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.
Tuesday, November 20, 2007
Thursday, October 18, 2007
O Oprah, Get Real About Your Thyroid
Oprah Winfrey has taken the same tack as Gail Devers when Gail was first discovered to have thyroid disease.She was over the top with her explanation of the effects of her radiation therapy. Weeks in the hospital! Burned legs! All not true, but good enough for a movie deal. She has, however become a great advocate for thyroid patients ever since.The great O has stated her thyroid was blown out. And that 4 weeks of vacation to reduce stress fixed her.She stated her failure to lose weight when she was hyperthyroid, and the massive weight gain when she became hypothyroid.
The many years of weight problems well documented on all her shows.lij
The many years of weight problems well documented on all her shows.lij
Sunday, July 29, 2007
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.
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.
Friday, April 27, 2007
Kidney Cancer Presenting as a Thyroid Nodule
50 Y/O female was referred to me to evaluate a thyroid mass seen on MR to evaluate a
lateral neck mass. The mass was painless. She did not have a prior history of thyroid disease. The thyroid was nodular on the right. The neck mass on the right was 2 cm and not tender. The ultrasound confirmed a mass in the thyroid on the right, and smaller masses on the left. Masses were also noted in the area of both inferior parathyroid glands. The blood flow by power Doppler was a firestorm pattern on the right side only. She was normal by TSH,T4, and TPO antibodies. Prior FNA of the lateral neck mass was non-diagnostic. Prior studies revealed a high serum calcium. I confirmed that, but the PTH was ND. The parathyroid area masses had to be abnormal nodes. This was not hyperparathyroidism. When the calcitonin was also ND, I knew we were not dealing with a MEA syndrome, Medullary thyroid cancer, parathyroid adenoma. I decided to biopsy the neck mass,and do flow cytometry,and thyroglobulin washings to rule out lymphoma, and metastatic thyroid cancer. Both were negative. The cells seen in the neck and thyroid nodule by US guided FNA were very large and consistent with a bad cancer of unknown etiology. When she returned to discuss results, she told me she had a bump on the top of her head in the scalp, that came on the same time the neck mass was noted. It was red, and pulsated 1.5 cm in size. She was told it was nothing to worry about. I ordered a PET/CT because there was still unanswered questions on the origin of these cells. Was it anaplastic thyroid cancer, or metastatic cancer to the thyroid from somewhere else. Both of these possibilities are very rare clinical practice. Usually, thyroid mets from somewhere such as breast are incidental findings at autopsy, not presenting as a thyroid nodule. The PET/CT was abnormal. A >9 cm mass was seen in the kidney. Masses were seen in the liver, lungs, pancreas, neck lymph nodes, celiac plexis, and infiltration into the thyroid gland on both sides. The bump on the top of her hear was positive as well.
In 30+ years I have never had a case like this. Metastatic Anaplastic Ca to the thyroid from possible kidney origin. A excision biopsy of the neck mass to try to determine the origin, and a referral to an oncologist was planned.
lateral neck mass. The mass was painless. She did not have a prior history of thyroid disease. The thyroid was nodular on the right. The neck mass on the right was 2 cm and not tender. The ultrasound confirmed a mass in the thyroid on the right, and smaller masses on the left. Masses were also noted in the area of both inferior parathyroid glands. The blood flow by power Doppler was a firestorm pattern on the right side only. She was normal by TSH,T4, and TPO antibodies. Prior FNA of the lateral neck mass was non-diagnostic. Prior studies revealed a high serum calcium. I confirmed that, but the PTH was ND. The parathyroid area masses had to be abnormal nodes. This was not hyperparathyroidism. When the calcitonin was also ND, I knew we were not dealing with a MEA syndrome, Medullary thyroid cancer, parathyroid adenoma. I decided to biopsy the neck mass,and do flow cytometry,and thyroglobulin washings to rule out lymphoma, and metastatic thyroid cancer. Both were negative. The cells seen in the neck and thyroid nodule by US guided FNA were very large and consistent with a bad cancer of unknown etiology. When she returned to discuss results, she told me she had a bump on the top of her head in the scalp, that came on the same time the neck mass was noted. It was red, and pulsated 1.5 cm in size. She was told it was nothing to worry about. I ordered a PET/CT because there was still unanswered questions on the origin of these cells. Was it anaplastic thyroid cancer, or metastatic cancer to the thyroid from somewhere else. Both of these possibilities are very rare clinical practice. Usually, thyroid mets from somewhere such as breast are incidental findings at autopsy, not presenting as a thyroid nodule. The PET/CT was abnormal. A >9 cm mass was seen in the kidney. Masses were seen in the liver, lungs, pancreas, neck lymph nodes, celiac plexis, and infiltration into the thyroid gland on both sides. The bump on the top of her hear was positive as well.
