More Research--Thyroid Cancer

Waiting for the biopsy results is an agonizing period. No one wants cancer. Normal cells stop growing when they touch each other. Essentially, a cell multiplies by cloning itself, and when the space is full, the cells don't multiply. Imagine if cells did not have the ability to tell when they should stop multiplying. We would be a blob of goopy cells, dragging all over the floor with no shape.

Cancer is when cells touch and don't know to stop multiplying. The problem in our body is not that we have cancer itself. Cancer is just cells. They are not poisonous or carnivorous cells that eat other cells. The problem is that this mass of cells may grow too large and disrupt the normal processes within our body. Look at it another way. If cancer grew on your skin and grew out, never touching anything inside, you might be funny looking, but your heart, lungs, brain, glands and organs would all be able to function normally.

Well, cancer does not just grow outward. It grows wherever the cells lodge. If a single cancel cell lodges in the lung, and then starts to multiply, it will eventually get large enough to where it starts to interfere with your breathing. Too much cancer in a certain spot in your body will eventually cause the organ or body part to stop functioning--leading to additional illnesses or death.

So, I can have thyroid cancer and some of the thyroid cells in my neck slough off, and then they travel through the lymph nodes or bloodstream and get lodged in my tongue, my toe, my heart, my bones, my brain or my lung. The interesting thing is that this thyroid cancer cell, that may be now growing inside my lung, is not called lung cancer, but thyroid cancer within the lung. The bottom line is the type of cancer depends where the cancer cell came from.


There are five main types of thyroid cancer:

• Papillary cancer
• Follicular cancer
• Medullary cancer
• Anaplastic cancer
• Thyroidlymphoma

The following information if from the Mayo Clinic with some editing by me to make it more simple to understand:

First, every enlarged thyroid is not cancer. In fact, about 80% of all enlarged thyroids or even bumps or nodules on a thyroid are just benign growths--that cause no harm. Many doctors will not even want to perform surgery, if there is no cancer and the thyroid is working properly.

Papillary cancer

This is the most common type of thyroid cancer. About 80% of the thyroid cancers out there are papillary. You often hear about the "good type" of thyroid cancer, as if there is ever a good cancer. It develops from thyroid follicle cells and usually appears as a single mass in one lobe of the thyroid. Anyone, including children, can develop papillary cancer, but it's most common in women who are between 30 and 50 years of age.

Although most papillary cancers grow slowly, they often spread to the lymph nodes early in the course of the disease. This usually doesn't affect the outlook for recovery, which is generally excellent when the cancer is small and its spread limited to the lymph nodes in your neck. The prognosis isn't as positive for people with very large tumors or in the rare cases when papillary cancer has invaded tissues other than the lymph nodes. But even papillary tumors that have spread to the lungs or bone often can be successfully treated with radioactive iodine (radioiodine).

Follicular cancer

This type of cancer is more aggressive and affects a slightly older population than does papillary cancer. Follicular tumors don't usually spread to the lymph nodes but are likely to invade the veins and arteries within the thyroid. From there, they may spread to organs such as your lungs and bone. A variant of Follicular cancer is a more aggressive form, called Hurthle cell cancer. Hurthle cell cancer is rare, representing about 1-3% of thyroid cancers.

Medullary cancer

Rather than arising from follicle cells, this type of thyroid cancer develops in calcitonin-producing C cells. Medullary cancer may spread to the lymph nodes or other organs before a lump is detected or blood tests show an increase in calcitonin or CEA, which is produced by the cancer cells.

There are three main types of medullary cancer:

1. Sporadic. Sporadic tumors make up the great majority of medullary cancers. They primarily affect people between the ages of 40 and 60 and are not inherited.

2. Familial. Familial medullary cancers are inherited, but unlike MEN 2 cancers, affect only the thyroid gland. They are usually slower growing than MEN 2 tumors, and they primarily affect people who are in their 40s and 50s.

3. Anaplastic cancer (anaplastic carcinoma)This rare form of thyroid cancer is sometimes called undifferentiated cancer because it looks very different from normal thyroid tissue under a microscope. It appears to develop from an existing, undiagnosed papillary or follicular cancer. Anaplastic cancer is extremely aggressive, spreads rapidly to the lymph nodes and trachea, and then to other organs, especially the lungs and bone. For that reason, it's often not curable surgically by the time it's diagnosed. Unfortunately, other therapies, such as radiation, aren't usually successful in controlling anaplastic cancer.

Thyroid lymphoma

This rare type of cancer doesn't develop from thyroid follicular cells or C cells. Instead, it starts in immune system cells called lymphocytes. Although most lymphomas begin in the lymph nodes, some occasionally appear in other organs, such as the thyroid.

Research--so what is the thyroid anyway?

