PEI: What is PercutanI and why do you need to know about about it, if you have recurrent thyroid cancer in your neck lymph nodes after prior surgeries

PEI: What is PEI and why do I need to know about it, if I have a thyroid cyst, or parathyroid cyst, and have been told to have surgery?

Case Presentation:
50 Y/O Chinese male was told in Shanghai, that the only therapy for his recurrent thyroid cyst was surgery. A modern Chinese male hits the web to research this, before submitting for surgery. He found thyroid,com, and emailed me about coming to the USA for a consultation. He was euthyroid, on no medications, and had a 15 cc pure cyst.
The ultrasound guided FNA biopsy confirmed the cyst was indeed thyroid in nature, and the biopsy was negative for cancer. When he next visited the USA, under US guidance I
withdrew 15 cc of cyst fluid and re-injected 7.5 cc of medical grade ethanol. There was no pain or complications. He returned to see me 6 weeks later. The cyst was not visible anymore, and the ultrasound confirmed it was >99% ablated. There was a 1-2 mm residual seen on ultrasound.He had his wish come true to fix the cyst, but without major surgery, and hospitalization.

This PEI procedure can be used as primary treatment for non-functioning parathyroid cysts, and thyroglossal ducts that have recurred and failed surgery. It is mandatory to rule out cancer in mixed cysts of any nature before PEI is considered as a therapy option. It has another major use in the treatment of recurrent cancer lymph nodes in thyroid cancer patients,after a recurrence and prior neck explorations.

Good Luck,

Dr.G.

Murder by Thyroid Poisoning, or Paranoia?

A 40+ Y/O male presented to the ER with a rapid pulse and insomnia for a week.
He told the ER physician that he felt he was being poisoned by a female friend.
He stated that for 6 weeks he has been eating at her condo, and became progressively sicker in the last 2 weeks. He developed insomnia, anxiety and rapid heart beat which was confirmed
at the ER at 160/minute.The thyroid was mildly enlarged. He described the poison plot to the physician, who had the patients stomach pumped. He described a grifter scam to get his money and his paid up house, by making him weak, and signing over all his assets. The scam was worked by the female age 35, and her boy friend. The thyroid hormone was ground up and put in his food. The delayed symptoms occurred 30 days after he began eating at her condo. When I first saw him, I asked how did he know he was being poisoned, with Synthroid, a brand name for thyroxine. He said it was a well known grifter scam listed on websites about scam artists. His heart rate was normal 4 days after the ER visit. No tremor, but still complained of insomnia. His thyroid was enlarged and nodular. However, the T4,T3, TSH, and antibodies were all normal.
The thyroglobulin TG was drawn at first to make sure it was exogenous induced hyperthyroidism, not Graves disease. When the TG came back normal, not suppressed, I knew he was not being poisoned by thyroid hormone placed in his food. His story was very strange. He has a goiter and small nodule which needs my follow up, but what about this poisoning story? When confronted with the news, he was shocked that his imagined poisoning was not real. I told him he had serious problem with reality, and needed to get help. He had planned to get the police to arrest the female, but I found no smoking gun. His paranoid thoughts were out of control. His small goiter was not enough to suspect poisoning. Also his I/123 thyroid uptake was normal. He said he would see a therapist, but did not go to the one I recommended.
Until next time,

Good thyroid health,

Dr.G.

Why Surgery Not Needed for most Goiter Patients

Why take the risk of a hospital visit to remove a non-cancerous goiter. Hospital induced secondary diseases, and the real risk of complications from the surgery makes many turned off by surgery. The alternative use of low dose radio-iodine, 30 Millicuries is a great way to reduce goiter size, and stop complications from the knife and all it's ramifications. With a small booster shot of TSH, to increase thyroid iodine uptake, you can deliver enough radiation to decrease the gland by about 50%.Doses below 80 Millicuies are not associated with secondary cancers of other organs, such breast cancer. Call your local thyroidologist for details before you listen to the physician how recommends surgery as the only option.
www.thyroidologists.com

Hashimotos Thyroiditis, HT: A Thyroid Cancer Risk?

The TSH may be elevated for years before the patient is diagnosed with chronic thyroiditis.Thyroid cancer cells have receptors for TSH. There is a 3 fold increase in cancer if Thyroiditis is present. How many family physicians,internists, and even endocrinologists know that,and do a High frequency ultrasound on their patients with Hashimoto's Thyroidits? Even small nodules not palpable by your physician, but seen on ultrasound can be as dangerous as a larger one that was felt by your physician.If you have thyroiditis, insist on a thyroid ultrasound.

