Head & Neck Oncology and Endocrine Surgery

The thyroid is a butterfly shaped endocrine gland which resides in the front of neck just above your breast bone. The function of this gland is to control your body’s metabolism. It releases hormones into the bloodstream which then act on the cells in the body to control the rate of their activity (metabolism). Hyperthyroidism is if you have too much thyroid hormone (T3 and T4) driving your cells to be overactive causing you to have symptoms such as anxiety, irritability, racing heart rate, losing weight, sweating, shaking hands, loose bowel movements, etc. Hypothyroidism is if you have too little thyroid hormone (T3 and T4) driving your cells to be underactive causing you to have symptoms such as depression, fatigue, weight gain, constipation, etc.

Thyroid Nodules: Thyroid nodules are the overgrowth of cells of the thyroid forming a nodule (ball/lump/mass/neoplasm). They are very common with statistics showing that anywhere from 1 out of every 3 people to half of all people over 60 years old having thyroid nodules. A high percentage of these nodules are benign. Once a nodule is found (patient notes a mass, physician feels it on exam, incidentally seen on imaging done for another reason) an ultrasound should be performed to evaluate the thyroid gland for other nodules and to determine the characteristics of the thyroid nodule(s). This will help decide whether further work up is needed such as a fine needle aspiration (biopsy). Not all thyroid nodules require a fine needle aspiration and your doctor will help determine this based on the ultrasound characteristics. If a fine needle aspiration is needed it is performed using a very fine needle to take samples (usually a couple of times) of the nodule. These samples will be reviewed under a microscope by a pathologist to get a diagnosis. There are 6 possible results:

1. Nondiagnostic/insufficient: not enough cells were obtained to make a diagnosis and a repeat fine needle aspiration is needed.
2. Benign: this gives the nodule about a 3% risk of being malignant and usually means no surgery is needed. A repeat ultrasound will be performed after some time to determine if there is any change in the nodule. If it does change with time a repeat fine needle aspiration may be needed.
3. Follicular lesion of undetermined significance/atypia of undetermined significance: this does have a meaning it give this nodule about a 15% (15 out of 100) chance of being malignant (cancerous). Surgeons used to perform surgery to remove the side of the thyroid with the nodule in it to have the nodule evaluated by a pathologist to determine if it was malignant or not. Now a separate sample from the fine needle aspiration (sometimes requiring a repeat fine needle aspiration to obtain more cells) is sent for molecular analysis. These results can further separate this category into benign giving it a 5% chance of being a cancer or suspicious giving it a 50% chance of being a cancer. These results are then used by you and your surgeon to help determine the best course of treatment.
4. Follicular neoplasm/suspicious for follicular neoplasm: this gives the nodule about a 25% risk of being malignant. They are treated similar to the above category with a sample being sent for molecular testing (please see category #3 above).
5. Suspicious for malignancy: this gives the nodule about a 70% risk of being a cancer. This will most likely need surgery and you and your surgeon will come up with a surgical plan.
6. Malignant: this gives the nodule about a 98% chance of being a cancer. This will most likely need surgery and you and your surgeon will come up with a surgical plan.

Thyroid Goiter: This simply means the thyroid itself is larger than normal. This can happen when the whole gland becomes swollen or when there are multiple nodules that have grown in the thyroid gland. This can be caused by various things and the treatment is dependent on the cause and symptoms. One of the common reasons for needing surgery for a thyroid goiter is compressive symptoms. These are caused by the large thyroid taking up extra space in your neck causing issues with swallowing, changes in your voice, or issues with breathing.

Thyroid Cancer: There are three types of thyroid cancer the most common being differentiated thyroid cancer (papillary and follicular (Hurthle cell)), medullary thyroid cancer, and anaplastic (undifferentiated) thyroid cancer. The majority of thyroid cancers do not cause symptoms other than a nodule in the thyroid. It rarely affects the function of the thyroid gland. Some patients will note an enlarging lump in the neck, changes in their voice, or issues with swallowing. It is diagnosed with a fine needle aspiration (please see Thyroid Nodules section above for further information on this). There are some risk factors for thyroid cancer which are prior radiation to the neck, working in an environment with high radiation exposure, and genetics (usually an extensive family history of thyroid cancer or other endocrine system disorders) but for the majority of patient’s the cause is unknown. Once thyroid cancer is diagnosed the most likely course of action will be surgery dependent on the type of thyroid cancer and extent of disease. If the thyroid cancer is small and confined within the thyroid gland sometimes surgery can be limited to taking only half of the thyroid. If the entire thyroid is removed then you will need to take a pill every day after surgery for the rest of your life to replace the thyroid hormone in your body. Sometimes the lymph nodes in the neck contain thyroid cancer and require removal at the time of initial surgery or sometimes at a later date if detected during follow up.