I went home thinking now is the time to learn more about the thyroid and the different types of cancer.

The thyroid is a butterfly shaped gland in your neck, underneath the Adam's apple or larynx. At its normal size, it is less than an ounce, about 10-20 grams in an adult. It is made up of two halves, called lobes, that lie along the trachea (your windpipe) and are joined by a narrow band of thyroid tissue, known as the isthmus.

What does the thyroid do?

The thyroid takes iodine and converts it into two hormones: triiodothyronine and thyroxine, often referred to as T3 and T4. (The “3” and the “4” are related directly to the amount of iodine molecules which are used to create these hormones.). It also produces something called Calcitonin.

The function of the thyroid gland is to take iodine, found in many foods, and convert it into thyroid hormones. Thyroid cells are the only cells which absorb iodine. The thyroid cells combine iodine and the amino acid called tyrosine to make T3 and T4. The T3 and T4 are then released into the blood stream throughout the body where they control metabolism---the speed at which your cellular functions work.

If your thyroid gland does not make enough of these hormones, you will be hypo-thyroid, gain weight and lack energy. If your thyroid gland makes too much of the T3 and T4 hormones, you will be hyper-thyroid, will lose weight and have an increase in your appetite, and may feel agitated.

Calcitonin works with another hormone called parathyroid hormone. This is made by glands called the parathyroid glands, which are behind the thyroid gland and are attached to it. If you have your thyroid gland removed, the surgeon will try to leave the parathyroid glands intact. Your parathyroid glands can be affected by the operation and take a while to get back to normal. So, your doctor may ask you to take supplemental calcium for awhile, after your surgery.

The Fine Needle Biopsy

A fine needle biopsy (FNB) also know as a fine needle aspiration biopsy (FNAB) is just what it says--cells withdrawn from your body using a very fine needle. An alternative to a fine needle biopsy would be a core needle biopsy. The core needle is like taking the core out of an apple, but not quite that large. It is obviously a larger sample. The other main type of biopsy is surgical biopsy where the surgeon actually removes all or part of the area, which could be an organ itself, like the thyroid. In any case, the purpose of the biopsy is to remove cells, so they can be analyzed to determine if there is a malignancy in the tumor.

I laid back on the exam table at Dr. Wotten's office. Dr. Wotten said I had to make my thyroid pronounced to make the fine needle biopsy easier to obtain. I did this by laying my head back off the edge of the table and then arching my neck and back. Dr. Wotten helped by putting a couple of pillows under my head. It was uncomfortable in this position. The thyroid was already obviously enlarged, pushing on my esophagus, making it hard to breath, and to talk. My voice was already much deeper than it should be, but friends and family had become used to my voice and thought it was normal. Like flexing a muscle, I was doing the same thing with my thyroid, making it even more difficult and uncomfortable. In addition, I was anticipating a needle piercing my neck several times, so, mentally, at least on the inside, I was a little shaken.

Dr. Wotten said he was first going to numb the skin area by rubbing lidocaine over my neck, which he did. Unlike the numbness you feel when you obtain anesthesia from the dentist and have a have a cavity filled, the numbness from the lidocaine was minimal. Not knowing what pain I would feel from the fine needle were greater, but there was not much I could do, or say, at at that time. Dr. Wotten turned to a table behind him and grabbed a syringe. That's when I saw that "fine needle" that was going to be stuck in my neck. It was very fine. Almost invisible, but it was also very long. Yikes! But, being raised to be tough, I just bit my tongue and did not say a word.

Dr. Wotten leaned over my neck, and said. You are going to feel a small prick. Trying to lighten the situation, I said "not today thank you". I am not sure if he ever figured out the connotation I was referring to--he never laughed, so I just shut up and allowed the procedure to begin.

It was indeed a small prick, but most of the pain was just the discomfort because of the pressure on my neck and thyroid. The needle was inserted fairly deeply and then Dr. Wotten wiggled it around slightly in an attempt to dislodge cells from my thyroid and then withdraw them through the syringe. After about 10 seconds total, the needle was withdrawn, with part of me inside the syringe.

Then, Dr. Wooten did this again. And again. He said "Just a few more times, and we will be done." I said "a few"? The word "few" is one of those terms that can mean from 3-12 to some people. I asked--"How many is a few?" Dr. Wotten said "three more". This meant that in about a minute, I would be done. Each time, the needle was inserted, it was wiggled around, and then withdrawn.

Done. Finally. Then, I sat up, realized that I was dizzy and needed to sit there for a few minutes to recover. Dr. Wotten helped me to a chair outside, where three other people who had FNBs were sitting. Each one held a cold pack next to their neck. I joined the crowd and did the same. Dr. Wotten said we needed to wait for about 15-20 minutes to make sure the bleeding had stopped and that we would be OK to leave.