Use of Radioiodine for Thyroid cancer is not needed in Low Risk Patients

Why are nuclear medicine departments in major community hospitals still recommending
ablation therapy for most if not all their patients, regardless of the level of prognostic risk. Two major medical centers with top ten ratings, still have high rates of hospital treated high dose >75 Millicurie therapy for even low risk patients. One uses 150 MCI as standard therapy! 80 MCi or more have increased incidence of solid tumors of the stomach,bladder,prostate,penis, breast,and many more. Why is this happening even though the literature has no evidence it is helpful? The answer is found in the referral patterns of a given center. Busy diabetes and internal medicine endocrinologists and surgeons, commonly defer radiation decisions to the nuclear physician. It is like Little Red Riding Hood asking the wolf for his opinion on the best thing for dinner that night. The need for a new leader to decide the need for adjunct therapy should be a clinical thyroidologist, not the nuclear medicine physician. A clinical thyroidologist with the ability to do lymph node mapping, thyroglobulin, USGFNA of suspect cancer nodes, and can develop an endocrine neck lab to help the many endocrinologists who are too busy to master the skills to be expert at lymph node FNA, percutaneous ethanol injections of cancer nodes, would be the ideal new player in this field. The days of routine use of total body scan and radiation therapy by nuclear medicine is in decline, and that of thyroid ultrasonographers are in ascendancy.

What to Do about Recurrent Cancer Neck Nodes, When You have had Multiple Surgeries, or Have Contraindications to Further Radioiodine or Surgery?

The patient has papillary thyroid cancer. She had originally a total thyroidectomy, and central compartment node removal. 2/6 nodes were positive.
This was followed by radio-iodine therapy. She developed recurrence in the left lateral neck, treated by modified neck removal of 26 nodes. 12/26 were positive for cancer. She had a second course of I/131, and still had detectable cancer marker, which was followed until it began to rise 2 years later. The lymph node mapping by high frequency ultrasound found abnormal nodes in the left neck again, and new abnormal node in the central compartment. Both areas were sites of a previous surgery. They would be difficult to open again without a risk to her parathyroids or recurrent nerves. The thyroid surgeon, the patient and I decided it was safe to go after the central compartment node, if I could mark the location by injecting a small amount of methylene blue on the surface of the node, by ultrasound guidance one hour before surgery. The left neck was left to me to use Percutaneous Ethanol Injections to "kill" those few nodes, rather than risk a second surgery on the left neck.The surgery was fast and without complications. The surgeon found the node easily with my blue mark. The left neck node was "killed" by injecting small amount of ethanol directly into the cancer node. The blood flow by power Doppler was destroyed by the ethanol. The cancer marker decreased and she was followed yearly for 2 years without recurrence.

Two new tools added to treat our thyroid cancer patients

PEI for treating cancer nodes
USG Methylene Dye for localization of cancer nodes for the surgeon.

Dr.G.

Gangster with Graves' Disease

Jimmy Breslin's new book "The Good Rat" tells the story that Salvatore "The Bull" Gravano developed Graves'Disease. He became quite sick with hyperthyroid symptoms, after ratting out mob boss John Gotti. He had pulled out his hair, and left a head that was bald and pink.Folds of flesh hung around his eyes.Because Mr.Breslin feels politicians are as crooked as mobsters, he would not be surprised that the first President Bush had Graves' disease during the first Gulf War.

