can be done at six month or annual intervals depending upon whether the nodule is stable. Most nodules grow very slowly and never need to be removed. However, thyroid nodules which exceed 4 cm will almost inevitably cause difficulties with swallowing; if they grow even larger, they will begin to push in on the airway. This airway compression is rarely noted by the patient. It first shows up as shortness of breath on exertion. Many patients attribute this shortness of breath to them being out of shape. Airway compression can easily be seen on ultrasound but looking for this is rarely a part of a routine ultrasound done at the hospital. The risks of thyroid surgery in an experienced thyroid surgeon’s hands are very low. However, even with the most experienced surgeon, the risk increases as the size of the nodule increases. So, if a thyroid nodule is clearly growing over time, it is better to be removed when it is large (>4cm) rather than when it becomes excessively large.
A benign FNA is reassuring but doesn’t always mean that the nodule is not a problem. Large nodules can be life-threatening, even though they are benign. Benign means that there is no risk of spread outside the thyroid, but it doesn’t always mean there are no risks! Recently, we removed an 18 cm lobe from a lady who had severe airway compression. This operation could have been done years earlier and the delay in referral for this enormous goiter only increased her surgical risks! To make matters worse, she had a prior lobectomy on the other side, done by a general surgeon who had paralyzed her vocal cord nerve. This case was made even more challenging because this massive thyroid had grown into the chest and was pushing on the arch of the aorta! Thankfully, everything went well, and we removed her thyroid lobe without any complications. However, her delay in referral, her prior experience with a low-volume surgeon, and her attributing her shortness of breath to her weight, all led to a higher-risk operation than it needed to be!
If the thyroid FNA returns cancer or suspicion for cancer, then surgical treatment is the recommended choice. There are no other treatment options which come even close to the high cure rates that are obtained by thyroid surgery. Most common forms of thyroid cancer have very high cure rates, especially when diagnosed early. While the prognosis for most people with thyroid cancer is very good, the rate of recurrence or persistence can be up to 30% and recurrences can occur even decades after the initial treatment. For more information on thyroid cancer, click here.
If the FNA results are indeterminant, then decision making becomes much more complex. Whether molecular testing, repeat serial ultrasounds and observation over time, or surgery is recommended, it is highly individualized. Certainly, ultrasound characteristics should be taken into account when evaluating next steps for an indeterminant lesion. An experienced thyroid surgeon can guide the patient to decisions which lower risk and provide better outcomes.
If you or your medical provider has discovered a thyroid nodule in your neck, this is going to require a specialist’s evaluation. Typically, the workup is multistaged. The first step is a careful patient history including attention to any past head or neck irradiation. This would be done for conditions like cancer of the neck, breast, or lungs. A history of radiation exposure also is a very important risk factor for thyroid cancer. Some patients received radiation treatments for adenoid enlargements or even acne. This is not something that is practiced today, but in older patients these treatments may have been received. Others may have been exposed to radiation from x-rays, or CT scans particularly if they work in radiology. Finally, a family history of thyroid cancer is very important in the evaluation. Other thyroid related diseases such as Cowden syndrome, Multiple Endocrine Neoplasia (MEN type 2), familial polyposis, Carney complex, or Werner syndrome in a close relative are all important information for your doctor to know.
Physical examination during the workup is pretty straightforward and painless. This will focus on enlargements in the neck, looking for not only the thyroid itself but for any enlarged lymph nodes in the area. Typically, a neck ultrasound is going to be the best way to visualize the thyroid and determine the type of nodule that is present. The ultrasound examination is probably the most critical decisionmaking test in evaluation of the thyroid nodule.
Depending upon the characteristics of the thyroid nodule on ultrasound, it may be elected to proceed with a fine needle aspiration biopsy which would be done under ultrasound guidance. Criteria for FNA have changed in recent years and the American Thyroid Association has specific guidelines available on their website that are categorized by the type of nodule that is seen on ultrasound. An older test, called a thyroid uptake scan uses low dose radioactivity to evaluate the thyroid. This test is typically unnecessary for workup of a thyroid nodule, given better alternatives now available. Ordering uptake scans for nodules was a common practice as it resulted in a nodule being assigned to the “hot nodule” or “cold nodule” category. The thinking was that hot nodules were never cancerous while cold nodules were highly suspicious for cancer. Neither of these assumptions are true! Thankfully, this dated test has been supplanted by the far superior ultrasound-guided FNA. It is quite rare that an uptake scan is needed for routine thyroid nodule evaluation. One caveat- the uptake scan can still be useful in limited cases for the evaluation of hyperthyroidism. More on hyperthyroidism can be found here. But, determining whether a nodule is “hot” or “cold” by uptake scan is not a needed part of thyroid nodule evaluation.
