His Thyroid Cancer didn't take up Radioiodine. Was this a true test, or hidden contamination by unknown iodine intake?

41 year old male had a well differentiated papillary thyroid cancer removed and was in the process of receiving radioiodine treatment, when it was noted on Ultrasound that a mass was seen in the thyroid area. The biopsy, and
washings for cancer marker,thyroglobulin were positive.
The whole body scan with the TSH > 110 was negative although there was an obvious cancer mass present. I put the patients on low iodine diet, but do not routinely get
24 hour urine iodine to look for unknown sources of iodine contamination. The failure to take up iodine is not a good sign, therefore, I needed to be sure this was true.After his surgery, to remove the mass and strip the nodes, I have set up a protocol to insure there was no iodine contamination. He denied any iodine contrast before the first body scan, and claimed to be strictly on the L.I.D.
The patient will be withdrawn from LT4 and then withdrawn from LT3. 2 weeks of L.I.D will follow. A 24 hour urine for iodine and creatnine will be done. Lithium, a drug known to block release of iodine from the thyroid, will be given for 5 days to "hold" the iodine in any remaining thyroid cancer, or normal thyroid tissue. One last try at getting uptake will be with 100-150 Millicuries I/131. A body scan at day 7 post therapy will tell us if he truly has a thyroid cancer that does not allow us the ability to use radioiodine in his future care. The loss of the ability to take up radioiodine is a sign of a more aggressive tumor. Alternative methods to follow patients, will have to include, in addition to ultrasound, thyroglobulin, MR, and CT, a P.E.T. scan. However positive areas on P.E.T. can not be treated at the present time, unless they can be found on CT, and then surgically removed.

Happy New Year,

Dr.G.

Is Low Level Radioiodine Exposure Harmful?

According to studies at Fred Hutchison Cancer Center in Seattle, on 3440 subjects born near Hanford Nuclear Site in the 1940's, there was no increase in thyroid cancer,thyroiditis,or hypothyroidism. 1986 it was revealed that Iodine/131 was released from the site from 1944-1957. The subjects were exposed to a median dose of 97 mGy.
From 1992-1997 they were examined, had ultrasounds, and a needle biopsy if indicated.
Ionizing radiation does cause thyroid cancer, but low level exposure through ingestion of milk containing I/131 was not associated with increase cancer risk in this study.

I have several thyroid patients from the Hadford area, and they were glad to hear that their thyroid problem was not due to secret nuclear testing by the USA at Hanford.

Happy New Year

Dr.G.

Ref: Scott Davis et al, JAMA 2004;292:2600-2613

World Iodine Excess/ Deficiency / Thyroid Health

Thyroid Health


In the last 10 years there has been a reduction in the number of countries with a public health problem due to Iodine deficiency ( 110 countries in 1993 had a problem ). In 2003 only 54 countries had a continuing health problem. Iodine deficiency is a significant cause of mental developmental problems in children. The plan of universal salt iodization, has been successful, but more needs to be done. Soil iodine deficiency, leads to low levels in food, and results in the thyroid gland failing to make enough thyroid hormone. The result is a series of functional, and developmental problems called Iodine Deficiency Disorders. Cretinism is the most extreme problem. However, the subtle disorders leading to poor school performance, reduced intellectual ability, and impaired work capacity, are the main reason for the universal iodization program. The USA is sufficient in iodine, except in young women during pregnancy.Some need iodine added to their vitamins during pregnancy.

29 countries have excess iodine intake. Excess iodine can be a problem for patients with thyroid diseases such as Hashimoto's thyroiditis. Iodine induced thyroid disorders, can cause hypothyroidism, hyperthyroidism, nodules, and goiter. People with goiters from iodine insuficient areas of the world, can develop toxic hyperthyroid goiter years after entering the US, caused by the increase in iodine intake in our country.

Dr.G.
www.thyroid.com

Toxic Hot Nodule and Cancer?

Thyroid Case of the Week.

40 Y/O female, was noted to have suppressed TSH ( <0.01 ), during an infertility evaluation.
Asymptomatic. Has had a suppressed TSH for 2 years.
Father: Hyperthyroid on Antithyroid drugs
Mother: Hypothyroid on thyroid hormone.
Infertility for 2 1/2 years
Ultrasound: 1 cm mass is noted in her left lobe. Right normal normal.
Thyroid scan: Hot left lobe with suppressed right lobe.
A diagnosis of Autonomous hot nodule with subclinical hyperthyroidism was made.
Normal uptakes at 6/24 hours.
FT4,FT3, TPO, TSI all normal.
Because of her age, and her desire to get pregnant soon, she was offered surgery, instead of radioiodine.
Surgery :left lobectomy.
Pathology Papillary Thyroid cancer, with 1 node positive.
Post surgery Thyroglobulin 10.3 This is consistent with output from a single remnant right lobe.
Second surgery: Right lobectomy: Normal thyroid, but 1/3 nodes positive.

