Cancer Surgery Pre-Operative Lymph Node Evaluation is Important

With the new high frequency ultrasound machines, it is now possible to evaluate the lymph nodes in patients with proven papillary, follicular, or medullary cancer on FNA, prior to the surgery. This will allow the surgeon to add a lymph node removal to the total thyroidectomy and central compartment surgery.Here is a case.

61 Y/O female with FNA proven papillary thyroid cancer on USG FNA, returns for a pre-op neck US lymph node evaluation. There are 3 nodes located lateral to the primary thyroid cancer thyroid nodule. They are suspicious as they do not have hilar lines. These are found in benign nodes, and disappear in cancer nodes.There is chaiotic blood flow in the nodes, on power doppler. They are tall compared to width with a ratio >0.5. Biopsy was positive for papillary cancer, and the Thyroglobulin washings were positive for high levels of TG in the node. The surgeon was notified about positive nodes in zone 4 on the right lateral to the thyroid mass. He was advised to consider node removal along the whole right jugular chain at the time of the standard total thyroidectomy, and central compartment node removal.

What this means to patients with biopsy proven cancer, is that they need a diagnostic Neck lymph node ultrasound with new high frequency untrasound machines, and if a suspicious node is found, then an USguided FNA, and Cancer Tg washing should be done.
This will result in a change in the surgery if positive.


Dr.G.

The Absent Thyroid Lobe or Thyroid Hemiagenisis

The last blog about a patient born with only half of a thyroid, was followed by questions of why, from emailers ?
Well, there are some 100 cases of failure to produce a thyroid lobe.Usually it is in a female, and 75% on the left lobe.There is a high degree of disease in the opposite lobe. The most common disease is Hyperthyroid Graves'. Absent thyroid lobe was found in less than 0.01% of 24,000 screened children. There is an even rarer type, that includes the isthmus. My patient had absent isthmus and left lobe. She also had a nodular cystic goiter in the remaining lobe. The past work up included thyroid scans before and after Bovine TSH Stimulation. Now the ultrasound allows early definitive diagnosis. Failure to know about this can cause patients to become hypothyroid after unilateral lobectomy. If the lobe is absent, the patient needs thyroid hormone therapy. Usually, if the lobe is normal, and present, the patient may not need thyroid hormone after lobectomy.


Dr.G.

What Happened to the Left Lobe of my Thyroid?

40 Y/O female presented with a right side 2.5 cm nodule felt by her internist.She was euthyroid, with normal TSH, negative TPO antibodies. A large mass was visible from across the room. The left lobe was not palpible. The ultrasound confirmed the presence of a complex cystic mass. However, when we looked at the left lobe it was absent!
She asked me what happened to her left lobe, if she did not have surgery? This is a rare congenital defect. total absence of the lobe, plus isthmus. This will not impact the overall thyroid problem, but if she needs surgery, to remove the right nodule and lobe, she will be rendered hypothyroid, and will need to take thyroid hormone.Her work up for the nodule was negative, and she was treated with thyroid hormone.

Dr.G.

Pregnancy Problems without Support from her Thyroidologist

32 Y/O female calls about her thyroid condition after 2 misscarriages. She is my patient, and was treated with radioiodine for Graves' Disease 3 years ago.She was last seen 2 years ago, and stated she was seeing her internist for her thyroid hormone RX's, and did not feel she needed to see me. During the last two years, she had two miscarriages. She a prior a prenancy which resulted in a healthy baby. The last one prompted her return for my opinion. She had elevated TSH when she last conceived ( TSH 7.0 ). She took prenatal vitamins which contained iron, at the same time as her thyroid hormone.She stated none of the other doctors, including her OB told her iron caused decreased absorbtion of the thyroid hormone,. and hypothyroidism. She also was never told that she needed prenatal vitamins with iodine during the pregnancy. However she was lucky, that the vitamins, called
Citracal had 150 mcg of iodine. She was never told of the potential danger of the Graves' thyroid stimulation antibody, TSI, which can not hurt her, because she had her thyroid gland destroyed by Radioactive iodine, but could stimulate her baby's thyroid, causing Neonatal Graves Disease. This is a rare, but serious disease she could pass to her baby. A blood test, which was never done in the two pregnancies, could have diagnosed this and allowed early therapy. I told her she was high risk, due to her Graves' thyroid diease and therapy, and needed to be sure her TSH was normal 0.5-2.0, before conception. IQ and neuologic problems occur if you are hypothyroid at conception. Also 6 weeks after conception, there is a 20-50% increase in thyroid hormone needed during the pregnancy. Finally, The thyroid blood hormones need to be kept in the upper normal range, during the pregnancy, and 6 week post delivery, there is a lowering of the dose back to pre-pregnancy levels. She felt she did not need me during the prior pregnancies, but clearly realized she was wrong. I am monitoring her thyroid status this time.