Link to further information below:

The American Association of Endocrine Surgeons Info on Thyroid

The parathyroid glands are four tiny glands located in the neck behind the thyroid gland, two on each side. The parathyroid glands have nothing to do with the thyroid, they just got their confusing name because they live behind the thyroid. These glands control the body’s calcium levels. They work to tightly control the level of calcium in the blood through production of a hormone, parathyroid hormone (PTH). When the calcium is low in the blood then the PTH should be high to increase the calcium and vice versa when the calcium is high in the blood then the PTH should be low because extra calcium is not needed. Calcium affects many systems in the body including the heart, nervous system, bones, and kidneys.

Primary Hyperparathyroidism: This is when one or multiple of the parathyroid glands are not responding to the calcium levels in the blood. Instead the PTH is continued to be produced despite high calcium in the blood. The diagnosis of primary hyperparathyroidism is based on blood tests alone. If the calcium is high or even in the high normal range and the PTH is high or even in the high normal range this is hyperparathyroidism. Untreated hyperparathyroidism can cause long term effects such as kidney stones and osteoporosis. It can also cause symptoms throughout the body including fatigue, joint/bone pain, muscle weakness, mood swings, depression, “brain fog”, ulcers, and abdominal pain to name a few. Currently the only cure for primary hyperparathyroidism is surgery to remove the abnormal gland(s). A person only needs half of a parathyroid gland to do the work that all four glands typically do. Prior to surgery tests will be performed to try to locate the abnormal gland(s). These could include an ultrasound, CT scan, or other nuclear medicine tests. These tests are not for diagnosis, they are only to aid in locating the abnormal parathyroid(s) during surgery. They do not always show any abnormalities this does not change the need for surgery just that the surgeon will need to look at all four glands. A bone density scan should also be performed to determine the extent of bone loss. If there is bone loss it can be treated once the abnormal parathyroid(s) have been removed.

Secondary Hyperparathyroidism: This is when all four parathyroid glands overgrow due a process outside of the parathyroid glands. The most common reason is kidney disease but it can also be caused by lithium use, vitamin D deficiency, poor absorption of vitamins in the intestines, malnutrition, or high magnesium levels in the blood. In the majority of cases the calcium in the blood work is low to normal while the PTH is high. These constant high levels of PTH can cause other issues in the body such as osteoporosis, calciphylaxis (ulcers in the skin due to calcium being deposited in the skin), heart disease, and anemia (low blood counts). The first treatment for secondary hyperparathyroidism is medicine. At some point the secondary hyperparathyroidism will no longer respond to medical treatment and this is when surgery should be considered. The reasons for surgery are high calcium or phosphorous levels in the blood that is no longer being decreased by medical therapies (e.g. dialysis or medications), worsening osteoporosis, calciphylaxis, uncontrollable itching, or consistent very high PTH levels in the blood work (>800). The typical operations for this disease are total parathyroidectomy with autotransplantation (removing all four parathyroid glands from the neck and reimplanting a portion of a gland in the muscle in the forearm) or subtotal parathyroidectomy (removing 3.5 parathyroid glands and leaving a portion of a gland in the neck). There are advantages and disadvantages to both of these approaches. Even after surgery the underlying problem which caused the parathyroid glands to overact (e.g. kidney disease) is typically still present which can cause the remaining portion of parathyroid to grow and need further surgery in the future. You and your surgeon will discuss your specific case and determine which operation is best suited for you.

Tertiary Hyperparathyroidism: This happens when secondary hyperparathyroidism transforms so that now all four parathyroid glands are overgrown except now they are constantly secreting PTH without responding to the calcium in the blood. Now both the PTH and calcium levels are consistently high in the blood work. One common time to see tertiary hyperparathyroidism is continued elevation of calcium and PTH after a kidney transplant. The treatment for tertiary hyperparathyroidism is surgery similar to secondary hyperparathyroidism (see above). You and your surgeon will discuss your specific case and determine the best surgical approach to use.