Comments.
I have never seen a hot nodule produced by a papillary thyroid cancer.
Follicular cancers if they are > 4 cm may make one toxic with suppressed TSH.
I do not understand this case. I can only speculate that the cancer was near, but not
the exact area that produced increased iodine uptake.The patient has a normal TSH post lobe removal TSH 1.4. The cancer is being treated by thyroid hormone suppression, and follow up with ultrasound, and Thyroglobulin. If there is persistent TG in 3-6 months, Radioiodine will be used. She still wants to get pregnant ASAP.

Dr.G
www.thyroid.com

Deborah Norville's Thyroid ?

It has been several weeks since I posted my observation related to a possible mass in the thyroid area on Deborah Norville.I noted this while watching her MSNBC news show. She has not emailed back. I hope I was wrong, or that she went to her doctor to check out my observation. Some people will not acknowledge my email, but go for a check up anyway. I wish her luck.

Dr.G.
www.thyroid.com

New Year 2005 Thyroid Blog

Well, I finally found a weblog home at blogger.com. My two previous attempted sites were not very user freindly.
Welcome to The Thyroid Blog.
The first entry will follow on 12/28/2004.
thanks,
Dr.G.

Does Deborah Norville have a Thyroid Goiter?

Deborah Norville Has a Thyroid Goiter! While watching MSNBC's news show with Deborah Norville, I was struck by the mass in the area of her thyroid in the midline. Does she know she has a thyroid problem? It was clearly moving up and down while she talked and swallowed. If you look at the neck of someone on TV, you may be able to see an enlarged thyroid or nodule. I have picked up goiters while watching TV, but not all the people were glad to hear from me about their problem. Several have come to see me for treatment. I do not know if she knows she has a goiter, but I will email MSNBC to tell her about my finding. In 1974, I was just starting my thyroid center, and still did not have my office built out, when watching a local news show, I noticed the anchor had a lump in her neck. I was excited to see if she knew about the lump. I called her. She was unaware of the thyroid problem. She wanted to see me right away. I had to use another physician's office for the examination. I did a needle biopsy. It was a pure cyst. She was very happy it was not cancer. Dr.G.

Chief Justice of the Supreme Court, William Rehnquist Update

Rehnquist Update: The press release today stated he would not be on the bench for oral arguments on Monday.This still fits with my original thyroidblog report when he was first diagnosed with thyroid cancer.I predicted he would not return to the bench due to anaplastic thyroid cancer. I am sorry I was right, and hope he has a peaceful few weeks left. Usually chemotherpy, and radiation are not very helpful with this very aggressive tumor. The added side effects are not worth the use in my experience, except to relieve pain, prevent obstruction, and allow him to breathe. His doctors should make him as comfortable as possible, and we can all hope for the best. His diagnosis is still a big secret, but the history points to anaplastic as the best fit. Dr.G.

Prostate Cancer brachytherapy may expose the thyroid gland to radiation?

It seems a long way from the prostate to the thyroid gland, but the tiny seeds implanted in the prostate, which contain radioactive iodine, may break open and release I/131 iodine into the blood stream. The thyroid is the main site for uptake of the iodine. Cleveland Clinic doctors describe a case where there was increased uptake of the radioiodine in the patients thyroid gland.The doctors looked for seed migration in 246 cases. 23,184 seeds were implanted. 75 seeds were released into the urine, while 25 migrated to the chest.The case with the thyroid radiation probably had the seeds damaged inside the prostate, releasing I/131 into the blood stream, where it would head to the thyroid for uptake. The use of this type of therapy is on the increase. If the radiation dose to the thyroid is above normal, they can block the radioiodine uptake with iodine solution, or KI. Any radiation to the thyroid is significant, and therefore this may be another source of radiation induced thyroid disease.The thyroid doctor may need to ask about the type of prostate cancer therapy in his history taking from now on. Read the whole article at Journal of Urology Nov 2004.

Seaweeds Part 2

They are increasingly common now in food and food suppliments in the U.S. 15% of Americans enjoy Japanese cooking. They are considered an all natural source of minerals.Seaweeds are used for flavoring in Asian soup stocks, and other dishes where they remove the seaweed before serving. What is the effect on thyroid patients that are sensitive to iodine? Normals will escape from the effects of excess iodine, but patients with autoimmune thyroid disease will have negative effects. It can cause hypothyroidism in Hashimoto's thyroiditis, with growth of the goiter and even nodule formation. It can cause toxic hyperthyroidism in patients with nodular goiter. The problem is difficult because of the variation in iodine content of different seaweeds.People in Japan and Korea are habituated to their high iodine intake, but people with thyroid disease in low iodine consuming countries are at risk for iodine induced thyroid disease.