Initial lab tests should include a thyroid stimulating hormone (TSH measurement). Further blood work may be performed but a TSH is sufficient for initial screening purposes.
It is important to understand that there are no blood tests that can determine the nature of a thyroid nodule! A fine needle aspiration biopsy is the most reliable way to sort out the 85-90% of thyroid nodules that are benign from those that are cancerous. A blood test does not determine the status of a thyroid nodule, but it does give information about the surrounding thyroid and how well that is functioning. While the FNA is the best method for determining whether cancer is present, there are limitations to this technique. Occasionally FNA is not diagnostic and further steps would then be warranted. There is also a middle ground called indeterminant which can require more detailed evaluation which will be described here on this website.
The fine needle aspiration biopsy should only be done under ultrasound guidance. Sometimes the thyroid nodule is evident enough that it can easily be felt. Some people will elect to do a biopsy without ultrasound guidance. This is not recommended and not good practice! Many nodules contain more suspicious or less suspicious areas. A needle biopsy should be testing the most suspicious areas within a nodule which can only be determined while looking by ultrasound. Ultrasound guidance also ensures that the normal thyroid that surrounds a nodule is not removed and sampled. This would lead to a misleading (benign) diagnosis or a false-positive biopsy result. Since the fine needle aspiration involves multiple needles, we highly recommend that the patient be numbed by a short local injection. This involves a pinch and a burn for less than 10 seconds. After appropriate time is allowed for the numbing medicine to fully work, a fine needle aspiration involves a deep pressure sensation but not an intolerable amount of pain. It is curious that many of our patients report that they have had prior FNA biopsies which were extraordinarily painful. In our hands, we have seen that they report remarkably better experiences in the way that we perform these biopsies. While an FNA is not the most comfortable procedure to undergo, certainly it should not be an extraordinarily painful experience. One of the most common mistakes that we see is that patients are numbed and not given adequate time for the numbing medicine to take effect. This leads to a very uncomfortable biopsy and patients often tell us that they would rather have surgery than to have the needle test repeated. This is a reflection of a poorly done FNA!
The technical challenges of thyroid surgery are well known. For the best possible outcomes and the least chance of complications patients need to make well-informed and wise decisions. Here are the basic questions to ask when making this important decision.
A qualified surgeon will be board certified either by the American Academy of Otolaryngology/Head and Neck Surgery or a member of the American Association of Endocrine Surgeons. General surgeons board certified by the American College of Surgeons do not have advanced training in head and neck surgery but may feel qualified to perform basic thyroid and parathyroid operations. Advanced cases, especially those requiring neck dissections should be done by surgeons with advanced training specifically in those procedures.
Volume matters! Surgeon experience is the number one predictor of complication rates. The American Thyroid Association states that low volume surgeons, who perform more than 80% of thyroidectomies in the US, have a 19% complication rate. This is far too high! By contrast, the ATA cites high volume surgeons as averaging 7.5% rate of complications- which is still too high! By the ATA definition, low volume surgeons do less than 10 thyroid operations per year – which explains why nearly one in five patients have complicaitons. By comparison, a high volume surgeon exceeds 100 operations per year and only 1 in 13 patients have complications (2015 ATA Thyroid Nodule Guidelines) . For many surgeons, thyroidectomy represents the most delicate and challenging surgery they perform. For the head and neck surgeon, parotidectomy (where the facial nerve is at risk) presents finer and more numerous nerves that require surgical dissection. The results show permanently on the patients face – just as the voice will indicate the status of the nerves encountered in thyroidectomy. You want a surgeon who does many delicate surgeries and is comfortable in the small spaces of the neck.