Link to further information below:

The American Association of Endocrine Surgeons Info on Parathyroid

Salivary glands’, including the parotid glands, function is to make saliva which helps lubricate the mouth/throat and also provides enzymes to start the digestion of food. There are two types of salivary glands: major and minor salivary glands. There are three sets of major salivary glands: parotid, submandibular, and sublingual. There are also hundreds of minor salivary glands throughout the mouth.

Parotid Glands: This gland is located just in front of the ear and extends to just below the ear on both sides of the head. It is the largest of the salivary glands and the one most likely to get a tumor. The majority of parotid tumors are benign (not cancer) with about 25% being malignant. The typical sign of a parotid tumor is a lump or swelling in front of the ear or at the edge of the jaw. There are many types of tumors that can occur in the parotid gland. Once a possible parotid tumor has been found imaging will be performed (e.g. ultrasound, CT scan, MRI) to better evaluate the tumor. Once your doctor has reviewed the imaging you will discuss with them obtaining a fine needle aspiration (biopsy) of the tumor. If a fine needle aspiration is needed it is performed using a very fine needle to take samples (usually a couple of times) of the nodule. These samples will be reviewed under a microscope by a pathologist to get a diagnosis. You and your doctor will discuss the results of the imaging and biopsy to determine the next best step in your treatment. If it is decided that surgery is the next best step (which can occur even if the tumor biopsy is benign as some benign parotid tumors can change over time to cancer) you and your doctor will discuss at length the surgical procedure. This will involve taking a portion or all of the parotid gland (parotidectomy) and may involve removing some of the lymph nodes from the neck. The biggest risk of parotidectomy is to the facial nerve. This nerve runs through the parotid gland and has several branches that control the movement of the face. During surgery meticulous care is taken to preserve the facial nerve including nerve monitoring where after the patient is asleep tiny needles are placed in the muscles of the face to help monitor the function of the facial nerve branches throughout the surgery. Despite all precautions there is still a risk of injury to the nerve causing paralysis of the face or a portion of the face which may be permanent or temporary.

Submandibular Glands: These glands are located under the chin on both sides and the saliva they produce is secreted into the mouth under the tongue. They are less likely to have a tumor as compared to the parotid glands but submandibular gland tumors have about a 50% chance of being cancer (malignant). The work up and treatment of these tumors is the same as for tumors in the parotid gland (see section on Parotid Glands above). Once the work up is completed you and your surgeon will discuss the next best steps in your care including possible surgery to remove the affected gland and possibly some lymph nodes from the neck. The biggest risk of this surgery is to the nerves in the area in particular the marginal mandibular nerve which could give you a crooked smile, the lingual nerve which could cause numbness to a portion of the tongue, and the hypoglossal nerve which could cause abnormal movement of the tongue. Meticulous care will be taken during surgery to preserve these nerves including nerve monitoring where after the patient is asleep tiny needles are placed in the muscles controlled by these nerves to help monitor the function of the nerves throughout the surgery. Despite all precautions there is still a risk of injury to the nerves but the resulting abnormalities can be easily adjusted to with time and possible therapy.

Sublingual Glands: This pair of glands are located underneath the tongue under the floor of the mouth. They are the smallest of the major salivary glands and the least likely to develop a tumor. The work up and treatment of these tumors is the same as for tumors in the parotid gland (see section on Parotid Glands). Once the work up is completed you and your surgeon will discuss the next best steps in your care including possible surgery to remove the affected gland through an incision in the floor of the mouth. The biggest risk of this surgery is to the lingual nerve which could cause numbness to a portion of the tongue which may be permanent or temporary. Despite all precautions there is still a risk of injury to the nerves but the resulting numbness can be easily adjusted to with time.

Minor Salivary Glands: These can also develop cancer and the surgery is dependent on the exact location and size of the tumor. The surgery will consist of removing the tumor and a portion of the surrounding tissue in order to get a clean margin (cancer free margin). You and your surgeon will discuss at your appointment the specifics of your tumor and the treatment needed.

Just like the rest of our body skin cancer develops in the head and neck region as well. The difference is that this area has many highly specialized structures that require a specialist who understands the anatomy and physiology of the head and neck region to efficiently treat these cancers surgically. If your Dermatologist or Primary Care Provider (PCP) has determined that you need surgical intervention for a head and neck skin cancer seek out a surgeon who is well versed in this area of the body. Skin cancers are typically broken down into melanoma and non-melanoma (squamous cell and basal cell) cancers.

