A real case Recently, a young patient from Fujian was admitted to the ward of Xinhua Hospital of Shanghai Jiaotong University School of Medicine, who was a patient of Professor Chu Bingfeng, the chief physician of general surgery. The patient was only 14 years old and in the prime of life, but unfortunately he had thyroid cancer. His parents took him everywhere to seek medical help, from the north to the south, and from all the famous hospitals, and finally decided to ask Professor Chu to save his life. The patient has been successfully operated and is now in the recovery stage. Professor Chu told us that there are so many patients with thyroid disease today that Xinhua Hospital alone performs more than 1,500 surgeries for thyroid disease each year, including 400 to 500 surgeries for malignant thyroid tumors. The benefit of the popularity of medical checkups is that we can detect diseases earlier and treat them in time. Especially for malignant thyroid tumors, once detected early, they can be treated as early as possible to avoid the regret of “small holes not being mended and big holes suffering”. In addition, there are many rumors about thyroid tumor, so are they true? Let’s listen to what Professor Chu said. The reason why there are more and more thyroid tumor patients is that, according to Professor Chu, besides the fact that more and more people are suffering from it because of certain factors, there is also a factor that the detection rate of physical examination is getting higher and higher, which is attributed to the thyroid ultrasound. In the past, medical means were limited and people’s awareness of medical checkups was low, so the detection rate of thyroid tumors was not high, but now that people’s awareness of medical checkups has increased, they can be easily detected through ultrasound, which has a resolution of 2mm and the ultrasound probe can probe horizontally and vertically from all directions, so even small nodules can be easily detected. An experienced ultrasonographer can quickly draw conclusions and grade the nodules. However, “What is the nature of the nodule? Malignant? Benign?” These cannot yet be reflected 100% by ultrasound, so if the ultrasound suggests a thyroid nodule after a physical examination, it is important to visit a surgeon who specializes in thyroid disease and ask them to make a professional judgment. Professor Chu informed that fine needle aspiration biopsy is recommended for all nodules suspected of being malignant. For example, 1) solid hypoechoic nodules larger than 10mm in diameter; 2) thyroid nodules of any size with suspected extracapsular growth or metastasis in the cervical lymph nodes on ultrasound; 3) nodules with irregular boundaries, burr-like, tiny calcifications or disturbance of blood flow signal within the nodule on ultrasound, although less than 10mm in diameter. These nodules require further fine-needle aspiration biopsy. Currently, needle aspiration cytology of thyroid nodules is the most accurate and cost-effective method to evaluate the nature of thyroid nodules before surgery. Besides that, is there any significance of CT thyroid examination? Prof. Chu informed that CT is not used as a routine thyroid examination, but CT examination can allow the surgeon to understand the location of the patient’s tumor and the relationship with the surrounding nerves and trachea before surgery. Eventually, the nature of the patient’s thyroid tumor will be clarified and postoperative paraffin section pathology will be done. Whether iodized salt and radiation can cause thyroid tumor For a long time, there are rumors that the high incidence of thyroid tumor nowadays is related to iodized salt. Therefore, in clinical practice, many patients ask: “Is the reason why I have thyroid tumor related to the consumption of iodized salt?” However, Prof. Chu pointed out that high iodine intake can indeed cause thyroid tumors, but the claim that “iodized salt causes thyroid malignant tumors” has been rejected, and the iodine content in iodized salt is not enough to cause tumors. The occurrence of thyroid tumors is related to genetic factors, autoimmune and mental factors, and people who work under high stress and are under long-term stress also belong to the high-risk group. The conclusion that taking iodine supplementation intervention can transform thyroid malignant tumors to low malignancy has been widely accepted recently. In addition, how to eat iodized salt for patients who already suffer from hyperthyroidism (hyperthyroidism for short) or hypothyroidism (hypothyroidism for short) is also a matter of concern. Professor Chu said that hyperthyroidism and hypothyroidism are problems with hormone metabolism, and iodine is involved in the synthesis, transport, secretion and excretion of thyroxine. So if there is too much iodine, then too much thyroxine is synthesized, the thyroid gland can’t control it, it is secreted directly and becomes hyperactive, so hyperthyroid patients should limit the consumption of iodized salt. If the iodine is too little during puberty or pregnancy, the thyroid gland will swell up because of the inability to synthesize thyroxine, so the intake of iodine should be increased. In addition to the problem of iodized salt, there are rumors that “nowadays, there is radiation everywhere and radiation can cause thyroid tumors.” Is this true? Professor Chu said that the radiation that we can come into contact with everyday, such as cell phone radiation and computer radiation, these will have little effect on the thyroid gland. Radiation that can really cause thyroid tumors, such as (1) radiotherapy treatment for patients with head and neck tumors, for example; (2) radiation caused by nuclear leakage. We should wear a lead scarf to protect our thyroid gland when we do CT during medical checkups and even