Thyroid Cancer Radiation Therapy USA Today Front Page Story

This article, "It kills thyroid cancer, but is radiation safe?, by Sternberg, and DeBarrios in the November19 USAToday, is full of facts about radiation therapy with radioactive iodine131, RAI/131 for well differentiated thyroid cancer. It is also full of errors.
Paragraph 5. The claim that RAI/131 is responsible for 97% survival rate is dead wrong.
The vast majority of Thyroid cancer is low risk, and would survive WITHOUT radioidine.
Good surgery, and thyroid hormone are the keys, not RAI/131.
Paragraph 13.The statement that things you touch become radioactive is very misleading.The patient is emitting gamma rays from the neck. The radiation on your fingers and clothes is beta radiation.It is not like gamma, or Xrays. It can not travel more than a millimeter.Washing your hands, dishes and clothes will remove this very very low risk radiation.
Gamma,and Xray penetrate, while gamma most be swallowed.
Paragraph 20. The physician states only two things can go wrong with RAI/131 therapy.
In addition to his joking about dropping it on his foot, there are acute radiation effects to the salivary glands, including painful swollen salivary glands, dry mouth, and increase incidence of solid tumors.
Paragraph28. "Thyroid cancer has a mild reputation because I-131 treatment is so effective, for most forms of the disease." That is flat out wrong. The disease is mild
because it is removed at surgery, and treated with thyroid hormone to suppress the TSH.
To credit RAI-131 for curing patients is a gross over-statement. Since sensitive thyroglobulin TG cancer marker testing, and endocrine neck ultrasound, there is less need for the previous cancer follow up method, total body I-131 body imaging. Also with lower and lower limits of the TG assay, low dose I-131 ablation of the remnant normal thyroid left after surgery is less necessary.Therefore even low dose I-131
is either not necessary in most low risk cancers,or has radiation exposure effects
that did not help them, but could cause problems years later.
Paragraph29.
A distinguished cancer surgeon over states the case for the so called "magic bullet".
Quote" RAI-131 goes straight the thyroid cells, and kills them". Radioiodine 131, does not just go to the thyroid cells as stated. The total body scan shows uptake in the breast, kidney, bladder, and brain, and thyroid. Late onset cancers of these organs have been shown to occur from I-131.
Paragraph 30.
"Doctors likely will be using I-131 more often as time goes by." This hopefully is also wrong. Low risk thyroid cancer, the vast majority of all thyroid cancers, is being treated with less I-131, or none, as diagnostic cancer markers and endocrine neck ultrasound become the tests of choice for cancer follow up, allowing more accurate measure of cure, without outdated frequent I-131 body scans. Also the practice of chasing lymph nodes with I-131, when it is a poor method to cure neck node disease, is hopefully on the way out as a common practice.
Paragraph 31.
"About 90% get treated with I-131." Wow, 90 % are low risk cases, and I-131 is not of value in these cases, but it is still dished out as if it was a cure all This is true, but is too high with modern diagnostic studies. After total thyroidectomy, and a suppressive dose of thyroid hormone, in a low risk case, with very low TG cancer marker, and negative endocrine neck ultrasound, makes I-131 unnecessary, and not needed in most cases.Many centers have markedly decreased their number of new cancer cases treated after surgery with I-131.
Paragraphs 34-35
Second hand radiation is a problem for uninformed patients. all patients in my practice are given intense teaching to avoid second hand radiation.The NCRPM 200 page guidelines work if the physicians take the time to educate as well as treat.
Paragraph 44.
Wow, 50% treated patients get nausea? 8% vomit?. I have treated with I-131 since 1974 in my office, and had only one patient vomit. Nausea is more likely from the Thyrogen R given before the I-131 dosing occurs.

This type of article is not helpful to patients. It is full of less than accurate information.
Low risk patients, do not die, but need to be followed for recurrence.
TG, and neck ultrasound are better at finding recurrence, than all the I-131.

Bloody Bad Thyroid Smears Can Lead to The Wrong Diagnosis

81 year old male comes to see me for a second opinion. He was told he had a tumor of the thyroid called follicular neoplasm. He was told it was a 20 % chance it was cancer. As part of my routine evaluation, I obtained the biopsy material from the hospital. The physician was a general endocrinologist, at one of the top hospital centers in the USA. The smears were very poor. They was air dried artifact resulting in enlarged cells suggesting cancer. There was blood obscuring the cellular detail. Even more disturbing was the presence of Thin Prep material. Thin Prep is for cervical pap smears. They are not useful for thyroid FNA. The Thin Prep material was used to make a diagnosis pushing the endocrinologist to recommend surgery. The ( physician did not know that a thin prep was obtained. The pathologist told me they do it because the smears are commonly poorly done, yielding bloody unreadable material. She stated that the thin prep, made by washing the needle into a solution, is a fall back to try to save the case from an inadequate result. I told her she needed to get all her referral physicians to make better smears, rather than using another poor method. I repeated the FNA with smears only, with good technique, and the result was a benign thyroid nodule. This 81 year old did not need a surgery, with it's increase risks for hospital complications.

What should the endocrinologist do about the poor material he gets ?
They need to use the cytology version of the old real estate saw,"location,location,location", and substitute "smears,smears,smears".
( This was a quote from John Abele MD, expert thyroid cytologist )


What does the pathologist do?
They need to be up to date, and not use incorrect methods to correct a problem only solved by workshops on smearing technique.

What to do as a patient?

Always get another opinion on your thyroid FNA. There are many pitfalls in doing the FNA, making smears, and assuring that the material is properly handled by the pathology people. Finally reading thyroid smears is one of the hardest jobs for a pathologist. When told you need surgery, and before you see a surgeon, get the slides reviewed by an expert, during a second opinion visit to a clinical thyroidologist. Try www.thyroidologists for one of our members, or come to see me.


Until the next thyroid rounds,

Dr.G.