In 30+ years I have never had a case like this. Metastatic Anaplastic Ca to the thyroid from possible kidney origin. A excision biopsy of the neck mass to try to determine the origin, and a referral to an oncologist was planned.
Monday, March 26, 2007
Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protein Deficency, Hypo-TBG -emia.
40 Y/O F with a diagnosis of TBG deficency since age 16. She was noted by an endocrinologist, to have a small goiter then. No therapy was directed toward the goiter. Over the next 20+ years the patient was treated with thyroxine, T3, Triac,
Armour thyroid, and large amounts of iodine containing supplements. She had multiple CT scans with iodine contrast.The low Total T4 confused the physicians, into treating her for hypothyroidism. Her usual thyroid tests were compatible with low TBG.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in iodine induced hyperthyroidism. However,there were other periods of hyperthyroidism caused by her large iodine intake. 2 years ago, a thyroid scan showed high iodine uptake and multiple hot nodules on scanning. There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome, an unproven, and dangerous T3 therapy Rxed by a physician, that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. She had a multinodular goiter with 4 autonomous hot nodules, on repeat thyroid scan, which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency, meant she was hyperthyroid. She is now off all thyroid preparations, and clean of supplement iodine, and is about to be treated with radioactive iodine to ablate the pre-toxic autonomous nodules in her goiter.
Key to case.
Hot nodules on seen on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Rare Low TBG is not a disease, and has no effects on the patient, but it can mask real disease, and in some cases cause unnecessary treatment for hypothyroidism.
Rare high TBG can cause the opposite effect. In 30 years I have stopped 2 patients from therapy for hyperthyroidism, who had excess TBG. They had high Total T4, a simple goiter, and were not toxic hyperthyroid.
Until the next thyroid rounds,
Dr.G.
Armour thyroid, and large amounts of iodine containing supplements. She had multiple CT scans with iodine contrast.The low Total T4 confused the physicians, into treating her for hypothyroidism. Her usual thyroid tests were compatible with low TBG.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in iodine induced hyperthyroidism. However,there were other periods of hyperthyroidism caused by her large iodine intake. 2 years ago, a thyroid scan showed high iodine uptake and multiple hot nodules on scanning. There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome, an unproven, and dangerous T3 therapy Rxed by a physician, that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. She had a multinodular goiter with 4 autonomous hot nodules, on repeat thyroid scan, which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency, meant she was hyperthyroid. She is now off all thyroid preparations, and clean of supplement iodine, and is about to be treated with radioactive iodine to ablate the pre-toxic autonomous nodules in her goiter.
Key to case.
Hot nodules on seen on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Rare Low TBG is not a disease, and has no effects on the patient, but it can mask real disease, and in some cases cause unnecessary treatment for hypothyroidism.
Rare high TBG can cause the opposite effect. In 30 years I have stopped 2 patients from therapy for hyperthyroidism, who had excess TBG. They had high Total T4, a simple goiter, and were not toxic hyperthyroid.
Until the next thyroid rounds,
Dr.G.
Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protien Deficency, Hypo-TBG -emia.
40 Y/O F with a diagnosis of TBG deficency since age 16. She was noted by an endocrinologist, to have a small goiter then. No therapy was directed toward the goiter. Over the next 20+ years the patient was treated with thyroxine, T3, Triac,
Armour thyroid, and hugh amounts of iodine contaning supplements. She had multiple CT scan with iodine contrast.The low Total T4 confused the physicians, in her being treated for hypothyroidism. Her usual thyroid tests were compatible with TBG deficency.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in hyperthyroidism.
However, there were other periods of hyperthyroidism caused by her large iodine intake.
2 years ago a thyroid scan showed high uptake and multiple hot areas on scanning.
There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome T3 therapy that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. she had multinodular with autonomous hot nodules which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency meant she was hyperthyroid.She is now off all
thyroid preparations, and clean of supplement iodine, and is about to be treated with radioiodine to ablate the toxic nodules in her goiter.
Key to case.
Hot nodules on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Untill the next thyrroid rounds,
Dr.G.
Armour thyroid, and hugh amounts of iodine contaning supplements. She had multiple CT scan with iodine contrast.The low Total T4 confused the physicians, in her being treated for hypothyroidism. Her usual thyroid tests were compatible with TBG deficency.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in hyperthyroidism.
However, there were other periods of hyperthyroidism caused by her large iodine intake.
2 years ago a thyroid scan showed high uptake and multiple hot areas on scanning.
There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome T3 therapy that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. she had multinodular with autonomous hot nodules which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency meant she was hyperthyroid.She is now off all
thyroid preparations, and clean of supplement iodine, and is about to be treated with radioiodine to ablate the toxic nodules in her goiter.
Key to case.
Hot nodules on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Untill the next thyrroid rounds,
Dr.G.