when we have teeth extracted for taking pictures. In addition, do not go to areas where nuclear leakage has occurred. Do thyroid tumors always require surgery? Professor Chu has also met many patients who have done their homework beforehand, and they have looked up a lot of information. These patients would often ask, “Does it have to be surgery?” Professor Chu informed that there are four main types of thyroid cancer: 90% are papillary carcinoma, a few are follicular carcinoma, even fewer are undifferentiated carcinoma, and there is also medullary carcinoma. Undifferentiated carcinoma is highly malignant, usually occurs in the elderly, and most of them have a survival period of less than one year. The vast majority of thyroid tumors do survive for 5-10 years with tumor, but after this period, the difference between operated and unoperated tumors becomes very obvious. If the cancer cells metastasize through the bloodstream, for example, to the lungs, lung failure will occur, and in some cases, the whole body will metastasize, which will cause the patient’s death; or if the cancer is not operated, the thyroid cancer will become bigger and bigger, and affect the surrounding organs, and the trachea and esophagus will be rotten and worn out, which will be more troublesome. Therefore, once a malignant thyroid tumor is suspected, it should be removed by surgery as soon as possible. Surgery is the main treatment method for thyroid tumors at present. Professor Chu said that although thyroid surgery may not seem big, it is a delicate job that requires doctors to do their best. In addition to removal of the tumor, preventive or radical clearance of the surrounding lymph nodes is required. The cervical lymph nodes around the thyroid gland can be divided into 7 groups, and the 6th group is the closest to the thyroid gland, so it is also called “outpost lymph nodes”, where metastasis is most likely to occur. Intraoperative lymph node imaging will be performed with reagents to see if there are metastases in the sentinel lymph nodes. If the preoperative ultrasound already indicates metastasis, then it must be cleared. If the ultrasound does not indicate metastasis, then the lymph nodes that are visualized are cleared prophylactically during surgery. If the lymph nodes have already metastasized laterally, then the surrounding lymph nodes should be cleared and radical clearance should be done. Professor Chu said that during the surgery, nerve and parathyroid gland protection should also be taken into account. Surgery on the thyroid gland can very easily injure the nerves and parathyroid glands, and these injuries can be very traumatic for the patient, so it is important to avoid miscutting. This requires that the patient must find a specialist physician for treatment. In clinical practice, some patients also ask: “Is Chinese medicine treatment effective?” Or: “Is ablation surgery better?” Professor Chu said that some Chinese herbal medicines with the effect of dispersing stasis and resolving nodules can indeed treat small tumors, but some substantial tumors are difficult to be eliminated by Chinese medicine. At present, it is believed that those suspected tumors should still be removed surgically. Ablation therapy for thyroid tumors is a method, but it is not currently used as a routine treatment. Professor Chu believes that this method may be more suitable for patients without surgical indications, such as those with poor cardiopulmonary function, older ones, and those with advanced tumors that cannot be treated surgically. Of course, ablation itself also has certain indications. In conclusion, Professor Chu reminded that when choosing a treatment method, we should listen to the opinions of thyroid specialists and choose the best one for our own situation. The Chinese people are very concerned about food, especially about the diet after the disease. Often, tumor patients will ask Professor Chu, “Am I not allowed to eat what I have been given? Can’t I eat any seafood?” Professor Chu said, in fact, there is no complete contraindication to the post-operative diet. As mentioned before, iodine intake is different for patients with hyperthyroidism and hypothyroidism. Patients with hyperthyroidism should consume less iodine and iodine-rich foods are contraindicated, while patients with hypothyroidism during puberty and pregnancy should consume more iodine. Patients with malignant thyroid tumors will be required to take medication after surgery until they become mildly hyperthyroid, so iodine intake should be properly controlled during this time. In some patients, the parathyroid glands are damaged by surgery, and there may be problems with calcium regulation. In addition to therapeutic calcium supplementation, diet should include more calcium-containing foods until parathyroid gland function is restored and blood calcium regulation is normal, so that patients can pass through this period comfortably. It is also rumored on the internet that cruciferous vegetables such as cabbage, rape, mustard …… are not allowed to be eaten by thyroid tumor patients. Professor Chu said, in fact, a little of these vegetables will not have much effect. In conclusion, Professor Chu believes that as long as the thyroid gland function is normal for thyroid tumor patients, then there is no absolute taboo on diet, and a balanced diet is the most beneficial to the body. The thyroid gland is also an emotional regulating organ, so a depressed mood is not good for it. Finally, Professor Chu reminded that for patients with thyroid tumor, regular follow-up is the most important. Whether patients have been operated or not, it is important to visit your primary care physician regularly. Regular follow-up can detect whether the thyroid nodules have changed in time and provide the best time for further treatment.