It made me feel comfortable seeing other people who just had a FNB. Hey, I thought--maybe this thyroid thing is common. I was thinking that here I was, with three other people who had the same procedure on the same day--the same hour.

In about fifteen minutes, Dr. Wotten visited me, took a look at my neck and said "you are free to go. I will call you in a few days with the outcome".

The Drive Home

My home is Jasper is in the north Georgia mountains about 60 miles north of the Atlanta metro area. We moved there on December 23, 2006 to get away from the stress, traffic and high-paced life of a major metropolitan area that I had been in all my life.

On the way home, I called my wife Kim and my parents and told them that everything was OK, and that I biopsy was scheduled for the next day. Silence. Dread. No one wants to hear the word biopsy. Cancer is really not known in my family. It is something that other people have. I told everyone that is just precautionary--cancer of the thyroid is very rare. A goiter, or the growth of a thyroid is common--with many people having a minor growth, living with it, and never even knowing their thyroid has grown. 80% of all goiters are benign. With my family history, I would likely be one more in the family to not have cancer. I was not worried. The thyroid had been large for years. My internist, Dr. James Capo, at a large medical practice in Atlanta, had never even mentioned that my thyroid was enlarged, so I was sure it would not be cancer.

Ultra Sound

I went into a small room with just enough room for a small exam bed/table and the ultrasound equipment. A technician in her 30's came in and said that the exam would only take a few minutes. She asked me to lay back, and arch my neck back, essentially by putting my head off the table. This was so the thyroid would be stretched out. She then put ointment on my neck and then touched a blunt probe hooked to a computer to my neck. She scrolled up and down and across my neck. Occasionally, should would stop, press a button on the equipment and out would come a Polaroid picture. She took picture after picture.



Dr. Wotten walked in and looked surprised. "You took all those pictures?, he asked.". She commented simply "yes". This was not a good sound to me. OK. So she takes 15-20 pictures of my thyroid and he thinks this is a lot. Why? Maybe because of the big size? Maybe because she sees something that she thinks is important? Something bad?



Dr. Wotten said--"Steve, we need to do a fine needle biopsy. I want to see if this is cancer." My mind started to get fuzzy. So, why the concern now? What did he see? So I bluntly asked: "What do you see?" "Well, Steve. This is big. It is a multiple of the size of a normal thyroid and when they get this big, there is a chance it is cancer. But, in most cases, they are benign--we just want to be sure." Dr. Wotten asked if I could return the next day to do a fine needle biopsy. A fine needle biopsy is when he takes a very thin needle on a syringe and inserts it into my thyroid at several points, to withdraw some cells. The cells are then biopsied to determine if the growth is malignant or not.

Talking to an endocrinologist

I had never been to an endocrinologist before. I arrived at the office and walked in to the waiting room of mostly elderly people. I thought--"OK, I am the young guy here." I am the one who is going to leave smiling, after the doctor tells me I am too young to have anything wrong with me.

I waited for the doctor in one of the treatment rooms for a few minutes, reading a few brochures about hyperthyroidism and diabetes. Dr. Wotten (sounds like Cotton) walked in an sat in a chair about 10 feet from me. He did not have to come closer. "You need to have that removed" is all he needed to say. I replied "So, it is big, huh". "Yes", he said. "Have you ever been exposed to radiation?", he asked.

Great. I have known this guy for 10 seconds and he is so astonished by the size of my thyroid that he thinks I was exposed to a nuclear blast or something. This is not a good sign. I had gotten used to my big thyroid slowly growing over the years, so much so that I must have forgotten what I looked liked when it was the normal size. I replied to him "Nope. Never exposed to radiation." "Well, that's one of the biggest ones I have seen. It will continue to grow and it needs to be taken out".

Before the appointment, I had been on the Internet and read about the thyroid. Normally, it cannot be seen from the outside of your body. It is usually the size of a a shot-glass, shaped like a butterfly, lying beneath the Adam's apple. The thyroid produces a hormone called Thyroxin, the helps regulate bodily functions like heart rate, metabolism, and body temperature. People with too much thyroxin generally can be overactive, high-paced, and maybe underweight because of their increased metabolism. People with too little thyroxin might be the reverse. In fact, a lot of people with weight control problems would often blame the thyroid for their weight gain. Dr. Wotten said the first thing he wanted to do was to test my blood to see how much thyroxin hormone my thyroid was producing. I would either bee euthroid (normal), hyperthyroid (too much) or hypothyroid (too low). He said that in many cases, the thyroid can be huge, but still produce the correct amount of thyroxin. He went on to explain that the thyroid is told how much to produce by another gland in the brain, called the pituitary. The pituitary gland detects the amount of thyroxin in the blood and creates a hormone called thyroid stimulating hormone (TSH) that tells the thyroid when to turn on or turn off, as my body needs more thyroxin. The bottom line is my thyroid can be giant, like it is, but I would still have the right amount of thyroxine hormone.