Friday, March 23, 2007
Rare TBG Deficiency Confuses Physicians, and They Miss Her Real Thyroid Problem.
40 Y/O F with 24 year history of decreased TBG. This rare harmless defect, should not mask other thyroid disorders. Her initial exam revealed a goiter. Nothing was done until testing confirmed a multinodular R>L. She had periods of transient hyperthyroidism after iodine supplements for a CT cscan, or kelp liquid drops, or even low dose thyroid hormone. She had multiple suppressed TSH values, off or on Thyroid hormone therapy. Over the counter Triac, caused Hyperthyroidism. The goiteer and all the nodules continued to grow. The total T4 is always low in TBG deficiency.
However hyperthyroidism exists when the total T4 is normal or high with suppressed TSH. A 6/24 Hour uptake and scan was abnormal. The uptake was high, and the scan showed hot nodules. The diagnosis of Toxic Nodular Goiter with masking effects of TBG deficiency was made, and after multiple benign FNA samples, under US guidence, it was elected to treat with RAI/131.
Clues included normal TT4 with suppressed TSH. The TT4 is always low in TBG deficiency.
Radioiodine 131 was used to control the thyrotoxicosis
However hyperthyroidism exists when the total T4 is normal or high with suppressed TSH. A 6/24 Hour uptake and scan was abnormal. The uptake was high, and the scan showed hot nodules. The diagnosis of Toxic Nodular Goiter with masking effects of TBG deficiency was made, and after multiple benign FNA samples, under US guidence, it was elected to treat with RAI/131.
Clues included normal TT4 with suppressed TSH. The TT4 is always low in TBG deficiency.
Radioiodine 131 was used to control the thyrotoxicosis
Thursday, March 15, 2007
Seaweed Goiter, or How I Grew My Thyroid While Ingesting Large Amounts Kelp
50 Y/O F had a small nodule 6 years ago which was biopsied and told it was benign. She refused thyroid hormone suppression, and when it continued to grow, she even refused surgery. She treated the goiter nodule with her own home plan as suggested by the internet.If you have thyroid problems,it stated, take iodine supplements.She did that for the next 5 years as the nodular goiter continued to grow! She had multiple biopsies and she claimed that biopsies caused the goiter to grew. She finally saw me last week. She is euthyroid with a large bilateral goiter with her trachea moved to one side to make room for the larger right lobe. The US showed another big nodule on the other lobe. Now she needs to stop the iodine supplements, and Kelp, and have yet another biopsy of the new nodule.
What did she learn?
Iodine is not only not good for goiters in the USA, because we have enough iodine in our diet, but it can be down right harmful.
Do Not Take Iodine Supplements without being informed of the dangers if you have a goiter, Hashimoto's thyroiditis, or nodules.
See you next time on Thyroid Rounds at Santa Monica Thyroid Center,
Good Day,
Dr.G.
What did she learn?
Iodine is not only not good for goiters in the USA, because we have enough iodine in our diet, but it can be down right harmful.
Do Not Take Iodine Supplements without being informed of the dangers if you have a goiter, Hashimoto's thyroiditis, or nodules.
See you next time on Thyroid Rounds at Santa Monica Thyroid Center,
Good Day,
Dr.G.
A Rare Cure of Medullary Thyroid Cancer ???
This is a follow up of the patient with MCT, who had the best chance for cure.
After a 6 hour surgery, and total removal of the thyroid, central compartment nodes, and right and left neck node removal, he had a post op calcitonin on <2, N<2.
Is this a cure? Time will tell as there is 0.0-0.19 under the curve. I am hopeful his calcitonin will remain undetectable in the future. The surgeon operated for 6 hours to remove all the nodes and the thyroid gland. Yearly neck lymph node real time ultrasound, and calcitonin cancer marker testing will needed for years to finally answer the cure question.
Bravo!
See you next time on rounds at the Santa Monica thyroid Center.
Good Day,
Dr.G.
After a 6 hour surgery, and total removal of the thyroid, central compartment nodes, and right and left neck node removal, he had a post op calcitonin on <2, N<2.
Is this a cure? Time will tell as there is 0.0-0.19 under the curve. I am hopeful his calcitonin will remain undetectable in the future. The surgeon operated for 6 hours to remove all the nodes and the thyroid gland. Yearly neck lymph node real time ultrasound, and calcitonin cancer marker testing will needed for years to finally answer the cure question.
Bravo!
See you next time on rounds at the Santa Monica thyroid Center.
Good Day,
Dr.G.
Acute Leukemia and MCT, Medullary Thyroid Cancer
One year ago I saw a a 60 Y/O M with a thyroid nodule. He was in remission from Leukemia, and wanted to explore the reason for the nodule. He had only Chemotherapy.
