Tuesday, February 22, 2011

Molecular Classifier saves surgery on a suspicious nodule

Here is the result of an Afirma molecular classifier test done on a male patient set to go to surgery for a suspicious follicular lesion. they wanted to do a lobectomy.The Afirma sample was taken during a repeat FNA and the needle washout was sent to Veracyte for Afirma. The report shown below was benign. He was not a candidate for surgery, and will be followed with yearly examinations and ultrasound.

Monday, February 07, 2011

HMO Offers Poor and Outdated Thyroid Cancer Diagnosis and Therapy To One of Their Own Employees.

45 Y/O F had a isthmus nodule felt by her GI physician. An ultrasound done by a radiologist noted more nodules and one of them was biopsied. The results were suspicious, but she refused a lobectomy until an outside opinion that she had to pay for out of her own pocket.A second biopsy was even less helpful. After it they still wanted to operate. Finally, she heard about molecular classifiers that could tell if a suspicious biopsy was benign from my website. She was asymptomatic, had 2 firm nodules on my examination. My endocrine neck diagnostic ultrasound result was dramatic. She had 3 very suspicious nodules with microcalcifications, and the whole right side of her neck lateral to the biggest suspicious nodule was full of 5-10 mm abnormal lymph nodes with all the criteria for thyroid cancer spread to local regional lymph nodes. There was no mention of the nodes in the radiology report. Ultrasound techs are not taught endocrine neck changes, such as lymph nodes or parathyroid glands, and only report the thyroid. Many biopsies done by radiology departments are done by PAs, not by radiologists. The biopsy was inferior and only suggested suspicious, because they failed to do smears and only did thin prep. This is a poor substitute for smears, and caused the endocrinologist to recommend lobectomy instead of total thyroidectomy. She did not have a pre-op ultrasound lymph node evaluation before planning to send her for surgery. The second opinion changed everything. She needed a lymph node biopsy and needle washout test for cancer marker thyroglobulin. She will surely be positive for metastatic thyroid cancer in many nodes in her right neck. She now has a pre-op Thyroglobulin test which was not planned before the surgery. She will now have a total thyroidectomy, and central compartment node dissection, but will have a complete level 2-5 node dissection. This is called a Modified radical neck dissection MRND. She was on her way to have a second right neck surgery in one year, which they would have told her it was a recurrence, but it was there all the time BEFORE the first surgery, if she did not get her own second opinion. Please, do not go in for thyroid surgery without an outside second opinion. She would have had many surgeries, and multiple doses of radioiodine as a result of an initial evaluation and therapy plan which was flawed.

Wednesday, January 05, 2011

Save Unnecessary Thyroid Surgery with new Afirma Molecular Marker Test

Well thyroid patients heading to elective surgery for suspicious but not positive diagnosis of thyroid cancer, there is now a test, Afirma that can save you and 35,000 others this year from that surgery. It is a marker test with 143 genes, that if present on a 2 pass ultrasound guided FNA will give you a 96% chance it is benign. This is good enough to allow your thyroidologist to follow you yearly without surgery. The first soft opening 3 months of the year Veracyte Corp will do the test for you without out of pocket expense to you. They will bill your medicare,medical, and private insurance, and if there is any money due from you they will send you a letter telling you that you do not owe anything.
How does it work?
First, thyroid surgery is elective and is not an emergency no matter what the doctors tell you. Thyroid cancer is only 5% of all nodules, and it is slow growing to allow definite time for second opinions by experts.
There is time for more opinions, even when it is already on the surgery plan tommorow!
If the nodule was not called benign,or for sure cancer, then Afirma could be just the test you need to prevent a surgery, complications, and 12 weeks of recovery.

1. Call and make a consultation with me or a thyroidologist near you that offers Afirma.
2. Bring you FNA actual slides, or ask me to get them for you. If I decide the FNA is inadequate for diagnosis, which is a common occurence due to poor smearing and biopsy technique, i will repeat the biopsy and get the Afirma marker.
3. If the repeat FNA is benign or cancer I will discard the Afirma sample. However, if it is unclear as to the diagnosis,I will send the Afirma test to Veracyte. You get charged for my collection of the sample, and Veracyte will only bill your insurance if you have any. No out of pocket fees to you. If you have the 143 good genes the nodule is benign, and no surgery is needed. You can contact my office for more information on Afirma. 310-393-8860, fax 310-395-8147, or email dr.guttler@thyroid.com

