>> You don't miss your water until the well runs dry, and you don't appreciate your endocrine system until it starts to act up.

Stay with us as we talk with endocrine surgeon Doctor George Taylor about surgical treatment for endocrine disorders.

Next, on Kentucky health.

>> Kentucky health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> The endocrine system is comprised of a series of glands that are nestled in, confined and out of the way spaces in our brains, necks, abdomen, and pelvis.

These glands produce hormones which regulate bodily functions as diverse as blood sugar levels, response to stress, reproduction, growth, and general homeostasis or well-being.

Dysfunction of these glands, as characterized by either an over or underproduction of these hormones, results in disruption of normal bodily functions, albeit rare.

Endocrine glands.

Like other organs and structures in our bodies, do develop benign and malignant tumors.

The most common type of endocrine cancer is cancer of the thyroid, with about 64,000 cases being diagnosed each year.

Though the number of endocrine cancers remains low, the number has been increasing.

This increase is thought to be a consequence of several factors, including an aging population.

Incidental findings on other diagnostic tests, increased awareness, chemical pollutants, and better diagnostic tools.

Surgeries is one of the options in the treatment algorithm thanks to advances in technique.

When surgery is required to, survival and functional outcomes has improved.

To discuss the surgical treatment of endocrine neoplasia, we have as our guest today, Doctor George Taylor.

Doctor Taylor earned his bachelor's degree at Hamilton College, his Master of science at Drexel University College of Medicine, and then his medical degree from the School of Medicine at the State University of New York at Stony Brook.

After completing his residency in general surgery at Temple University Hospital, he then did a fellowship in endocrine surgery at the Medical College of Wisconsin.

Doctor Taylor is an assistant professor in the Department of Surgery at the University of Louisville, and specializes in endocrine surgery and surgical oncology.

Doctor Taylor.

George, thanks for being with us today.

>> Thanks for having me.

>> What got you interested in surgery?

>> It was, I guess, an experience that I had as an undergrad.

I did an internship as a nurse's aide at a rehabilitation hospital, really helping patients get in and out of bed as they recovered and rehabilitated from orthopedic surgery and from strokes.

I felt extremely gratified by physically helping patients in their recovery process.

And I had that same gratification again when I was on my surgery rotation in medical school, I felt doing things physically for my patients and watching them be cured was extremely gratifying and what I wanted to do with my life.

>> I'm sure when you talk to your medicine colleagues and you use the term I like to cure people as opposed to treat them, I'm sure they're real happy about that.

We'll keep that between ourselves.

Okay, so what are endocrine glands?

>> Yeah.

So endocrine glands are defined as a group of cells that send out hormones into the bloodstream.

Chemical messengers that regulate the other tissues throughout the rest of the body.

The biggest ones that come to mind are the thyroid the parathyroid glands.

The adrenal glands are the ones that I can surgically treat.

There's also the pancreas and the pituitary.

>> Where are these things located?

>> So the pituitary you mentioned earlier, nestled in in the brain, inside the skull, near the base of the brain, the pancreas in the middle of the abdomen, thyroid and parathyroid in sort of the base of the front of your neck in front of your windpipe.

And the adrenal glands sit on top of your kidneys.

>> So tell me about the thyroid gland.

You said it's up here in our neck, but what does it kind of some of the functions that it does.

>> Sure.

It has a sort of a broad reaching control hand in various metabolic processes.

Your heart rate, your body temperature, your weight and your energy level.

It doesn't directly control all of those things, but it helps monitor them and make sure they're all doing the right things at the right time.

>> And then the parathyroid glands.

Now I'm going to assume para meaning around.

But they're also they're near the thyroid.

>> Yes.

Correct.

What I like to tell patients is while they're named the same as the thyroid gland, they have nothing to do with that function.

Okay.

It would be as if, I guess the police station and the school, you know, we know what they do, that they do separate jobs.

But the parathyroid gland, it would be as if you named the police station the next to the school building instead of the police station does completely separate things.

The parathyroid controls your body's calcium levels within your bloodstream, but not as, as as closely related to the thyroid as it.

>> But they're right there behind the thyroid gland, right behind it.