Non-melanoma Skin Cancers: The two most common forms of non-melanoma skin cancers are squamous cell and basal cell based on the types of cells the cancer developed from. Basal cell being the most common form is a slow growing cancer but over time can become quite large or invade nearby structures if not treated. Squamous cell can be more aggressive and deeper but not to the extent of melanoma. Both of these skin cancers tend to be easily treated if caught early. Typical signs of one of these cancers is a new spot on the skin, a non-healing lesion, a lesion that changes size, shape, color, texture, or feel, and bleeding/crusting of an area of the skin. Diagnosis is obtained by performing a biopsy of the area typically by your Dermatologist or PCP. There are many treatments for this type of skin cancer that can be performed by a Dermatologist or PCP. If your provider determines you need a surgeon to perform the excision then seek out a head and neck specialist who understands intimately the anatomy and physiology of the region.

Melanoma: This is the most dangerous form of skin cancer. It has a higher possibility of metastatic disease to the lymph nodes or other structures/organs. Wide surgical excision (removal) of the melanoma is the treatment. Dependent on the size of the melanoma, how deep it goes into the skin, its characteristics on biopsy, and its location will determine how large of an excision needs to be performed. Some wounds will be able to be closed at the initial surgery dependent on the size and location of the wound. If it is determined the wound needs to be closed by rotating or transferring skin from another area of the body this will be performed during a separate procedure. The reason for this is to ensure the final pathology (under the microscope) shows all margins are clear of cancer and no further surgery is needed to clear the margins of cancer. Depending on the depth of the melanoma on the biopsy it may be determined that a sentinel lymph node biopsy is needed to ensure the melanoma has not spread to the lymph nodes. You and your surgeon will discuss this at your office appointment prior to planning the surgery. A sentinel lymph node is considered the first lymph node or nodes where the cancer would go if it metastasizes. If you need a sentinel lymph node biopsy the day of surgery you will be sent to the nuclear medicine department of the hospital and have a procedure where injection of a tracer is placed around the melanoma and imaging is obtained to follow the tracer to identify the sentinel lymph node(s). During surgery your surgeon will have a device that can detect the tracer to help guide removal of the sentinel lymph node(s). These lymph node(s) will be sent to pathology to be examined under the microscope to determine if there is any metastatic melanoma in the lymph nodes.

Head and neck cancers encompass any cancer in the nose, sinuses, throat, larynx (voice box), mouth, and lips (salivary gland, skin, and thyroid cancers are also encompassed in Head and Neck Surgical Oncology but are talked about under their respective tabs above since they act and are treated slightly differently). The majority of head and neck cancers are squamous cell carcinoma which can typically be related to a history of tobacco and alcohol use or can be related to the human papilloma virus (HPV), a sexually transmitted disease. The symptoms associated with head and neck cancer vary by where it is located but can be a mass/lump in the neck, sores/spots in the mouth/throat that do not heal, issues with breathing, changes in the voice, and difficulty with swallowing. When you are evaluated by the doctor for a possible head and neck cancer there are a variety of tests that may be performed including:

• Fiberoptic laryngoscopy: This is performed in the office where the doctor will spray your nostrils with a numbing medicine and insert a tiny camera through the nose to view the throat/voice box area.
• Ultrasound
• CT scans
• MRIs
• PET scans: This is where a tagged sugar is injected in an IV and a scan is performed to look for areas of high sugar uptake throughout the body. Any area in the body where cells are turning over quickly will pick up the sugar and light up on the scan including inflammation, infection, and cancer. The scan is used to determine exactly where in the body the cancer is located.
• Fine needle aspiration (biopsy): This is performed using a very fine needle to take samples (usually a couple of times) of the mass. These samples will be reviewed under a microscope by a pathologist to help get a diagnosis.

At this point you and your surgeon will discuss the findings of the work up and determine what the next best steps for treatment will be for your specific case. Treatment can range from surgery, radiation, chemotherapy with radiation, or surgery followed by chemotherapy and radiation. There are also some possible targeted therapies that may be used if it is deemed appropriate for your specific cancer. Your surgeon will not be the only member of your cancer treatment team there will also be a Medical Oncologist and possibly a Radiation Oncologist along with other therapists/nutritionists. Once your primary treatment is completed you will be given a schedule that will include frequent visits every few months with your surgeon and oncologists. Each year you are cancer free after treatment your appointments will be decreased and at five years after your treatment if you remain cancer free you will see your surgeon and oncologist once a year.