Dr.G.

40 Years after a Total Thyroidectomy, a thyroid nodule is found.

A 60 Y/O female, decides to have her thyroid re-evaluated,after her 2 children were found to have thyroid disease. She had her thyroid removed 40 years ago, and remembers they told her they left 1/16 of the thyroid.She also remembers that gland removed, was not harboring cancer. She took thyroid hormone for 40 years until her visit to see me, for replacement therapy, after the surgery.She does not recall any other therapy, such as radioiodine after the surgery. She had a 1-2 cm nodule in the right lobe.It was firm.There was a well healed thyroidectomy scar. He thyroid tests were normal, including TSH on LT4 therapy, and TPO antibody.
The ultrasound showed absent left lobe, but a right lobe with a nodule with coarse calcifications. The nodule had an irregular shape. Because of previous surgery, and the low risk situation, I elected to scan her with I/123. The right lobe was present with a cold nodule in the area of palpated mass. There was faint uptake in the left lobe. I elected to do an ultrasound guided biopsy of this calcified mass, because there was no way to get the medical records, pathology report, or slides from a 40 year old surgery in the southern state of Georgia. I expected the biopsy to be a remnant benign goiter nodule, or Hashimoto's thyroiditis that had recently involved the thyroid tissue left after the original surgery. I was shocked to see papillary thyroid cancer staring up at me from my microscope!
This is a good lesson for us thyroidologists. If you can't get the old records, including the original pathology report and slides, you must treat the case as a new case, and do a complete work up. The coarse calcification 40 years after her surgery was a red herring. She will have a pre-op neck lymph node evaluation, to see if the cancer has spread to her nodes, and will have a node biopsy if I find any suspicious nodes. This will add a node removal to the surgery. If the neck nodes are negative, I will ask the thyroid surgeon to remove the remaining thyroid,nodule, and clean out the central compartment.

Dr.G.

The Growth Hormone,DHEA, Bioidentical Estrogen, and Thyroid Hormone "Cocktail"

61 Y/O female was referred by her worried primary care physician.She had seen a doctor in Beverly Hills, who wanted to treat her with a cocktail of Human Growth hormone, DHEA, bioidentical estrogen, and thyroid hormone T4. He asked her to see me before starting the thyroid hormone. She has all the classic symptoms of hair loss, low body temp., fatigue, constipation, dry skin, and depression. The physical exam was normal. The thyroid was not enlarged, no nodules were felt. To complete the exam, a thyroid ultrasound was done to be 100% sure the thyroid was normal structurally. It was normal in size and sound wave texture. The thyroid tests were also normal, including TSH of 1.8 normal 0.4-4.0. The doctor in B.H. told her the symptoms were due to thyroid deficiency, even though the thyroid blood testing has always been normal, including 2 years ago when another alternative physician in Santa Monica gave her thyroid hormone for 6 monhs without an improvement in her similar symptoms. She told me the BH physician adds thyroid to all his patient's hormone "cocktails", even if all thyroid tests are normal. To help her to decide not to go back to that doctor, I even did an ultrasound to prove that she had a lovely normal thyroid that worked perfectly well.Taking thyroid hormone would not help, but could hurt her in the long run.Bone loss, and heart problems were a real possibility in her age group.

Remember, symptoms are non-specific, and must be confirmed by thyroid hormone blood studies.

Dr.G

Alcohol Injections for Toxic Nodule?

43 Y/O female with a long history of refusing surgery, or radioactive iodine for a toxic nodule, presents with information obtained from the internet, about alcohol injection to destroy her toxic nodule.She dose not want radioactive iodine or surgery.The mass is 5x4 cm in size.It is mostly solid. The TSH confirms hyperthyroidism, <0.01. I told her that her large non-cystic toxic nodule would probably be reduced in size with alcohol by 60%, but only 20% chance of a cure of her hyperthyroid state with a return a normal TSH. This is a poor form of therapy for solid toxic nodules. There is 100% success with surgery, or radioiodine in curing the hyperthyroid state,and reducing, or removing the toxic nodule.

It is vary hard for patients to read the medical journals, and plan a therapy course.
Most experts have given up using alcohol to treat solid nodules, and reserve it for cysts.Cyst therpy with alcohol,however, is very effective.


Dr.G.

Medullary Thyroid Cancer with Low levels of Calcitonin years after the Surgery.Where is the cancer located?