>> Most people have four of them.

They're there, two on each side, directly behind the thyroid gland.

>> Now, the adrenal glands, where are they and what are they up to?

>> Yeah.

You have two adrenal glands.

They each sit on top of your kidney.

And similar to the parathyroid and the thyroid, they do not really control anything to do with your kidney.

They secrete a various slew of hormones.

Yeah I can go through them if you like.

Sure.

The I guess the innermost part of the adrenal gland produces your fight or flight hormone or adrenaline.

>> Okay.

>> What it's named after, it's for very quick bursts of, of stress to your body so that you can get out of danger quickly.

That hormone adrenaline will give you laser focus, will increase your heart rate and elevate your blood pressure, like I said, so you can get out of danger quickly.

It also secretes a hormone called cortisol, sort of a preparatory hormone.

For the next time you're under a lot of stress, maybe you can run faster for longer, but it does do that by increasing the amount of blood sugar in your body can also, sorry, in your bloodstream, increasing your blood pressure, mobilizing your fat stores, and having you distribute your fat in different ways.

The next set of hormones are sex related hormones or DHEA.

Sulfate is the one that's mostly produced by the adrenal gland.

It has a precursor to testosterone and estrogens that, you know, make males well.

>> That's a lot of stuff from this one little.

And it has nothing to do with the kidneys, though.

No relationship to the kidney function.

>> Yeah.

The last hormone I'm going to mention.

Oh sorry.

Aldosterone works hand in hand with the kidney to regulate.

>> So it does have some relationship.

>> Right okay.

Right.

But from far away right.

It just secretes this hormone into the bloodstream to help regulate the amount of salt and water in your body to elevate your blood pressure.

If you retain salt and water or to decrease, if you allow your kidney to, to get rid of it in your urine.

>> So it seems that these glands, which you've been talking about, even though they may be very close to some other things, they exert their influence throughout the body, not just locally where they are then.

>> Correct?

Yeah.

Through the action of their hormones on target tissues throughout the body, they don't exactly play a direct role except for putting their hormone in the bloodstream and then letting that do its job.

>> It's a heck of a job if you can get it right.

Now.

Let's shift gears a little bit, because I know you, I imagine, work very closely with endocrinologists.

The medical side of handling things.

Correct.

But your area of specialty being endocrine surgeon and surgical oncologist is tumors of the endocrine glands.

How common are these.

>> Yeah.

So it depends on which gland you're talking about.

The three that I treat the thyroid parathyroid and adrenal gland very rare.

You know I guess if we start with the thyroid many people have thyroid nodules.

You know depending on, on on the research you look at, anywhere from 20 to 50 or 60% of people have thyroid nodules.

And and they're really usually asymptomatic.

And they get picked up routinely on scans or radiology, radiology studies done for other reasons.

And a very small percentage, about 10% or less of those are ever turn into cancer.

So it's very uncommon that you have a malignancy of the thyroid.

And then even less common would be that of the adrenal.

>> So when we talk about thyroid, just for a minute, if you don't mind, I want to come through each one of these.

So I mentioned about 64,000 cases of thyroid cancer a year.

Is that a pretty reasonable number if we can hang our hat on to as far as.

>> Yeah, I think over the last, I guess since the last set of guidelines came out from the American Thyroid Association, we've actually been trying to be less aggressive in our work up in treatment of thyroid cancer.

So that number being stable, even though we are, I guess, picking up more cases, we're also being less aggressive because thyroid cancer in and of itself has a very good prognosis.

And we've found as a society that medical society as a whole, in that we've been sort of overtreating thyroid cancer.

A lot of people may have thyroid cancer and not know it and live a perfectly normal life and die of something else other than the thyroid cancer.

So that number, like you said, being stable doesn't surprise me, given the fact that we're starting to become less aggressive in working up thyroid cancer.

>> That's interesting because you know your experience.

I'm sure you mentioned the word cancer to somebody.

And this blank look is going to come over everybody's face.

And now you're going to tell me, oh, we can just sit here and watch this thing.

I really yeah.

>> So I'd like to preface every time, you know, I lay that diagnosis out for a patient that if you are to get any type of cancer.

