Leading with HOPE: The Thyroid Head and Neck Oncology and Pediatric Endocrine Center

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, director of the Cleveland Clinic Voice Center in our Head and Neck Institute. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from our institute by following @CleClinicHNI. Today, I'm excited to talk with Dr. Rachel Georgopoulos, a pediatric otolaryngologist-head and neck surgeon, and director of the Thyroid Head and Neck Oncology and Pediatric Endocrine Center at Cleveland Clinic Children's. Dr. Georgopoulos, welcome to Head and Neck Innovations.

Rachel Georgopoulos: Thank you so much. Thank you so much for having me. I'm honored to be here today.

Paul Bryson: Well, let's begin by having you share some background on yourself for our listeners, where you're from, where you're trained, how you came to Cleveland Clinic.

Rachel Georgopoulos: Yeah, so I'm actually originally from New York. I did my undergrad at Binghamton University and then my medical school training really close to home at Stony Brook University. I went to Philadelphia to do my residency at Temple, and then I did a pediatric go to Laryngology Fellowship at Texas Children's in Houston. And then I came to Cleveland Clinic first because it was a wonderful opportunity and I thought there was a great opportunity to grow this Thyroid HOPE Center, which was a true interest and passion of mine, but I have some family close by which was also a good attraction.

Paul Bryson:  Well, that's great and we're lucky to have you. It's been wonderful to see your career take off and all the patients and family's lives that you've touched. And as you might imagine, our listeners specialize in many different fields across medicine. If you would, could you give us a general overview of pediatric thyroid cancer, the incidence rates, what's causing a recent increase in diagnosis and maybe describe the unmet need that you saw here as you developed your program.

Rachel Georgopoulos: Yeah, absolutely. So I'll start by saying that pediatric thyroid cancer is definitely a different entity than adult thyroid cancer, and we've heard a lot about adult thyroid cancer incidents increase, and the same is true for pediatric thyroid cancer now.

It's speculated that the incidence of adult thyroid cancer is due to an increase in detection, and while some of that may be the case in pediatric thyroid cancer, we believe that there may be more to it than that. So there was a recent JAMA article that came out querying the SIRS database about the incidence of pediatric thyroid cancer, and we've seen a stark increase from 1973, particularly after 2006, where it used to be the incidence was about .48 per hundred thousand in 1973 to about 2006. I mean it's about 1.14 per hundred thousand. Now, I think part of that market increase detection being maybe one of them, is that we're seeing kids who maybe have a lot of medical comorbidities live longer than probably previously, kids with very significant cardiac issues that probably received a decent dose of radiation, kids with significant syndromes and medical comorbidities. I believe that that's probably contributing to some of the increase that we're seeing in pediatric thyroid cancer.

Paul Bryson:  What are some of the symptoms of thyroid cancer that head and neck surgeons and pediatricians and even parents should be looking for?

Rachel Georgopoulos: Yeah. Most of the time it's noticing a palpable thyroid nodule, just a lump on the neck. Now, when it gets more advanced, you start to see things like maybe changes to the voice, changes to swallow, but most of the time it's either looking at the neck and seeing some sort of an asymmetry or feeling something on thyroid exam.

Paul Bryson: So pretty insidious a lot of the time.

Rachel Georgopoulos: Absolutely.

Paul Bryson: Okay. Dr. Georgopoulos, can you speak a little bit to the differences between adults with thyroid cancer and children with thyroid cancer? I think there is sometimes the inference that with a disease like thyroid cancer, the treatment and the treatment approach and philosophy might be the same. Can you elaborate on that?

Rachel Georgopoulos: I'm just so glad that you asked. So there are a lot of differences and that's what sparked actually the American Thyroid Association creating pediatric specific guidelines. Pediatric thyroid cancer tends to be more local, regionally aggressive. Oftentimes, we can offer things like hemithyroidectomy for papillary thyroid cancer that's small enough in an adult, whereas in kids, the recommendation is to do a total thyroidectomy. There have been multiple cases actually that I've had where we've may have had a centimeter or even a subcentimeter papillary thyroid cancer in one lobe and then there's a microscopic papillary in the contralateral lobe. And so, that's not uncommon and that's why it's recommended that we do a total thyroidectomy in kids. In addition, our decision to do a central compartment neck dissection, we definitely have a much lower threshold for doing that. Again, that's because local, regionally, the disease just tends to be much more aggressive than it is in our adult counterparts. And so, there are definite differences in terms of how the disease presents and how we should be treating it upfront.

Paul Bryson: At Cleveland Clinic Children's, we have a dedicated center now for research and treatment of this disease. And if you can, can you talk a little bit about the center for Thyroid HOPE? And the advent of this, maybe how you've brought together diverse service lines to really take a comprehensive look at children with thyroid cancers and... just tell us a little bit more about the center.

Rachel Georgopoulos: Absolutely. So part of my center is a champion in pediatric oncology, and then we also have a pediatric endocrinologist, and we meet with a pediatric radiologist as well to review some of our thyroid ultrasounds and imaging. One of the nice features for our Thyroid HOPE Centers is that the patients will see both myself, the pediatric otolaryngologist, as well as the endocrinologist at the same day to help minimize their need for coming back for additional appointments. We'll review imaging and blood work before and after, so that there's a comprehensive plan for patients. And then we also have a biorepository for our thyroid specimens, so if a patient undergoes surgery, we're collecting their thyroid specimens, so that we can do future research on them as well. That was really great.