I had a few questions:

1. Why would the thyroid be so big?
2. If it is producing the right amount of thyroxin, why take it out?
3. Do I have to remove the thyroid now (versus a year from now)?
4. What is involved in the surgery?
5. What is involved with replacing the thyroid hormone, assuming I had no thyroid anymore.


Dr. Wotten explained that the thyroid could have grown because of exposure to radiation, the lack of iodine in my diet (which is virtuallly impossible in the US, but is common in underdeveloped countries), genetic factors (I have no family members with this problem) or because of cancer. Cancer? Not what I wanted to hear. But then, cancer was rare. Thyroid cancer is one of the rarest out there. Plus, I had no family history of thyroid cancer, or cancer in general. It would be very unlikely that I would have thyroid cancer.

He said that the growing thyroid would not stop growing and it could eventually make it difficult to talk, swallow or even breathe. Well, I had already experienced the difficult to breathe problem. And, after thinking about it, my voice would often be hoarse at different times of the day, especially after exercising. I now realized that my giant thyroid was probably the root of these problems.

As far as the surgery, it said it was "outpatient". Can you believe that? Remove an organ and go home the same day? That made me feel good. Anything that could be done on an outpatient basis could not be too bad. Think about it--you arrive at 11:00 and are on your way home at 3:00. This was good to hear.

We spent a few minutes talking about replacement thyroxin. My thyroid would be gone, and I would just take a pill to replace the hormone. Simple. I just hate the fact that I would be dependent on taking a drug every day for the rest of my life. What would happen if there was a war? What happened if the world fell apart and I could not get my medicine? Those thoughts were truly what I was thinking. "So, doc. What happens if I don't take my pill"?, I asked. " You will be hypothyroid and start slowing down, and gain weight.", he replied. "No, I mean really stop taking it--I just don't take it again.". "Oh", he looked a little confused. "Well, after about three months, you die". Got it. (I went home that night, looked online and found a year supply for about $800. Note to self: In event of nuclear war, immediately place order for 10 years of thyroxin. Before they nuke the manufacturer. )



The blood was drawn by a nurse and Dr. Wotten came back in with one more comment. "Steve, before you leave, we want to do an ultrasound. Your thyroid is very big and we want to take a look and see how invasive the growth is and to get a better look at the size." OK. We can do the ultrasound. Dr. Wooten had said it was most likely benign--it turns out that thyroid cancer is rare, so, no problem if they wanted to take a look inside, from the outside--go for it.

That's when things started to get interesting....

October 2007--First signs

I woke up in the morning unable to breathe. My throat was sore, and laying back flat in my bed, it felt like my throat had collapsed. My throat did not hurt too much and I have had a few sore throats over the past ten years, but something was different this time. Had my throat collapsed? Did I eat something that caused my throat to swell? I could not even swallow.

I went into the bathroom and stared at myself in the mirror. Suddenly, I could breath again. What happened? Why could I breath when standing but not while laying down?

One year earlier, I had moved to the small mountain town of Jasper, Georgia, about 60 miles north of metro Atlanta. I had visited my Atlanta internist, Dr. James Capo, about three months earlier for something else. This time, because of the pain and my trouble breathing laying down, I thought I would visit a local Jasper doctor to check out my sore throat. I wanted to be able to sleep better that night.

The appointment at the doctor's office was about 10 minutes from my home. Like most modern physician offices, a physician's assistant did a lot of the work. The assistant came in and listened to me complain about not being able to breathe, hoarseness and a sore throat. She stuck a tongue depressor in my mouth, and said that I had a minor irritation and prescribed an antibiotic. She was somewhat concerned that I had trouble breathing and she sat back, looked at my face and neck and said "You know you have a goiter and you should check it out". Now, being a biology major 25 years ago in college, I remembered the term "goiter", and I remember it being an "enlargement" but an enlargement of what?

I went home, looked at my neck and at this "goiter". Nothing looked different on the outside from what I normally see. I looked the way I did several years ago, except for a few more gray hairs. I did see an enlargement, a swelling around my Adam's apple. Was this the goiter? It had been there for a number of years. Pretty obvious. But nothing to worry about, right? Dr. Capo doctor never said anything about it, so why worry? Being 48, I thought this was just something that happened with age, as I put on a few extra pounds over the years. I kept in shape, but at 180 pounds, I was about 1o pounds more than I felt I should be.

Next step--go to the Internet and look up "goiter".

Goiter: An enlargement of the butterfly shaped thyroid gland, at the base of the neck, under the Adam's apple. The enlargement can be benign or malignant--cancer. Uh oh. Warning sign.