Yeah, it's a horrible diagnosis to receive.

Yes, but probably one of the best outcomes in cancer survival is papillary thyroid cancer, a subset of thyroid cancer.

And the most common form of thyroid cancer are papillary and follicular.

That's about 90% of thyroid cancers that come up and that number 90%.

That's about the survival rate 20, 30 years out of anybody diagnosed with papillary or follicular thyroid cancer.

It's a very favorable prognosis.

So one of the the best cancers that you can get.

>> Are you more likely to operate on someone with a thyroid nodule or a thyroid cancer?

>> That's a great question.

It depends on a lot of factors, I guess.

More likely on a thyroid cancer, because we know for cancers in the rest of the body, even though thyroid cancer progresses slowly, it will eventually, if not operated on spread and cause problems in the rest of the body.

Thyroid nodules do get operated on even if they're not cancer for various reasons.

You mentioned overactive glands.

Thyroid nodules can secrete increased amounts of thyroid hormone.

That's a reason to to take them out.

If there's no medical treatment that will help, or some of the medical treatments you use for overactive thyroid nodules, you can't be on forever.

Oh, so that's a reason to take out a thyroid nodule.

And then if it's been growing for a while and pressing on your windpipe or your esophagus, your your food pipe causing you problems, swallowing or changes in your voice also a reason to take it out.

>> Is there a fear that one of these nodules may become a cancer?

>> Yes and no.

I would say, you know, we don't we don't know enough about the progression of a of a thyroid nodule to, to become thyroid cancer.

Like I said, very slow, slow growing.

Yeah.

We don't know what triggers any conversion there to I guess papillary or follicular thyroid cancer.

But if they do grow past a certain size, we're confident that the methods that we have to observe it, which would be ultrasound and a biopsy with a needle, sometimes you can get sampling error and you might not be able to get the best picture of what is going on in that nodule.

With the methods that we have now.

So past a certain size four centimeters, usually we recommend it comes out anyway.

>> Gotcha.

What are the in your experience, what are some of the big risk factors for developing a cancer of the thyroid?

>> Yeah, the biggest one would be exposure to radiation.

And that could be from various sources of the most common in the United States would be if you had a head or neck cancer or a lymphoma that required radiation therapy.

I also know some people back back in the day would get radiation for things that weren't cancer, like, you know, acne or other benign skin conditions, occupational exposure to radiation usually has to be quite a hefty dose in order for you to be at risk for thyroid cancer.

But radiation exposure probably the biggest one family history of thyroid cancer.

Some syndromes carry an increased risk.

Cowden syndrome and Werner syndrome, to name a few, and then there are are some chemicals that you get exposed to.

>> In particular ones that we have.

Is it something that we have to watch out for, or the some of the pollutants that we're all going to generally be exposed to?

>> I would say not.

Not necessarily the latter, really in occupations that deal with flame retardants like polybrominated diphenyl ethers, those have an increased risk in the literature.

Again, very rare that people get exposed to those unless they're in industry.

And it's also rare that that does lead to a cancer.

But there is there is an association.

>> Let's change gears just a little bit and we'll talk about how you treat some surgical treatment.

Let's talk about parathyroid.

Now many of us have heard of what I guess bone diseases associated with hyperactive parathyroid.

How common is that?

Is that something that oftentimes requires a surgical intervention?

>> I would say parathyroid disease is only cured by surgical intervention.

>> Only cured okay.

>> But thankfully it is also rare.

Less than 1% of the population gets any sort of parathyroid disease, any sort of primary parathyroid disease.

But yes, you're correct in that if you do have hyperactive parathyroids, they tend to signal to your bones that you need to put more calcium in the blood.

So all that calcium that you've spent years collecting to make your bones strong, it's getting lost to your bloodstream and then your bones get weak.

Leads to osteoporosis and fracture.

>> Wow.

What about cancers of this gland?

I just don't think about that very often.

>> Yeah, I would say that I already mentioned that less than 1% of anybody in the West gets parathyroid disease.

Less than 1% of those people have it due to cancer.

So it is exceedingly rare.