Complication rates have been shown in many peer reviewed journals to be proportional to the volume of these type cases. Surgeons performing less than 100 operations per year had substantially higher rates of both temporary and permanent complications. High volume surgeons performing more than 100 operations per year had the lowest complication rates and the best outcomes. Repetition and practice make every surgeon better- whether they are mediocre or world class. Obviously, you want the best surgeon who gets the most practice!
Outcomes are measured in many ways. For some surgeons, outcomes are measured in the number of cases. A recent study on thyroid screening focused on the death rate from thyroid cancer. While, that is important it ignores quality of life as a critical component. Earlier detection means less extensive surgery and fewer adjunct therapies.
Young surgeons need to learn. They need to learn by operating on real people. So, we need residents and fellows to perform operations so that they can learn. You should ask who will be learning during your case, and how closely supervised those young surgeons will be. I perform each and every one of the operations for my patients. While I welcome students and residents to observe, I still do each and every operation myself. I also use the same surgical assistants for every single case. These physician assistants were trained, by me, to assist in exactly the manner I demand. The result? My complication rates are far lower than even the high-volume surgeons cited above.
One of the things I go to great effort to ensure is that each patient and family understands both their diagnosis and their treatment options. If anything, I may be guilty of trying to explain too much! But I truly believe that patients make the best decisions for themselves when they are fully informed, and their questions are answered in a manner that they can understand.
My care remains consistent in every phase of treatment – including after the surgery is done. I don’t pass off patients to another provider as soon as the wound is closed.
I take a personal interest in every patient, especially thyroids! Both my wife and I have thyroid nodules so thyroid care is personal to me.
Good relationships are built on honesty. I’m not very good at hiding my thoughts and emotions – so I don’t really try (which is why I don’t play poker for money!). I want my doctors to always be up front and forthcoming with me, so I take this approach with my patients. I hope that my openness and honesty earn the trust of each and every patient. In fact, this website is a reflection of who I am and my core values. As a Christian, my call goes beyond just a job or a career – I try each day to walk in the shoes of the great physician, Jesus Christ! If you know him, then you know what I mean, if you don’t – well I’d love to introduce you to him!
I think second opinions are valuable. If I do my job right, an honest second opinion will only make me look good. If a surgeon is offended by your interest in another opinion, go elsewhere! You need to be comfortable with your decision as you will live with the consequences of those decisions far longer than the surgeon you choose. Don’t let the thought of offending a surgeon keep you from the peace of mind that a second opinion can bring! Here’s my page on why I encourage second opinions!
The rate of injury from thyroidectomy is directly related to the amount of experience that the surgeon has. Recently the American Thyroid Association (ATA) cited a problem in that over 80% of thyroid operations were being performed by low- or intermediate-volume surgeons. They noted that low-volume and intermediate-volume surgeons had higher complication rates than high-volume surgeons. Low-volume surgeons perform less than 10 cases per year, sometimes only 1 or 2 cases per year! This is entirely inadequate to develop and maintain the high-level skills thyroid surgery demands!
Alarmingly, low-volume surgeons have complication rates as high as 18.9%. The ATA concluded that patients should be referred to high-volume thyroid surgeons, particularly if the case is extensive or complex. The bottom line from all this data is that the amount of surgeries that are done is critical in developing techniques which are meticulous and are more likely to avoid injury to delicate structures such as the recurrent laryngeal nerve and the parathyroid glands. If thyroid surgery is needed, choose your surgeon wisely!
Perhaps the most important decision is choosing the right thyroid surgeon. After that, it is also very important to choose the right type of surgery. This varies depending on the actual diagnosis and treatment plan. There are several different options for thyroid surgery.
If we think of the thyroid as a butterfly, removing one wing of the butterfly would be called a thyroid lobectomy. Removing one wing of the butterfly and the body of the butterfly would be called a hemithyroidectomy. Both options leave a part of the thyroid behind, which is good for supplying hormone needs for the patient after the operation. Most people who have a lobectomy or a hemithyroidectomy are able to maintain normal or near normal thyroid function despite having part of their thyroid removed.
