Keith Forwith
Innovative Thyroid Surgeon
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Innovative Thyroid Surgeon
Graves’ eye disease, often called Graves’ orbitopathy or exophthalmos, occurs in approximately 40% of patients who have Graves’ disease. There is no good evidence that treatment of Graves’ disease with antithyroid medication leads to any improvement in Graves’ eye disease! It has been noted that oftentimes hypothyroidism which can be induced by antithyroid medications can worsen orbitopathy. Recently, there are two large random controlled trials that showed de novo development of Graves’ orbitopathy or worsening in approximately 15% of patients who had already undergone radioactive iodine therapy.
The reason that the eyes tend to bulge in Graves’ disease is because of deposition in the eye muscles that control the eyes. The eye is contained in a bony cone that can be thought of like an ice cream cone. Deposition into the cone portion causes the eyeball (the ice cream portion) to bulge out of the cone. The more deposition that occurs within the cone, the more bulging occurs. The real risk in Graves’ orbitopathy is not just in the cosmetic appearance, but the potential for stretching of the optic nerve. This stretching of the optic nerve can even lead to blindness in severe cases. In addition to optic nerve effects, the deposition in the bony orbit can cause restriction of muscle movement – resulting in blurred vision or pain when the eye moves toward the middle of the face. Some of these visual changes can be improved with steroid therapy, however, the disease tends to progress as soon as steroid therapy is stopped.
Long-term steroid therapy is not safe or recommended for controlling Graves’ eye disease. The only option that will definitively stop the Graves’ orbitopathy and keep it from progressing is surgical removal of the thyroid gland. This can be done very safely in the hands of a high-volume, experienced thyroid surgeon. While we know that Graves’ disease operations have a higher complication rate, this can be minimized by seeking treatment with a high-volume surgeon. Frequently, orbital disease is improved simply by surgical intervention and removal of the thyroid gland. If the eye disease has made more permanent changes, there are some specific operations which can be done to correct the orbitopathy.
Graves’ disease is one of the more common diseases in the U.S. with approximately 1.2% of the population susceptible to it at some point in their lives. It is the most common cause of thyrotoxicosis, that is an overactive thyroid gland. While it is more frequently found in women, it can affect men as well. Graves’ disease is an autoimmune disease, that is antibodies are formed against the thyroid gland and stimulate the thyroid gland to make thyroid hormone even when there is plenty of thyroid hormone in circulation.
Typically, the thyroid gland is controlled by the pituitary gland which makes thyroid stimulating hormone (TSH) to control your thyroid. But in Graves’ disease, antibodies stimulate the thyroid and the thyroid continues to produce thyroid hormone well in excess of normal levels. What you will typically see on lab tests is that the thyroid stimulating hormone, made by the brain, is very low because it senses that no more thyroid hormone is needed. Normal thyroid levels typically run between 0.5 and 4.5 for TSH, but in Graves’ disease we will see these levels go to nearly 0 in the worst cases.
An overactive thyroid stimulated by Graves’ disease antibodies produces a whole host of symptoms. These can range from rapid heartbeat, high blood pressure, nervousness, anxiety, and basic jitteriness to a host of other symptoms. In fact, the list of thyroid symptoms from Graves’ disease is so long that I have put it into a separate list which you can see here. The large number of symptoms can make a patient feel a complete host of abnormal symptoms.
We always reassure Graves’ patients that they are not themselves when they are suffering from the ravages of Graves’ disease. The typical hyperthyroid patient has trouble thinking, has trouble concentrating and experiences a lot of emotional lability. It is not uncommon that in Graves’ disease a patient will be fine one moment and then upset, angry, or even crying the very next moment with very little stimulation. It is just so true that when you are suffering from Graves’ disease that you are not yourself. The good news is that with proper treatment you can get back to being yourself and enjoying the things that you did in the past. For roughly 30% of patients, Graves’ disease will spontaneously resolve typically over the course of 12-18 months. Sadly, for the remaining 70% the disease will not go away spontaneously, and definitive treatment would be necessary.
There are many complications that can occur from Graves’ disease aside from the long list of troublesome symptoms. Graves’ disease is just not healthy for your body and the longer Grave’s disease continues the more complications can occur. One of the most concerning risk factors in ongoing Graves disease is the development of atrial fibrillation. Atrial fibrillation is one of the more common irregular heart rhythms and puts the patient at risk for stroke. In addition, atrial fibrillation also causes fatigue, muscle weakness, and headache, amongst a whole other host of symptoms. Long-term Graves’ disease also puts people at risk for osteoporosis or osteopenia. Osteoporosis is weakening of the bones which puts the bones at risk for fracture, even with routine use. A milder version of osteoporosis called osteopenia can also be a consequence of Graves’ disease.