>> Not that common again.

All right.

And let's go to this thing which you really like to do.

Adrenals.

Now you talked about the difference, the three different big types of hormones that are being produced here.

So what about cancer?

I mean a cancer is a common thing that you see down here, or even benign lesions of the adrenal glands.

>> So I would say that about based on our.

Research of radiology, about 6% at most of people have a nodule or a growth on either of their adrenal glands.

And only about 25% of those are things that need to be worried about things that are either hyper functioning, secreting too many, too much hormone.

Yes, or a cancer.

So again, not not very common.

But either of those conditions do need to be treated surgically.

>> You know, it seems to me that since more people have been doing these whole body scans, either a CT scan or an MRI scan, we're having more incidental findings of this.

People say, I want to get a whole scan because I want to see what's going on in my body.

So are we finding more adrenal tumors because of that?

And is that what impact is that having?

>> Sure, I would I think that that 6% number is actually the more recent data.

So even though it may be increasing, how many incidental tumors of the adrenal gland, we're finding it's still a very small amount.

So I wouldn't go out and just get a whole body scan looking for an adrenal tumor.

And again, only 25% of those need to be intervened on.

But if you do have an incidental finding of an adrenal tumor, it should be worked up to make sure it's not overactive and making too much hormone.

These hormones, if they're in excess in your body, do cause long term detrimental effects.

>> But if you're asymptomatic, is it that you're catching something before it causes a problem?

Is that the idea?

>> That is, that is correct.

Long term exposure to high levels of cortisol, which is our body's natural steroid?

Yes.

Weakens your bones, leads to high blood pressure, and could lead to even diabetes as well.

Same thing with that aldosterone, high blood pressure, heart disease.

Same thing with the adrenaline.

You can't you can't have too much adrenaline in your body leads to stroke, high blood pressure.

>> Any particular thing that causes these, either the benign tumors of the adrenal gland or even the cancers, anything we got to watch out for the risk factors.

>> The biggest risk factors are family history.

There are some genetic mutations that are linked with certain adrenal nodules and overproducing adrenal tumors.

Other than that, nothing like thyroid disease, where you can pinpoint exposure to radiation.

There's there's really only the family link or bad luck.

>> When do you decide to operate on somebody who has when these cancers.

>> It's it's a decision that I make with the patient.

You know, like I said, at least for thyroid cancer, slow growing and has a very good prognosis, really whenever you catch it.

So it's usually not an emergency for adrenal tumors.

Sometimes the hormones that are made can make anesthesia unsafe.

So we do have to use some medications leading up to surgery to make sure the body can respond to anesthesia in a predictable way, so that we're not doing more harm than good by putting someone to sleep right before surgery.

>> Wow.

Tell me about techniques.

Used to be you operate on somebody's thyroid, you make this big long incision, you're going to do the adrenal and make a big cut back here.

What are you doing nowadays?

>> Yeah.

So I guess for thyroid disease, I could say that for surgery, I do use the traditional open incision there.

There are several centers in this country that do minimally invasive but distant access thyroid surgery.

So they can make small incisions in your mouth or in your armpit and sort of tunnel a great distance towards the thyroid and take it out that.

>> Way, taking the long way around to get to correct.

I don't get that one.

>> I would prefer the the neck incision.

It's it gives.

>> Are they as big as we used to make them or are these smaller.

>> A little bit smaller.

Now you know, for thyroid nodules that are hyperfunctioning or definitely benign but growing, you can use other minimally invasive techniques.

I spoke with a patient this morning about radiofrequency ablation or microwave ablation, essentially using a needle with a very special tip to heat up the tissue.

So without a big scar with only a needle hole, you can burn essentially a thyroid nodule from the inside and and have it, you know, the cells die and the, the body sort of take over with its immune system to, to fight it and break it down and, and deal with the nodule that way.

Those are for select cases.

But it is another way.

>> What about those little tiny parathyroids, though?

>> Yeah.

Parathyroids you do have to to deal with surgically.

I use a traditional incision in the neck.

Usually look at one or both sides.

I mentioned that there are two on each side.

The size of the incision.