Paul Bryson: Yeah. That's super great. It's great, great opportunity to look at this generation and then hopefully come up with some novel treatments in the future-

Rachel Georgopoulos: Absolutely.

Paul Bryson: ... and better understand maybe features of what's happening here.

Rachel Georgopoulos: Yeah. Absolutely.

Paul Bryson: When you think about the lifelong monitoring and the endocrine follow up, can you talk a little bit about that? Once that surgery is done, once the cancer has been removed, what might parents and patients expect as they move forward beyond their disease?

Rachel Georgopoulos: Yeah. Usually, what we'll do is once we have the final pathology, we'll risk stratify patients into a low, intermediate, and high risk and that actually will dictate what we do for upfront additional imaging, additional treatment, and then monitoring. But most people can expect to have a thyroid ultrasound, lateral neck ultrasound, and something called a thyroglobulin or a blood work done every three to six months, which is nice. Actually, thyroid cancer does have a blood marker that allows us to assess for things like recurrence and so, expect for at least around the first five years on average for us to be checking every about six months.

Paul Bryson: And as these children, I imagine you see a broad spectrum of age, as they transition into adolescent, into young adulthood, perhaps moving beyond what would typically be the pediatric time points. Any thoughts or considerations on how you transfer care or what those transitions of care might look like for the thyroid cancer patient-

Rachel Georgopoulos: Absolutely, yeah.

Paul Bryson: ... from childhood to adulthood?

Rachel Georgopoulos: We have a wonderful group of endocrinologists that do work with that transitional period and so, we do have a team to help with the pediatric patient that then goes into adulthood.

Paul Bryson: You alluded to some of the surgical management of thyroid cancer. Can you elaborate a little bit more on that and what other medical treatments are there?

Rachel Georgopoulos: Yeah. Luckily, most of the time, pediatric thyroid cancer is treated with surgery. Again, I bring up the comparison between kids, pediatric cases and adult cases. The treatment's very different. So whereas in adults, sometimes we'll do a hemithyroidectomy just take out one thyroid lobe. If a child's diagnosed with pediatric thyroid cancer, it's recommended to take the whole thyroid gland out and the incidence of there being metastasis within the neck is much higher than it is in adults. And so, we're definitely more aggressive with doing neck dissection, central compartment mostly, and total thyroidectomy.

And so, surgical management is the mainstay of management. Now, some children, depending on how aggressive their tumors are, will receive post-operative radioactive iodine. And then, we are looking at our specimens and sending them out to assess for reputations and there are some tyrosine kinase inhibitors that have come out to treat patients who have very aggressive metastatic disease. Not, thankfully, super common, but we do have options now.

Paul Bryson: Yeah. No, that's a great point. And it leads me to ask, so what's on the horizon as far as research? As you look at some of these unique mutations, you look at the biorepository. What do you see on the horizon in terms of specialized care? You may hear about it and other cancers and specialized immune modulators, specialized chemotherapeutic options? What's on the horizon in pediatric thyroid cancer?

Rachel Georgopoulos: Yeah. I think that we're unraveling a lot of information about the tumor microbiology. Right now, specifically those tyrosine kinase inhibitors. But we're doing a lot of research to look at what's the make-up of these thyroid tumors and are there specific chemotherapies that we can use in the case of advance to disease. Again, there are some clinical trials and some other tyrosine kinase inhibitors. Luckily, like I said, this is not often that we need to use them, but for kids who have very advanced disease, I think it's been a really great advance. And then, just continuing to look at what we can do upfront in terms of management and detection of local, regional spread. Right now, we're using a lot of ultrasound, which has been great, and biopsy.

Paul Bryson: Yeah. Yeah, the ultrasound's nice with the kids. Noninvasive, nonradiating.

Rachel Georgopoulos: Absolutely.

Paul Bryson: Yeah. I really appreciate you sharing some of the horizons, and research, and treatment, and what patients might expect here when they come to see you. For our listeners that might want patients to come and visit with you and get evaluated here in Cleveland, what is the best way to contact the center so that they can get referred or make an appointment?

Rachel Georgopoulos: You can call our administrative assistant at 216.445.4828 to make an appointment.

Paul Bryson: That's great. And as we wind down, I just wanted to thank you for all of your efforts in this space and for all the wonderful care that you're providing to patients and their families, particularly with thyroid cancer, something unexpected and often difficult for patients and families to wrap their minds around. What's a take-home message for our listeners, and even if there's some patients listening, what have you learned so far in this journey and what any other counsel you might give?

Rachel Georgopoulos: Yeah. Thank you. Thyroid cancer is a cancer diagnosis. There's a lot of support. There's a lot of hope that we have, and that's one of the reasons why we named it the Thyroid HOPE Center. It is a treatable disease. I think it's important to get plugged in with a team that will follow you lifelong for monitoring and surveillance which is why we created this Thyroid HOPE Center the way we did for patients, for other providers. We are here to provide help, support, and treatment to all the patients and support to our families as well.

Paul Bryson: Well, Rachel, it's been a pleasure. I really appreciate your time and your commitment to our patients and your program, so I look forward for more good things to come from you in the future.

To learn more about Cleveland Clinic Children's Thyroid HOPE Center, please visit clevelandclinic.org/thyroidhope. That's clevelandclinic.org/thyroidhope. And to speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Dr. Georgopoulos, thank you for joining Head and Neck Innovations.

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