Seaweeds are usually considered high in iodine content

Seaweeds are usually considered high in iodine content, and can cause problems for thyroid patients. However there are many types of seaweed. Korea, and Japan have over 60 species of seaweed. Food preparation can effect iodine content of seaweed. Nori the flat sheets used for sushi has a small amount of iodine, compared to Miso soup. Kelp flavored stock is used to make miso soup. The soup then has over 1000 mcgs of iodine! The cooking in water releases the iodine into the broth.This level of iodine can cause progression of thyroid disease in susceptable thyroid patients. All seaweeds are not equal in causing problems. Ground kelp has 8000 mcg/gram, Kelp 2500, Dulse 72, and Nori has 16. Young seaweed, and floating seaweed have higher iodine than sundried seaweed.Review the article by Braverman before you decide what type of seaweed you should eat. Thyroid vol.14 number 10 2004, page 836-841.

Potassium Iodide, KI, can flood the thyroid with iodine

Potassium Iodide, KI, can flood the thyroid with iodine, and prevent cancer causing radioactive iodine 131 from entering the thyroid gland after an accident or terrorist attack on one of our nuclear power plants or a dirty bomb. The use of KI was offered to states, but only 50% of them have agreed to stockpile them.They refused the KI because they felt people would feel they could stay at home if an attack occurred.You must evacuate and take the KI. The American Thyroid Association recommends KI for up to 200 miles surrounding the accident site. That was learned from the Chernoble accident in Russia. The KI only protects you from thyroid cancer, but not from the acute effects of radiation. Therefore, take your KI pill, as you drive away from the accident site. Dr.G. It is a month, and Judge Rehnquist has failed to return to the bench. This is further evidence he may have the severe form of thyroid cancer called anaplastic.

Anaplastic Ca is a rapidly fatal variant of thyroid cancer

Anaplastic Ca is a rapidly fatal variant of thyroid cancer. They rarely live more than 6 months from the time of diagnosis. M.D. Anderson Cancer Center prolonged the median survival of 30 patients to 10 months. The combination of surgery, radiation, and chemotherapy resulted in a 10 month median survival.27% of the patients lived 3 years. More research is needed to improve the dismal outlook for patients with anaplastic cancer of the thyroid.

Anaplastic Cancer

A patient called me today to tell me his mother died of anaplastic Cancer. The story was similar to Judge Rhenquist. She developed a rapidly growing lump, and when the surgeon went in, there was no way to remove the thyroid, and he just did a tracheostomy. She had some radiation therapy, and chemotherapy, but died within 3 months oif the diagnosis. The family was worried it was genetic.One even wanted to have thyroid surgery to prevent this happening to him! It is not a family cancer. It is very rare. It is usually found in elderly patients.

Maggie The Female Orangutan

Maggie the female orangutan at the Brookfield Zoo in Chicago was overweight, slept alot, snored, suffered constipation, passed excess gas. All attempts to lose weight failed.The male orangutans were not interesting to her sexually. Another orangutan was diagnosed with hypothyroidism at another zoo.Special thyroid testing by a University of Chicago endocrinologist confirmed hypothyroidism in Maggie. She has lost weight, and now is interested in the males, after therapy with thyroid hormone returned her to normal.

Reidel's Struma

The patient today has a rare thyroid disorder. It is called Reidel's Struma. She developed shortness of breath when she turned her head. The left lobe of her thyroid was woody hard, and it crossed the front of her airpipe. The use of steroids failed to improve the obstruction. She had a very difficult surgery to remove the thyroid tissue blocking her windpipe. This worked for a few years, but the symptom returned.I felt a hard mass again over her windpipe. Last weeks biopsy confirmed a recurrence of Reidel's disease. Today, she was told of the recurrence, and we tried to work out a new plan.She agreed to try Tamoxifen. There are published reports of it causing a regression in the fibrosis, and relief of obstruction. She realizes that if this does not work, she may need another surgery. This is an invasive non-cancerous fibrotic disease that invades the tissue outside the thyroid.There is no known cause, and steroids are usually effective. It can recur as in my patient. It is not Hashimoto's Thyroiditis. It can mimic a cancer. In my 30 years of thyroid private practice, this is the first case. However, at USC, I have seen 3-4 cases.

80 Year Old Female with a Large Growing Goiter

The patient today is an 80 year old female with a large growing goiter. She was told to have surgery. The biopsy was negative for cancer. The goiter was causing some obstructive symptoms. She returned today 2 years after she refused surgery, and elected to be treated with off label thyrogen to boost the thyroid uptake, which was low in her case. The uptake increased to 45% after thyrogen and I treated her with 30 Millicuries of Iodine/131. She has been symptom free and her goiter had decreased to the point it was not visible from across the room, as it had been 2 years ago. The use of Radioiodine therapy, with a boost in the thyroid uptake with thyrogen has allowed me to treat patients with this less invasive therapy, compared to standard thyroid surgery.

Chief Justice Would Not be In To Work

One day before the elections, they announced that the Chief Justice would not be in to work. They stated he was home getting outpatient radiation and chemotherpy. This information finally cleared up the situation about Rehnquist. The use of these agents mean he has anaplastic thyroid cancer. This should have caused a rush to the poles for those democrats that would like to add a less conservative justice to the court. There was no mention of this as a reason to vote at exit poles.

The government was able to keep this story under wraps until the election was over. Now GW Bush will be able to replace him, and not JFKerry. Dr.G.