When to take a biopsy

• 1) When the thyroid nodule is large (more than 1cm, more than 1.5cm for cystic tumors)
• 2) When cancer is suspected by imaging tests
• 3) When lymph node metastasis is suspected

1) Fine Needle Aspiration

It is the most important test for nodules. In a real time, a needle is placed in an area considered as a nodule while a radiologist is monitoring the ultrasound imaging . A negative pressure can be applied to obtain cells in the nodule.

2) Total biopsy

If the sample taken from the fine needle aspiration is not enough or the diagnosis is not certain, the core needle biopsy can be conducted to obtain sufficient amount of tissue and to make a reliable diagnosis. In our clinic, a core biopsy is performed immediately once considered that the sample of the fine needle aspiration is not sufficient.

CT / Magnetic Resonance Imaging (MRI)

CT / Magnetic Resonance Imaging (MRI) is necessary to diagnose the stage of breast cancer or metastases to the lymph nodes at armpits. It provides better clear images, which is superior to ultrasound images. A patient is not exposed to radiation. Daerim St. Mary's Hospital uses Ingenia CX 3.0T MRI equipment manufactured by Philips. It helps save examination time and microscopic lesions can be identified with high-quality images.

Nuclear Medicine to Scan Thyroid

• 1) Differential diagnosis of hyperthyroidism, hypothyroidism, and thyroiditis
• 2) Diagnosis of thyroid nodules
• 3) Diagnosis of metastasis before/after surgery
• 4) Diagnosis of parathyroid adenoma or hyperplasia

Treatment for Thyroid

Treatment of Hyperthyroidism and Hypothyroidism

There are three methods for hyperthyroidism treatments : antithyroid drugs, surgery, and isotope therapy. For Graves disease, antithyroid drugs are preferred as a primary treatment, but it is also a good treatment method to take an isotope treatment or a surgery since Graves disease is difficult to control with drugs and it has the high frequency of recurrence. It usually takes at least several weeks to see the effect of thyroid medications and several months to see the thyroid workingproperly. For hyperthyroidism, even though the thyroid works properly, it is likely to occur again once the medication is early stopped, so a long-term period of administration should be considered. If the patient takes the medication inconsistently or irregularly, the treatment period will be getting longer and the medication does not respond effectively. For hypothyroidism, the thyroid hormone is administered to maintain the level of thyroid hormone to the same level as in normal people, but it takes a long time to see the effect.

Treatment of Thyroid Nodules

Benign nodules are usually monitored periodically for changes. When the lump is found larger than 3cm, it causes a cosmetic problem, you feel pressure or pain in the neck due to the lump, or the lump grows even afterthe medication administered, it is recommended to remove it surgically or take the thyroidectomy with radiofrequency ablation. Once it is identified as a malignant nodule, taking a surgery can be the best treatment.

Radiofrequency Ablation (RFA)

It is a method to remove the tumor by using heat while a doctor monitors the ultrasound and places a thin needle (high frequency electrode) inside the thyroid tumor.

- When toperform the procedure (Benign Tumor)

• 1) When a thyroid tumor causes someissues related to a patient’s appearance
• 2) When a tumor causes pressures on the nerve or pain
• 3) When a small lump grows more than 3cm

- Advantages

• 1) General anesthesia is not required and the procedure can be performed in a short time.
• 2) There are no scars at all.
• 3) It can eliminate only targeted tumors and leavethe normal thyroid gland intact.
• 4) There are very few side effects.

- Disadvantages

• 1) The tumor is not immediately removed after the treatment, but the size is gradually reduced.
• 2) It can occur again in the possibility of 1~2%
• 3) It has not yet been applied to cancer.

Ethanol-based Tumor Ablation

This method is mainly used when the thyroid nodule is a cystic nodule. After extracting all the nodule content, 99% pure ethanol is injected into the nodule so that the tumor cells in the nodule can be regressed.

Traditional Thyroid Surgery (open surgery)

As one of the most commonly used surgical methods, a doctor performs about 5 cm skin incision in the middle of the neck.

- Advantages

• 1) Easy to see the targeted surgical area
• 2) Easy to perform cervical lymph gland dissection
• 3) Easy to detach nerves when tumor invadesnerves

- Disadvantages

• 1) Scar remains in the middle of the neck
• 2) After surgery, a patient can undergo skin swelling, paresthesia in anterior triangle of the neck, foreign body sensationcaused by adhesion in the neck

Endoscopic Thyroid Surgery

Endoscopic thyroid surgery is a surgical method which uses an endoscope through an incision in the armpit or areola area, avoiding the incision in the middle of the neck. Both areola incisions and axillary incisions are largely performed.

- Method (AxillaApproach)

To perform axilla approach, it starts from 5 to 6 cm skin incision at axilla (armpit) followed by approaching the space between the sternum and the clavicle at sternocleidomastoid muscle. After dissecting the underside of the scapular muscle to have the thyroid gland exposed, a surgeon inserts a retractor and performs an operation using an endoscope.

- Indication (Adaptation)

At the beginning, Endoscopic Thyroid Surgery highly was applied to well-differentiated cancers less than 2 cm and follicular tumors less than 5 cm without obvious invasion at thyroid capsule. However recently, the target group has been expanded towell-differentiated cancer T3 lesions, benign tumors 5-8 cm in size, and Graves disease.

- Advantages

With a lateral approach through axilla, Endoscopic Thyroid Surgery does not leave a scar on the anterior part of the neck. A lymphectomy in the middle of the neck can be completely performed. Compared to open surgery, it has more advantages as the upper laryngeal nerve can be checked and saved. It lessens pain, discomfort, and numbnesswhich can be caused by fibrosis and skin adhesion at the anterior part of the neck.

- Disadvantages and Exclusions

Relatively, it takes time longer than open surgery. It is not recommendable for the case that either thyroid gland itself or tumor is too large to secure space. Also, even if the lesion is small, the endoscopic thyroid surgery cannot be the option for the patients when the lesion is near the posterior capsule of thyroid gland and there is a possibility of invasion to airways, esophagus, and recurrent laryngeal nerves.