In a total thyroidectomy, the entire butterfly is removed. Because this operation removes all of the thyroid the patient will need to be on thyroid hormone replacement for the remainder of their lifetime. Thyroid hormone is important for every cell in the body and affects the way each and every cell function, so it is critical that the right hormone levels be established after removal of the thyroid.
Sometimes when the thyroid needs to be removed for thyroid cancer, additional work needs to be done at the same time. The lymph nodes that immediately surround the thyroid, referred to as the central neck compartment, often need to be cleaned out during a cancer operation. This is a much more difficult operation than a standard total thyroidectomy and involves increased risk of injury to both the parathyroids and the recurrent laryngeal nerve. This type of operation should only be done by expert surgeons who specialize in thyroid surgery. In more extensive cancer situations, the lymph nodes in the lateral neck may also need to be addressed surgically. These operations can be called modified radical neck dissections or selective neck dissections. In either case, the idea is that the lymph nodes where cancer has spread or is at risk for spreading are removed during the same operation in which the total thyroidectomy is performed. This is also a more complex operation and should only be done by experienced thyroid cancer surgeons. Surgeons who perform thyroidectomy on an occasional basis are not well-qualified for these more extensive operations.
Finally, there is sometimes a need for a reoperation. This may be because of unexpected cancer that was found in a first operation. Another reason for reoperation is that a thyroid remnant is left behind; this happens most often with low-volume surgeons. Revision surgeries of these types should be done by experienced thyroid surgeons that are high-volume. This lessens the chance for complications from these more difficult operations.
Which surgery is right for you depends upon a number of factors including the information we gather from ultrasound evaluation and from fine needle aspiration biopsy. These results need to be discussed with each and every patient and so is difficult to generalize. Thyroid cancer, which is highly treatable, has achieved high success rates primarily because total thyroidectomy has been the treatment of choice. There is more recent evidence that perhaps total thyroidectomy is not required in all cases and so lobectomy and hemithyroidectomy has become a viable option for selected patients. Discussions on which operation is best should be undertaken by the patient and surgeon and is certainly individualized for each and every patient. Whichever operation is chosen by the surgeon and patient after a long discussion, the risks of that surgery are going to be unique to that type of surgery. You can find more information on risks of surgery here.
Pediatric patients with thyroid cancer are at increased risk for a second cancer if they receive radioactive iodine therapy. A publication in Thyroid (the leading peer-reviewed journal) from June of 2015 involved 3,850 patients who underwent surgery and either did or did not receive radioactive iodine after surgical treatment. The research found a 42% increased risk for a second primary cancer amongst all the patients who were treated with radioactive iodine. No equivalent excess risk was noted in the patients who did not receive radioactive iodine.
Salivary cancers had the largest increase in risk from the radioactive iodine. The reason for this is that the radioactive iodine molecules will kill any cell that takes up that molecule. If there is not enough thyroid tissue to uptake all of that radioactive iodine, then the iodine will go somewhere. The most avid tissue after thyroid to take up iodine molecules are the salivary glands. So, what you see with the administration of radioactive iodine is that the salivary glands take up the excess radioactive iodine and therefore are permanently damaged. This not only leads to dry mouth which can be permanent and very bothersome, but it also leads to an increase of salivary gland cancer.
The younger the patient, the more risk there is that they can subsequently develop cancer in these areas. A study in Thyroid journal in May of 2009 also showed a risk of a second primary cancer after RAI treatment in patients who had thyroid cancer. The authors showed that the relative rate for a second thyroid cancer was significantly increased. There was also a relative risk of leukemia that was increased in thyroid cancers treated with RAI with a relative risk factor of 2.5. Both are serious potential complications from radioactive iodine therapy. So, does that mean we should never use RAI? This is clearly an individual decision that must be weighed between the thyroid surgeon and the patient. There are certainly reasons to use radioactive iodine in high risk or moderate risk patients. These are patients who may have residual disease or a particularly aggressive form of thyroid cancer and the risk involved with radioactive iodine may be worthwhile to achieve a cure of the thyroid cancer. However, in relatively low risk situations, radioactive iodine should be avoided. While in days past, radioactive iodine was given to nearly everyone who had thyroid cancer, this should not be the case today. The increased risk of cancer certainly gives us pause and the decision for radioactive iodine should be carefully weighed.
Innovative Thyroid Surgeon