Many patients have cancer marker for medullary thyroid cancer, years after the surgery. PET Scanning, MRI, CT, and Iodine scanning are usually negative. Where is the cancer?
A 52 Y/O female, 10 years after total thyroidectomy for medullary thyroid cancer sees me for a second opinion.She has a calcitonin of 35. Her pre-surgery calcitonin was 11,234. She knows she still has some cancer, but she is disturbed, that physicians can't find it. Also, she has a mother with the same disease. However, she is afraid to have her kids screened for the disease, because she is worried, they wont be able to get medical insurance, if they are found to have the same cancer. Her neck examination was negative except for a thyroidectomy scar. However, I was able to find, with the new high frequency Italian Ultrasound, several abnormal tall nodes in Zone 4 lateral to the thyroid bed,that had the findings of suspect cancer nodes. Using modern ultrasound methods, a biopsy of the largest node was performed, and washings from the aspirate from the node was positive for calcitonin. The patient is having a lateral neck lymph node surgery soon. As for the 6 children, who have not been sceened for cancer, they have set up appointments for DNA studies to see if they have the gene for this cancer. If they have the gene, and are treated by total thyroidectomy before the cancer occurs, they will be cured, and will never have the cancer at all.
They will be able to have medical insurance coverage, as the diagnosis was pre-cancer.The ones with the cancer will be picked up early with the best prognosis for long term survival.

Remember,if you have cancer marker for thyroid cancer, thyroglobulin TG, or Medullary cancer marker, calcitonin, and all the studies are negative, you need a complete neck cancer lymph node evaluation by a thyroidologist with high frequency ultrasound equipment, to look for the location of your residual metastatic cancer, which is surely there in the neck.

Check www.thyroidologists.com, for one of our thyroidologists near you.

Dr.G.

The Academy of Clinical Thyroidologists' Website Launched

4/19/2005

www.thyroidologists.com


The temporary website for the new society of clinical thyroidologists is up with a list of thyroidologists from around the country that practice clincal thyroidology almost exclusively. The site is www.thyroidologists.com. These physicians are meeting in Washington DC on May 22 2005 to begin the process of starting our society. The list is not complete, but will increase when we locate other clinical thyroidologist.These
physicians will be able to take care of any thyroid problem you may have. Visit them
for a thyroid evaluation soon.

Dr.G.

What is the difference between a Diagnostic Ultrasound and one done to guide the needle for a thyroid biopsy?

45 Y/O male sees me today for a second opinion. He has a large thyroid nodule, noted on
Chest Xray, and CT scans. An ultrasound guided biopsy was done.They only looked at the nodule, to aim the needles. There was no diagnostic U.S. done. When I saw him, I did the diagnostic U.S. with the new high freguency U.S. from Italy. There were multiple abnormal nodes directly next to the nodule. Some had a cystic component. These were 7-9 mm tall.They are suspicious for metastatic papillary thyroid cancer, and need to be biopsed, and a washing taken for thyroid cancer markers. His HMO failed to do a diagnostic U.S. and set him up for surgery. It is necessary to know about the nodes, BEFORE surgery, as it can change the extent of the surgery.
Beware of rushed and incomplete evaluations at HMO's, before they send you to surgery.
Anyone referred for thyroid surgery, should have a neck lymph node U.S. prior to the surgery, even when the biopsy is definitely positive for cancer. Positive nodes by node biopsy, will change the extent of the surgery to include central, and lateral neck node removal.

Dr.G.

Thyroid Surgery What are the risks?

Recurrent nerve injury accounts for 2-3% of medical legal claims in general surgery.
Identification of the nerve is a key to reduction in nerve injuries.

Nerves not identified during the surgery 5.2% nerve injury
Nerves identified during the surgery 1.2% nerve injury

Parathyroid Calcium damage 1-4% present incidence
This is due to these procedures at surgery
Routine idenification of the glands at surgery,
preserving blood supply, autotransplantation
of parathyroid glands damaged and without blood supply.

Experience of 50-150 thyroidectomies a year by the surgeon, results in the lowest complication rate.
Check out the surgeon before you sign up for the surgery

Dr.G.

Who Should Do Your Thyroid Surgery?

60,000 thyroidectomies were performed in the US in 2002.
This is the most common surgery done, even more than hernia repair! Remember the volume of cases per year is a key factor in short hospital stays, and a reduced complication rate for coronary bypass surgery, transplants, value repalcements, and pancreatic cancer surgery. Well, it also applies to thyroid cancer surgery. During 1991-1996, in Maryland, the high volume thyroid surgeons, had the best results! The one surgeon that did 346 thyroidectomies over 6 years, or 60 per year had the best results! Thyroid Vol.15 #3 p.185-187, 2005
The range of complication rates reported.
Permanent Nerve Damage 0%-14%
Permanent Parathyroid Damage 1.2-11%

Where do you want to be after surgery?
I would want to be in the 0% or 1.2 % group, who took the time to research the surgeon before letting them put me under their knives.