Tuesday, November 09, 2010

Lobectomy for a Large Benign Thyroid Nodule? Second Opinion Saved the Day

50 Y/O female for second opinion on a referral for a lobectomy for a very large thyroid nodule. The FNA of the nodule was benign, but because of the size her endocrinologists referred her for surgery. The ultrasound described two small insignificant nodules 7 mm each in the opposite lobe. My evaluation revealed a major historical finding not known by the first opinion physician. Her sister had thyroid cancer. My ultrasound again saw the nodules but they has 4 + Doppler blood flow in the nodules, irregular borders. My FNA of the large nodule was also benign, but because of the ultrasound findings and the family hx of thyroid cancer I biopsied the two suspicious small nodules not evaluated by the first opinion physician. Both were positive for papillary thyroid cancer. What should you learn as a thyroid patient with a nodule?
1. Get an outside second opinion from a clinical thyroidologist before going under the knife.
2. The second opinion found out during the history that she was at risk due to the fact her sister had thyroid cancer.
3. Careful evaluation of the thyroid by ultrasound revealed not 2 insignificant small nodules, but suspicious nodules for FNA.
4. The second opinion consultant had now changed the whole case from a simple lobectomy to remove a large benign nodule, to a total thyroidectomy for cancer. The lobectomy would have left her with thyroid cancer in the other side that the surgeon would not have felt as they were too small to palpate.
4. The two tests needed before surgery for thyroid cancer would not have been done. They are thyroglobulin cancer marker and an ultrasound 6 level lymph node mapping. This procedure can result in a change in the extent of surgery 30% of the time to include one or more lateral neck lymph node compartments.

It is no emergency to go to surgery for a thyroid nodule. Stop, Think, and get proactive.
Second opinion from an expert thyroidologist can save you from the wrong surgery, as in this example.

Friday, November 05, 2010

My Thyroid Ultrasound Referral Center is Certified by AIUM

Endocrine Neck Ultrasound Lab of Southern California is the only referral center on the west coast that has both the certification of the physician sonographer by the American College of Endocrinology ACE, and the ultrasound lab certified by the American Institute of Ultrasound Medicine.100 endocrinologists have been certified by ACE, but only 5 have had their ultrasound equipment certified by AIUM. My referral ultrasound center is the only one double certified on the west coast. This allows us see referrals from general endocrinologists,and thyroid surgeons for specific studies. Diagnostic Endocrine neck ultrasound, lymph node mapping before and after cancer surgery, parathyroid localization, USGFNA of nodules,lymph nodes, and parathyroid adenomas. Interventional sonography for Ethanol injection treatment of benign recurrent cysts to replace surgery, and recurrent papillary, medullary cancer lymph nodes after prior neck dissection.

Thursday, April 01, 2010

Clinical Thyroidologists: What we do for our patients.

In the last month in cooperation with filmmaker John Lynch, I have produced 5 2 minute videos to explain what a real clinical thyroidologist, who only see patients with thyroid disease or thyroid cancer does. The first one is an introduction to my center, and an example of the careful history and physical examination that still is the key to discovering the cause of the thyroid disease. The second is my clinical thyroid nuclear medicine section to evaluate toxic nodules, Graves disease, and cancer.The video is designed to explain why the thyroid expert is the best person to treat you, not the general nuclear medicine types who spend little time with thyroid patients. I can treat the cancer patients with radio-iodine as an outpatient. The hall mark of my center is the core thyroid lab, with excellent confirmed results for T4,T3,TSH,TPO Antibodies, Thyroglobulin, thyroglobulin antibodies,and Calcitonin. The Ultrasound section is top heavy with state of the art testing and treatment for nodules and cancer.We are one of the few centers to treat thyroid/parathyroid cysts,and cancer lymph nodes with ethanol. The thyroid cytology section is a leader in the field of alerting endocrinologist of the need to quality control the results of thyroid FNA,and surgical pathology results by general pathologists concerning their own private patients before subjecting them to surgery or radiation therapy. The videos are uploaded to my twitter site and blog.

Wednesday, June 24, 2009

Iodine Induced Graves' Disease Why Treat with Iodine?

48 Y/O Female with hypothyroidism was treated with iodine pills and T3 cytomel. While on high dose T3 and iodine, she developed double vision and pop eye on the right. MR= swollen eye muscles=Graves Eye Disease.The patient was hyperthyoid on examination. The thyroid was enlarged, firm, and Ultrasound showed Graves'firestorm blood flow. The iodine was stopped, as was the T3. She was started on beta blocker and a I/123 uptake was planned. No ultrasound was ever done.A real time ultrasound was positive. Several nodules were suspicious for cancer.A Biopsy was done, and it was negative for cancer.The patient was cooled off with beta blocker, and was treated with RAI/131.The eye disease stabilized and then a muscle relocation procedure cured the double vision.
What did we learn?
Always see an endocrinologist or thyroidologist if you are told by your primary MD, you have thyroid disease.

Good luck,