About 40% of Graves patients will suffer from eye changes, called orbitopathy. You may be familiar with the bulging eyes in celebrities such as Martin Feldman. The bulging eyes from Graves’ disease get worse as Graves’ disease progresses. Treating Grave’s disease surgically can halt the progression of orbitopathy and in many cases reverse the unwanted effects. Other complications of Graves disease are embolic events. These would be blood clots that can end up with shortness of breath or stroke. Graves’ disease has been known to even cause cardiovascular collapse and death in the most severe cases. Insulin resistance is noted to be worsened with Graves’ disease, making diabetes worse. Vitiligo, which is the skin disease that Michael Jackson had, is a common complication of Graves’ disease. Finally, Graves’ disease patients usually suffer from infertility. It is very difficult to get pregnant when the thyroid is not working properly.
After an FNA is performed, the pathologist will examine the cells that were sampled from the thyroid nodule. There is a uniform method of reporting FNA results that nearly all pathologists use. It is called the Bethesda grading system and breaks down results into six groups. Here are possible outcomes from an FNA:
A nondiagnostic FNA sample is not really a result. This occurs when there are not enough cells for the pathologist to make a firm recommendation based upon the findings. This happens less than 10% of the time and if this occurs, then the FNA will need to be repeated to gather more samples. These findings would be considered Bethesda category 1.
Of course, the most desired result from an FNA is that the pathologist would look at the cells and determine that the findings are benign. Normal thyroid cells have a distinct characteristic that allow for the pathologist to comfortably state that the nodule is benign and results from benign biopsies tend to be highly accurate. These findings would be Bethesda category 2.
The indeterminant category means that the pathologist looked at the samples taken from the FNA and could not firmly conclude that they were benign normal cells, nor did it have all the distinguishing features of thyroid cancer. There are several names used to describe this category of lesions. AUS is a typical designation which stands for atypical cytology of undetermined significance. This means that the thyroid cells that were seen were not normal but whether they were cancer could not be determined by the biopsy. Also seen in this indeterminant category are follicular lesions of undetermined significance (FLUS). Follicular lesions could represent benign follicular adenoma which is not a cancer and does not have risk of spread into other parts of the body. A minority of times, a follicular lesion can turn out to be a cancer which does have the potential for spread beyond the thyroid. Both AUS and FLUS are Bethesda category 3.
Sometimes the pathologist sees clear evidence that there is a tumor, also called a neoplasm. In the thyroid, it is not possible to determine whether a follicular neoplasm is benign or cancerous with a FNA. This type is Bethesda category 4 and described as either a follicular neoplasm or suspicious for a follicular neoplasm. The indeterminant category is by far the most difficult category to determine the next best steps for. Advice on next steps should be highly individualized based upon a number of risk factors from the patient history, as well as the ultrasound characteristics and the level of suspicion for each individual lesion. Molecular testing has come to play a prominent role in helping patients with indeterminant results. The use of molecular testing should be selective and weighed against the benefits of the surgical biopsy vs. the risk involved.
Thyroid cancer frequently has some very distinct characteristics which make it recognizable on even a small sampling from the fine needle aspiration. Cancer characteristics lead the pathologist to categorize the findings as either highly suspicious for cancer or cancer. Both of these would require surgical intervention for optimal treatment. Bethesda category 5 is suspicious for cancer while Bethesda category 6 indicates cancer. Whether a pathologist uses category 5 or 6 is often reflective of the confidence in the findings. Category 6 implies that there is no room for doubt and the findings lead to a firm conclusion of cancer. Frequently, pathologist will hedge – calling a result that is convincing for cancer a category 5, instead of 6. This leaves room for error, and probably more importantly, protects the pathologist from litigation risks should the final pathology appear different from the FNA sampling. This is an unfortunate reality of our current healthcare environment – where the threat of legal action alters the practice of medicine. As a result, the Bethesda category 5 is used for most cancer cases and the rate of cancer in category 5 is far higher than the 75% stated in the original Bethesda classification system. In actual practice, Bethesda category 5 represents cancer in more than 90% of the cases we see.
Innovative Thyroid Surgeon