Many HMO's let any general surgeon, or ENT, or head and neck surgeon do thyroid surgery. Think twice before allowing this to happen to you.

Dr.G.

Black Thyroid / A Rare Complication of Acne Therapy

No,this not some plot by the dark forces to invade the thyroid gland.
A 32 Y/O female presented with a cold nodule. The ultrasound guided biopsy was done, and when the slides returned to review, I was shocked to see all of the thyroid cells had black pigment granules in them. This was 4+ in every cell.The biopsy was negative for cancer, and was a colloid nodule. Years ago I did some research with a new drug called minocycline, Minocin R, and remembered it could cause black pigment in the thyroid gland in animal studies. I called the patient and asked her about acne therapy. She took Minocin for years for acne. The human cases with black thyroid are rare. Several cases were similar to this case, with black pigment in the colloid nodule. One had no pigment in the surrounding thyroid tissue, and the other had black pigment in the nodule, but also in the rest of the gland.There is no data about this pigment causing any functional problem of the gland.The exact cause of the pigment is unknown.

Dr.G.

Why Generic Substitution is Bad for Thyroid Patients

FDA considers generics equal to Synthroid. They are dead wrong. They are using the wrong standards to test the drugs.They used healthy volunteers instead of thyroid patients.They used T4, not TSH as the standard. If a generic was within 33% of Synthroid it was considered equal. Even with the new FDA baseline correction they were still 12.5% difference from Brand, and called equal! Wow, 12.5% is enough to throw your treatment off.If you get generic at the drugstore you would need another test in 6 weeks because it was a different amount, with the same dose on the bottle! How many of you are asked to get retested when they switch on you? The PDR calls for retesting after generic substitution.A recent study found 25% with significant change in there blood TSH tests with generic substitution. The groups most at risk are the elderly, from lipid,osteoporosis and heart complications from over, or underdosing that occurs with generic switching without retesting. Pregnancy also is a dangerous time for generic substitition. Thyroid cancer patients receiving T4 for supression of cancer growth could have either overdose, or underdose if substituted without a retest. T4 suppression is, after total thyroidi9ectomy, the best way to insure a relapse free course of your cancer. In my opinion Synthroid is the only long standing brand name.All the rest are generics to me. However the FDA calls Unithroid, and Levoxyl brands also.What to do if they try to substitute?
Be proactive and say "NO".

Dr.G

Levothyroid not the same drug!

Levothyroid is not the same drug.It is Novothyrox, and is not listed as an AB,1,2,3 drug that can be the same as any branded T4! The FDA allowed them to keep the name even though it was a different drug entirely. It is not listed as an FDA approved generic that is equal to the branded T4's. Consider talking to your doctor, about switching to a branded T4.

Dr.G.

T4/T3 Combination Therapy

The thyroid patients have been told by alternative physicians that recent studies
had proven that T4/T3 combos were better that monotherapy with T4.The New England Journal of Medicine article which sparked the combo idea, has not been confirmed in multiple studies since.Siegmund at al, showed no superior effect over monotherapy.They used 5% T3 substituted for T4. Clin Endo 2004:60,750-757. Also the TSH was more suppressed with the addition of 5% T3! Mood scores,and cognitive function were not inproved with T4/T3 combos. Escobar-Morreale, et al in Annals of Internal Medicine, 2005;412-424, used 7.5 mcg T3 plus 87.5 mcg T4, and compared with straight 100 mcg T4.The results were lower FT4, decreased TSH, unchanged FT3,and no difference in outcomes in the two groups. fatigue,depression,digital span, and general health scores were the same. When your doctor, or a website such as about.thyroid.com talks about the value of combo T4/T3 over T4 alone, quote these articles. Also remember, Armour is the original combo pill with both T4and T3 in a pig's ground up thyroid extract.Avoid that as well as other combo pills, such as Thyrolar, on the market.

D.G.

Rehnquest is still alive

Six months after surgery that did not include removal of his thyroid, but did include
a tracheostomy, he is back on the bench! This is very unusual for most cases of anaplastic Cancer of the thyroid. They are usually dead by 6 months. There has been no public notice of his diagnosis, but experts felt it was anaplastic. Maybe we are wrong.
There are other diseases with longer survival that can present with findings similar to anaplastic. Medullary,Lymphoma,and Tall cell variant of papillary thyroid cancer are examples. He also could have had a rare good response to experimental therapy.
If he lives past one year I will be among the doubters, about the original anaplastic diagnosis.

Dr.G.