Really about the same, about 4cm or 2in.

Not not that big of a of an incision.

>> I think the big one though, where techniques have changed is the adrenal.

>> For sure.

Yeah.

You mentioned, you know, in the old days I would get a big incision to, to fit two hands in your abdomen or through your back.

Now, laparoscopic surgery is sort of the standard of care for a lot of surgical diseases in the abdomen now.

So the small holes I like to use the robot or robotic surgery, which is essentially laparoscopic surgery with the ability to make finer movements or more articulated movements.

In essence, it allows for faster recovery and less post-operative pain than than traditional surgery.

>> Where are you coming?

Are you coming from the back or are you coming in somebody through the belly?

>> Yeah, both can be both ways.

Depends on the patient.

Depends on a lot of factors.

You know, if you've had prior abdominal surgery might be a little bit dangerous to go in through the front, even laparoscopically or robotically.

So you can go in through the back.

And then a lot of patients do not have favorable anatomy to go in through the back.

So then would also go through the front again with the small holes.

And the robot would lead to less pain than would be expected.

>> When you're operating on someone's glands, briefly tell me, do you have to worry about causing a deficiency of that hormone?

>> That's a great question.

Yes.

If you take out the entirety of the glandular tissue, that that gland is responsible for, they will not have a normal amount of that hormone for the rest of their life.

So if your entire thyroid is removed, we do prescribe thyroid hormone replacement called levothyroxine as the generic.

It's probably the most well tolerated medication or one of the most well tolerated medications in the world.

Similarly, for your adrenal glands, you can't.

Even though steroids sounds like a bad term, you can't, you can't.

You can't live without even a low level of steroids.

So taking out one adrenal gland, your other adrenal gland should compensate and create enough steroids for you.

But if it doesn't, or if for whatever reason, it's sort of asleep for a few months and forgot how to, we do prescribe steroids at a low level, not at the bulking up dose.

In order to make sure that you're living your life safely.

>> Wow.

Out of curiosity.

So because everybody's, you know, getting these little whole body scans and stuff like that friend family patient comes to you and says, Doctor Taylor, George, I want to get a whole body MRI.

You're going to tell them, go ahead and do it.

And what do you tell them?

If the adrenal gland lights up and they say, oh, here, I got this adrenal gland tumor, what do you do?

>> So I guess even before all that, if you are feeling well and asymptomatic, I don't think you need to go looking for problems.

Okay.

I think the likelihood that you have anything is pretty low.

So it might just be a lot of money for a lot.

Much ado about nothing.

If an adrenal nodule is found, then there are some things that we need to do to work it up and see if it's hyperfunctioning.

Most of them are are just blood tests.

And then depending on those blood tests, we take further steps.

>> It sounds like something we do to save money, but can actually increase the cost of things.

Correct?

Now we have to do this big workup.

>> Yes.

>> I don't know.

I think you're right.

If you're asymptomatic from something and you may not just leave it alone.

>> Yeah, there's a lot of of of wasted work up in the medical community.

So anytime we can find something that we don't need to do, like a whole body scan just because just because.

>> You know, I always take it as good advice when somebody that does something for a living tells me, don't do it.

I think that's a pretty good idea, that I don't necessarily need to go out and try to pursue something like.

>> That, for sure.

I think, contrary to popular belief, surgeons usually look for reasons not to operate on people.

>> Don't let that get.

>> Out, okay?

>> Right.

Doctor Taylor, thank you very much for being with us today.

It's been the most interesting discussion and I appreciate it.

And welcome to Louisville.

>> Thank you so much.

>> Thank you for being with us today.

I hope that you have a better appreciation for endocrine cancers and other endocrine tumors, as well as endocrine disease, in the ways to identify them early and the available treatment options.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org.

If you have a question or comment about this or other shows, we can be reached at KY health at ket.org.

I look forward to seeing you on the next Kentucky Health.

And in the meantime, if you think you have a concern or question about something going on with an endocrine gland, either be a tumor mass, something that you're concerned about, please talk to your primary health care provider.

And if you really want to know about surgery, even though you don't want to do it, see Doctor Taylor.

See you next week.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky