Thyroid disease is increasingly common. In this video, UCSF specialists clearly explain the basics of thyroid nodules and thyroid cancer, helping patients make sense of their treatment options, from monitoring to surgery to radioactive iodine.
mhm Hello and welcome to our first UCSF endocrine surgery. Webinar. My name is Wensheng, and I am a professor of surgery and under concert gin at UCSF, and I'll be moderating today's webinar joining me today. Our doctor, Jessica Gosnell, a professor of surgery and an expert endocrine surgeon at UCSF. Dr Cheng Ying lu, who is a professor of medicine and an expert thyroid endocrinologist here. UCSF and Dr Julianne Sosa, professor and chair of the UCSF Department of Surgery and an expert in thyroid cancer surgery. We are all specialists in the management of thyroid disease, and today we will be discussing the basics of management and treatment of thyroid modules and thyroid cancer. In the first section, Dr Gosnell and I will talk about the basics of thyroid modules and why they are important to pay attention to. In the second section, Doctor Liu and I will be discussing the evaluation of thyroid modules. That is, how do we work up and better characterized thyroid modules in the final section. I'll be talking with Dr Sosa about thyroid cancer. How common is it and what are some of the treatment options available? I'd like to start this first section by introducing Doctor Jessica Gosnell. Dr. Gosnell again is a professor of surgery and an expert thyroid surgeon here at UCSF. Hello, Jessica. And thank you for participating in our webinar today. Hi, 10. I'm gonna start off with a pretty basic question, and that is what is a thyroid nodule? That is a great question, and certainly one that we encounter quite a bit in endocrine surgery. I do have a few slides that I would love to share with our audience and, um, thyroid nodules. It's It's really a great place to start. Um, it's a very simple answer. A thyroid nodule is simply a lump or a mass, and it's usually within the substance of the thyroid gland. Occasionally it's on the surface, but usually it's within the thyroid itself. Which, as you see, is this kind of butterfly or bow tie or w shaped organ at the base of the neck. Andi firing modules can either be solid, meaning they are filled with cells, or they can be what we call cystic, meaning that they are fluid filled. So that's essentially what a thyroid nodule is. And how common are thyroid nodules. How often do we see them in clinical practice? Another great question. Fibroid modules are actually very, very common, and in fact, the you know, the more we look for them, the more we find them essentially. So there's a couple of statistics here that we know just from looking at populations of patients. UM, about 5% of women. ATTN. Any point we'll have a thyroid nodule. It's a little bit lower in men, and we know that it's very dependant on age. So about half of patients by the age of 60 will have a thyroid nodule. So not at all an uncommon situation. We also know that a zai mentioned before kind of the more we look for them, the more we're gonna find them, meaning that even if you could never detected or feel it, if you get an X ray even for some other reason, a very high percentage of patients will actually have a nodule. And this is this is a picture from an ultrasound, but we find very similar findings. If X rays are done, C T scans MRI's imaging for other reasons. So very, very common. And I guess that leads into my next question, which is basically how these air typically detected, and you kind of mentioned it. But what's your rough breakdown in terms of like patients who come in tow to see you in the office? How often are they found by this kind of accidental imaging study method or by themselves either feeling it or someone else feeling it or seeing it? Great? Um, yeah, I was thinking of it in a few buckets. So there's kind of the feeling bucket, meaning that either ah, physician or even a massage tech will actually find a little lump or a nodule in in the thyroid gland. But it's also patients, so patients may be putting on, you know, lotion may notice a little modularity in the next. So that's kind of bucket one, which is kind of someone is pal painting it or feeling it, Um, the other bucket is that occasionally we see them, and I kind of included in this bucket, Um, what you were just mentioning, like you can see it on on an X ray done for some other reason, but occasionally you'll actually see it so patients may notice something when they look in the mirror. Someone may notice something at the airport and pointed out Thio person, but it's like a visible, you know, it's actually a visible abnormality that people recognize. Um, and then I think the, you know, the probably the more rare bucket that we often think about is sometimes thyroid nodule is actually can cause symptoms, and that's how they, you know, kind of are discovered. Eso some of those symptoms, um, that I've included here, kind of more mechanical symptoms because of the size of the nodule. Like if it's a very large nodule, patients may have trouble swallowing. Or they may have actually a change in their voice a little bit of a raspy voice that that family members notice. Or they may have some challenges with even breathing or laying flat. So those air kind of mechanical and then more rare is they actually have symptoms because the nodule actually represents, um, a a situation where there is over functioning, meaning that nodule is actually secrete ing thyroid hormone that's causing a big constellation of symptoms. So those air kind of the three areas that we often detect thyroid modules nowadays, what would you say is the most common way. Do you think it's through? Ah, patient. Do you think it's through X rays? What? I mean, what's your kind of thought? Yeah, I suspect that, given the and just based on the numbers, that this is probably something that's that's image ing, uh, driven by imaging in large degree. That's certainly the other those other buckets air really important. But I think patients are now just getting so many types of image ing for so many different reason. It's definitely accounts for a high percentage of the patients that we see. And then your comment on someone else noticing in the person. There's a famous story in the news recently of a TV reporter down in Florida, and a concerned viewer actually messaged her and said, Your thyroid looks kind of big, and it didn't end up being that she had a thyroid nodule something needed to get taken care of. So people come come into our office and all different kinds of ways. Now, of course, the main question a lot of people are gonna be concerned about is is it cancerous? How off cleaner thyroid nodule is cancers? Yeah, you're right. It's definitely you know, probably the biggest concern that people have is, you know, is this cancer? And that's why I titled this slide thyroid nodule zehr usually benign. So I think it's really important that, um, we want to fully evaluate patients. But at the same time, the context is that most thyroid nodule zehr not cancerous and, uh, the degree to which the risk increases tends. Thio tends to depend on a lot of different other findings about the person and the old and the nodule itself. But in generally, we think that about 7 to 15% so it's pretty low percentage of patients that have a thyroid nodule will actually have thyroid cancer. So the flip side of that for our half full audience, you know, 10 10 to 15% or rather 85% of people will have a benign thyroid nodule. So the reason that there is such a big range in that the incidence of thyroid cancer is that it does depend the risk changes based on some underlying factors. For example, um, ultrasound features there could be certain things that we see on imaging that can be more or less worrisome, and that might increase the risk. There's certainly a number of patient related risk factors, such as age and gender, that can increase or decrease the risk. Onda. We know that there are several, um, environmental and family history related issues that increase the risk of thyroid cancer, such as a family history of thyroid cancer. Ah, history of ionizing radiations of head and neck region. And they're actually, um, several other exposures that I haven't listed here that are really under investigation in the world in terms of other environmental exposures that may be actually increasing the risk that many folks have for developing thyroid cancer. And then could you clarify a little bit? What do you mean by ionizing radiation? What kind of radiation exposure puts you at higher risk for thyroid cancer when when we think about radiation exposure as a risk factor? Um, certainly lots of folks are worried about just getting standard dental X rays, and certainly that area is under investigation. But when we're thinking about radiation exposure, we're usually thinking about a kind of a low dose radiation that's used as a treatment for other types of cancers, like head and neck cancers. When when folks are are young like when their childhood or in those patients that were actually treated with radiation for enlarged, famous or acne. These were things that were used somewhat routinely in the fifties. Unfortunately, we don't see that. Of course, other radiation exposure. Um, you know, we have certainly patients that were in areas where there was significant fallout from radiation type, um, emergencies. And those patients have certainly been shown to have much higher risks of thyroid cancer. Excellent. Thank you. I'd like to turn it over to our other Panelists for their thoughts or comments regarding the basics of Howard Modules. Doctor Sosa. Thanks, Dr Shen. I think Dr Ghazi l is really provided a great overview, I guess. Just some broad strokes, I would add, um, you know, thyroid nodule zehr super common. We think that upto half of Americans have a thyroid nodule. And the bottom line is that the overwhelming majority of these are nothing, meaning they are benign. Two patients. I say there are three and only three reasons to take a thyroid nodule out. One is if it's cancer or worrisome for cancer. Two. If it's causing there to be too much thyroid hormone meaning. If there is hyper thyroid ism and three is is if the nodule is big enough or in a tough place and causing you have symptoms which Dr Gosnell described otherwise surveillance or keeping an eye on the nodule is entirely appropriate. And, I would say is a medical community we've sort of reached consensus that a less is Mawr approached. Applies much of the time certainly much more than we used to believe. But to be able to ascertain whether you're in a worrisome group that needs surgery or a less worrisome group who is amenable to just being followed for that you need to solicit the opinion of a wise physician experienced in the management of thyroid nodule. Well, said Dr Sosa, we'd like to move on to the second section and I'll introduce Dr Chen Ying View, who is a professor of medicine and one of our expert thyroid endocrinologist, UCSF. And we're gonna talk about the evaluation of thyroid modules. Hello, Cheng, And thank you for participating in our webinar today. Thank you for having me here, Dr Shen, and we're gonna talk about the usual management of thyroid nodule. So when you see a patient in your endocrinology clinic with the thyroid nodule. What are some of the usual questions that you asked during that initial evaluation? Yeah, so there's a list of questions I usually ask, And maybe this is a good time that I share with you my slides here. So yeah, so there's essentially a list of things I asked, including symptoms on Duh radiation exposure. Aziz, where as family history, let's start out with symptoms. Most modules do not cause symptoms, however, a patient with the siren module that comes in for an evaluation, I think it's a good practice to look for symptoms. Dr Ghazni al mentioned earlier. When you have a big nodule or invasive nodule, uh, it can cause pressure to the Egyptian structures. Uh, the windpipe, esophagus and the vocal cord nerves and therefore symptoms to illicit for include lumping sensation in the throat, a difficulty swallowing a changing voice or fortunate and very rarely difficulty breathing. A pain is a very infrequent symptom of thyroid nodule. However, it does, uh, happened, and it results from a study enlargement of a small nodule due to bleeding or hemorrhage into the nodule because of fragile vessels surrounding the vessel coming to the history. Um, important question to ask, as Dr Gods now mentioned earlier, is radiation exposure. And there are different types of radiation exposure, including radio. Nuclear fall out the most well known is the Chernobyl disaster happened in 1986. Then there's total body radiation for childhood malignancy as part of the medical therapy. And there's also irradiation for benign conditions that was common practice back in the 19 twenties to 19 fifties. It's crazy for them to do that. Family history is also important off. Certain family of syndromes are associated with increased multi authority disease and thyroid cancer. And the list here, it's just an example. It's not meant to be exhaustive. So those are the questions that I typically ask of my patients, where they coming to ah, visit. Excellent. Excellent. And then once you've seen the patient and I imagine you do a physical examination, what kind of things are you looking for when you're feeling things? Nodule? Yeah, So physical exam, I think. Sorry. Nah, JAL's, um, it's important to look for suspicion for malignancy. A fixed hard nodule, um, should raise a suspicion for cancer, and in that situation. You also should look for associated enlarged link notes or what we call cervical Linfen Apathy. Um, for a large nodule or invasion Invasive nodule, uh, there signs that you can look for, um the Pemberton sign can be elicited by asking the patient to raise their arms above the head. And because of obstruction of Venus, um, return, there can be flushing and readiness appearance on the face and the neck. So that's the sign of large, substantial nodule or greater you mentioned needle biopsy for thyroid nodule. ALS. I'd like to ask which patients do you select toe undergo needle biopsy? This is an excellent question. Um, I want to show you first of all, fine needle aspiration is highly accurate in diagnosing malignancy, and it's a very safe procedure that can be performed in office routinely. Um, and in terms of deciding which nodule to biopsy, um, it really depends on the ultrasound characterization and the size of the fiery nodule. Ultrasound characterization has been utilized in evaluation of thyroid nodule since 19 sixties, and so there has been great advancement in techniques and image in quality, and we have also learned which ultrasound features in the nodule are associated with increased cancer risk on ultrasound, many cancers nodules appear highly suspicious and benign. Nodules usually have more benign and less suspicious features. So the combination of ultrasound features and the size will guide us in choosing which natural to biopsy now. Recently, there's been some talk about molecular testing thyroid modules, and you don't have to get too complicated. But can you just comment briefly about what is molecular testing? And then which patients do we choose to use that? Yes, that's another excellent question. When, um maybe I'll share you with the slide that shows the fine needle aspiration biopsy results. So here is my slide on the categories of F in a psychology. Once we decide to perform fine needle aspiration, essentially, the results can be classified into one of this six categories. And as you see that non diagnostic category, repeat biopsies needed benign category. Surveillance is recommended on the Category five suspicious for malignancy and Category six, the malignant category. Surgery is routinely recommended. I saved the Category three and four the last, because this the nodule in these two categories are psychologically indeterminant indeterminant because there are abnormal cells but not enough for cancer diagnosis. And they are obviously not normal enough for benign natural diagnosis leader. And this is where the molecular testing were coming. Now, the management options for those indeterminant three novels include repeat F in a molecular testing and surgery. So many of us have now chosen molecular testing. So we have three molecular testing available to us ASL listed here. And different institutions have their preferences at U. C s F. We have used authority V three quite frequently. Excellent. I'd like to open it up for further comments from either Dr Gosnell or Doctor Sosa. Dr. Gosnell, Any comments about the management or evaluation of thyroid modules? Yeah. Thank you, Dr Shen. Thank you, Doctor Liu. I, um I just wanted to point out that I think you can get a sense of how thoughtful we are in terms of whether patients need to have needle biopsy whether they need these more advanced tests. And I guess I just wanted to highlight how important it is that has endocrine surgeons. We work with our endocrinology colleagues like Dr Leah in terms of trying to make some of these decisions, so it's really important to have not just a surgeon, but we need a team of doctors sometimes to help, um, to take care of our patients. That was one point I wanted to make just toe. Also highlight how important the high resolution ultrasound. Most of us here really view the ultrasound as an extension of our physical exam. So it's something that happens, you know, really part and parcel with the physical exam and really gives us so much more information to that comment. Dr. So said, Thanks, Dr Shen. What I would add is that you know, Kobe has really, um, brought some degree of complexity to the evaluation of thyroid disease and thyroid modules, but I think we have accommodated it well. And it's important, uh, for patients to understand that the overwhelming majority of initial visits we can do remotely via telehealth on bond when additional testing is needed. For instance, ultrasound and biopsy. We can schedule that when it is indicated and when it is convenient for patients and that can be done very safely. So keep that in mind. No excellent points, and you're exactly right. Is Doctor Liu and Dr Gosnell already alluded to not every patient ends up needing some of these additional tests, and so we could be very selective and thoughtful and rational about who gets those extra tests. Thanks very much for our final section. I'd like to introduce Dr Julianne Sosa, professor and chair of the Department of Surgery at UCSF and an expert in thyroid cancer care. And we're going to talk about the basics of thyroid cancer and some of the current controversies and issues and thyroid cancer management. Hello, Julianne. And thank you for participating in this webinar today. It's a privilege. I'm gonna open up your slides and then we're gonna ask just a very basic question, which is how common is thyroid cancer. And I'd like to add on Can you define differentiated thyroid cancer, which is really the subject of our webinar today. Yeah, so I'm gonna use the word pandemic gingerly. But I would say until recently, there has been an epidemic in the United States of thyroid cancer and a pandemic of thyroid cancer in the world because observations made in the United States are reflected in virtually every developed and developing country. Maybe you can show my next slide. So until very recently, thyroid cancer has been the fastest increasing cancer in the United States. Within incidents, um, that has gone up more than three 100%. And that's been seen in virtually every subgroup men, women, young, old and in every race and ethnic group, which you'll see in this figure. Just over the last several years, things seem to be leveling off. This year, it's expected that nearly 53,000 Americans will be diagnosed with thyroid cancer. It's the number one cancer in men and women under the age of 30 and it is the number five most common cancer in women because it is more common in women than in men. So a lot of people have looked at this figure and they said, What's going on? What is happening, that is changing the incidence of thyroid cancer? And I would say that less is Mawr theme that I introduced earlier is really coming into play, and I think a lot of the rising incidents has been artifacts. Jewel from are just doing more tests in the United States. We doom or CAT scans, we doom or pet scans. We do more memories and ultrasounds, and as a result of all this testing, we have found more problems in your body, fortunately, most of which don't mean anything bad. And that's certainly been true in the overwhelming majority of thyroid nodule. Having said that, we also think they're probably some other things that have been at play, some of which are environmental exposures. And the number one thing I would point to is probably obesity. Obesity does appear to be associated with an increased risk of thyroid cancer and an increased aggressiveness of thyroid cancer, and it, in fact, may explain up to 25% of new cases. So one thing we may be all be able we may all be able to modify is how much we eat to reduce our risk of obesity and potentially thyroid cancer. So this increasing incidents that we show in this figure is being seen for virtually every flavor and variety of thyroid cancer. But the most common thyroid cancers are the differentiated thyroid cancers that you mentioned and differentiated. Thyroid cancers derive from what are called Filic Euler cells, and the important characteristic to know about these is that they love iodine. They are iodine advocate and why that's important for patients is to know that if you have a differentiated thyroid cancer at some point in your disease course, we may consider treating you with radioactive iodine. Why? Because the tumor may take that iodine up and tagged with radiation. It kills it, and that's typically done in the postoperative. Seven. Interesting. Thank you so much. What's the prognosis of differentiated thyroid cancer? You say it's going up in incidents, but what's the prognosis overall? Well, the prognosis is very good. It's very favorable. Why? Because thyroid cancer is generally a very indolent disease. Rarely do people succumb to thyroid cancer, and if you take all thyroid cancers, the five year survival rate is in excess of 98%. An important fact to know for patients is that about two thirds off all diagnoses of thyroid cancer are made early when the cancer is confined to the thyroid gland, meaning it hasn't escaped the thyroid and grown into any surrounding tissues or into lymph nodes. When this is the case, survival truly approaches nearly 100%. What are some of the treatment options for differentiated thyroid cancer? Yes. Oh, thank you for that. Until recently, there has been a lot of disagreement between different providers in different parts of the United States and different parts of the world about how best to treat thyroid cancer. And a lot of that is because the science is rapidly evolving. And a good thing for patients to know is that, Ah, lot of that science is performed at UCSF, where there are experienced scientists and experienced physicians and surgeons who take care of thyroid cancer patients. Fortunately, now in the United States, we have guidelines. These guidelines were most recently formulated in 2015, published in 2016, and they're shown here. You'll see that I was one of the authors of these guidelines. But an important thing for patients to know is that these guidelines air publicly available. You can Google them. They're found on the American Thyroid Association website, and the recommendations portion of the guidelines air pretty easy to understand. And at U. C S F. We deploy these evidence based guidelines each and every day in our clinics to try Thio afford our patients the best opportunity to have an excellent outcome, as I mentioned now, a couple of times in the past, there's been a general twin towards a less is mawr approach to the management of thyroid cancer, particularly differentiated thyroid cancer, of which the most common variety is papillary thyroid cancer. It now represents about nine out of 10 new cases of thyroid cancer, so perhaps you could go to the next slide. So, as Dr Gosnell described, the thyroid gland is a butterfly shaped organ that sits in the front of the neck. It sits on top of your wind pipe and your esophagus, which is your food tube on the right figure. I'm showing you the back of the thyroid glands with the trachea shown in the middle. I'm showing you this because I wanted to highlight two structures that are really important during thyroid surgery. The first is the recurrent laryngeal nerve. It's a nerve that goes to your voice box about the size of a human hair, and that has to be preserved during this operation to assure that you don't sustain a change invoice after surgery at places like U. C s F. This is an extraordinarily rare occurrence. Less than 0.1% risk the other organs. I wanted to show our the parathyroid glands There are four of them shown little yellow dots about the size of Ah A P, and these have to be preserved in order to avoid low calcium after surgery. Again, it places like UCSF super rare. We could go to my next slide. So the overwhelming majority of new cases of thyroid cancer are what we call low risk thyroid cancers. These air thyroid cancers that are less than four centimeters and size so smaller than, say, a quarter they're confined to the thyroid. They haven't escaped the glands, and they haven't spread thio any lymph nodes. So they're just in the gland itself. And now we know there are two strategic options that can be taken surgically next slide. One is we could remove half of your thyroid, which is called a low back to me. The second option, and you can go to slides in advance is to take your whole thyroid out, which is called a total thyroid ectomy. The important thing for patients to know is that whether you have a lobe ectomy or a total thyroid ectomy will afford you the same survival, which is excellent. However, the risks and benefits of each approach are slightly different. So it places like used CSF. We spend a lot of time with patients going over the stra to strategic options as well as their risks and benefits in order to find the right approach for each patient based on their values and their preferences. Now some patients, unfortunately, have high risk thyroid cancers, and perhaps you could go to my next slide. Dr. Shen and high risk thyroid cancers may be larger over four centimeters in size, multi focal, and they have escaped the thyroid, meaning spreading into surrounding tissue or into the lymph nodes. When that is three case, we want to determine it ahead of time before we go to the operating room. There is only one appropriate surgical option, which is the removal off all of the thyroid gland called a total thyroid ectomy. Next slide after surgery. We then sit tight, make sure patients heal from their operations. And the important thing for patients to know, particularly in this post coup bid era, is that we almost always come due these operations in the ambulatory setting such that they go home same day and can spend the night of surgery in their own bed with their loved ones. So after surgery we heal and then wait for the final pathology to come back, and that usually takes about a week. We then visit with you, usually remotely. You don't have to come into the hospital. You could do that from your home, and we make a decision whether any additional treatment is needed. And specifically, the treatment that might be needed is called radioactive iodine, so we rarely use chemotherapy and radiation therapy for thyroid cancer. Rather, we administer radioactive iodine via a pill, and it's typically done again in the outpatient setting, so you don't have to spend time in the hospital for your thyroid cancer to be treated. We really try to minimize that time next slide. And then the overwhelming majority of patients do really well with thyroid cancer, as I already described and their survivors of their thyroid cancer. So we then put you click the next slide into a surveillance strategy where we see you in our survivorship clinic, and what that means is you see our endocrinologist or our endocrine surgeons for blood tests and imaging studies, typically ultrasound to make sure that they don't experience a recurrence or a return of their thyroid cancer. That typically happens short term in the first five or maybe eight years after surgery. Next likely. And all of this is performed by a multi disciplinary team at U. C s F. We all get along really well are endocrinologists are surgeons are pathologists and our radiologist and for patients. The important thing to know is you have a number of experts, world experts providing their opinions to guide your management, not just one doctor. And so we hope that improves their chances of having a great outcome short and long term. Fantastic summary. And I do want to highlight the importance of a multidisciplinary, patient centered teams you've listed here. I'm going to shift gears a little bit and talk about something that's a little broader, but I think very important in the midst of our ongoing current events. And that is, and you feel a little to it a little bit. How has Cove in 19 changed our management of differentiated thyroid cancer or thyroid modules in general? UCSF Yeah, Thank you for that, Dr Shannon. Perhaps you could go to my next slide. So the important thing for patients to know. And here I am going to reassure is the thyroid Cancer is usually an indolent disease, meaning is slowly growing disease. So while we don't yet know the impact of Cove in 19 at a population level on patients with thyroid modules and thyroid cancer, we hope that it has not been profound. Having said that, six months have passed and we are now back at work, working hard, doing blood tests, doing image ING studies, doing molecular tests and, yes, importantly doing surgery. And therefore, we do hope that patients who know that they have a problem in their next solicit the opinion of their doctors and look for referral toe high volume centers like UCSF with expertise. We know when it's appropriate to operate, and we also know when it's appropriate, not toe operate. And I think that's an important distinction. This is our endocrine surgery team. You see, we have six endocrine surgeons and 1/7 endocrine surgeon. Who is that Zuckerberg San Francisco General Hospital, making us now the largest endocrine surgery team in the United States. I'm very proud of this team and being a part of it. Why? Because you can see how diverse it is. There are men, there are women, there are young people. There are old people from a variety of racial and ethnic differences. And so there's no one size fits all. But the important thing is everyone smiling. And I think that represents the passion that we have for what we do each and every day. And maybe you can show the next slide. And I would say, as chair of the Department of Surgery, this team is just part of a much larger team that is not only the department of surgery, but that is UCSF health. And the nice thing about that for patients is there's world experts in virtually every field and were rarely, if ever surprised by findings. So that's a safety net that is important tohave, particularly at thes chaotic and terrifying times. Well said, thank you very much. I wanted to open it up to Doctor Liu or Dr Gosnell. Do you have any comments about the management of thyroid cancer, Doctor Liu? Yes, that's ah, wonderful review by Dr Julian Sosa on. I cannot emphasize enough that most patients, indeed with differentiated thyroid cancer, do very, very well In fact, surgery can treat most of the cancer and small percent of patients when the radioactive Aydin treatment. And it's only about 2% of patients. We'll have metastases outside of neck so well said. And you know, I look forward Thio working of the team to get outpatient back in our clinic. Dr. Gosnell. Yeah, that was just a fantastic review. My only comment or something to highlight would be that because pirate cancer does have such an excellent prognosis and we have such a great team here at UCSF. I did wanna highlight how important it is for us to really have a patient centered approach. I think you got a little bit of sense with Dr Sosa's talk of. There's a lot of decision making, and that could be really challenging for patients to kind of navigate as they're learning all this. Um, but we're kind of committed to, I think, working with you and actually understanding your priorities and your values and how that may affect what we recommend. I love that one. Size does not fit all kind of comment. Well, I'd like to thank our participants and experts today. Doctors Jessica Gosnell, Kenyan view. And Julianne Sosa. I hope you have all learned something, Maura, About thyroid modules and thyroid cancer. I urge you to stay tuned for more UCSF endocrine surgery. Webinars. Thank you for your time and attention and stay well, me.