No External beam radiotherapy.The USGFNA was consistent with MCT. The pre-op calcitonin was about 1000 N <2. There was nodes in the central compartment, and down into the upper chest. USGFNA of lateral neck nodes was negative for cytology and calcitonin washings. The DNA studies confirmed sporadic, not family MCT. He had extensive surgery. The total thyroid was removed, as well as a node removal down into the upper chest by opening the chest. Both lateral neck node compartments were negative. Post op calcitonin was 40. He had worse problems with a recurrence of the leukemia. One year later after another remission and 4 weeks after the last round of chemotherapy, he presented himself in my office with a calcitonin of 81. The lymph node mapping of his neck was positive for abnormal shaped nodes on both sides. USGFNA of nodes in 4 lateral neck compartment was negative! Hunting for the Calcitonin rise, I did a thin slice PET/CT. The liver was PET/CT negative. He had nodes everywhere, but only one was PET positive. It was in a difficult position for FNA, and only 11 mm in size. I was able to due the biopsy, and show it was the probable source of the calcitonin rise. The surgeon was worried about finding the node group at the time of surgery. One hour before surgery, I injected 1% methylene blue dye on the anterior surface of the node to help in localization. There were smaller nodes near the PET positive one. The surgeon removed 3/12 nodes that were positive.The recovery was uneventful, and the calcitonin post op was 35.
What did we learn?
1. The prior leukemia caused generalized inflammation of nodes throughout his body, confusing me as to the initial place for USGFNA of nodes. The PET/CT was able to find the active MCT cancer node, and the CT slice number allowed us to find the right node to biopsy.
2. Calcitonin washings of the needle after smearing for cytology was the best way to diagnose lymph node mets from MCT.
3. Though MCT is more likely to cause death,than Papillary thyroid cancer, finding early recurrences before they spread to the liver can prolong life.
4.All areas of node surgery in the initial surgery were clear except the very posterior positive node found in Level IIb.
5. The best chance for survival and even cure is a radical surgery with removal of the thyroid, the central nodes and right and left lateral node compartments.
6. The surgeon must be expert in this type of surgery. I sent the patient to a world expert in Houston Texas at MD Anderson Cancer Center.
Until next time on thyroid rounds, at the Santa Monica Thyroid Center,
Good Day,
Dr.G.
No External beam radiotherapy.The USGFNA was consistent with MCT. The pre-op calcitonin was about 1000 N <2. There was nodes in the central compartment, and down into the upper chest. USGFNA of lateral neck nodes was negative for cytology and calcitonin washings. The DNA studies confirmed sporadic, not family MCT. He had extensive surgery. The total thyroid was removed, as well as a node removal down into the upper chest by opening the chest. Both lateral neck node compartments were negative. Post op calcitonin was 40. He had worse problems with a recurrence of the leukemia. One year later after another remission and 4 weeks after the last round of chemotherapy, he presented himself in my office with a calcitonin of 81. The lymph node mapping of his neck was positive for abnormal shaped nodes on both sides. USGFNA of nodes in 4 lateral neck compartment was negative! Hunting for the Calcitonin rise, I did a thin slice PET/CT. The liver was PET/CT negative. He had nodes everywhere, but only one was PET positive. It was in a difficult position for FNA, and only 11 mm in size. I was able to due the biopsy, and show it was the probable source of the calcitonin rise. The surgeon was worried about finding the node group at the time of surgery. One hour before surgery, I injected 1% methylene blue dye on the anterior surface of the node to help in localization. There were smaller nodes near the PET positive one. The surgeon removed 3/12 nodes that were positive.The recovery was uneventful, and the calcitonin post op was 35.
What did we learn?
1. The prior leukemia caused generalized inflammation of nodes throughout his body, confusing me as to the initial place for USGFNA of nodes. The PET/CT was able to find the active MCT cancer node, and the CT slice number allowed us to find the right node to biopsy.
2. Calcitonin washings of the needle after smearing for cytology was the best way to diagnose lymph node mets from MCT.
3. Though MCT is more likely to cause death,than Papillary thyroid cancer, finding early recurrences before they spread to the liver can prolong life.
4.All areas of node surgery in the initial surgery were clear except the very posterior positive node found in Level IIb.
5. The best chance for survival and even cure is a radical surgery with removal of the thyroid, the central nodes and right and left lateral node compartments.
6. The surgeon must be expert in this type of surgery. I sent the patient to a world expert in Houston Texas at MD Anderson Cancer Center.
Until next time on thyroid rounds, at the Santa Monica Thyroid Center,
Good Day,
Dr.G.
Thursday, March 01, 2007
Medullary Thyroid Cancer: One Chance to Cure
I saw a 50 Y/O male for second opinion with a Biopsy proven DX of Medullary Thyroid Carcinoma MCT. He had prior FNA of a 2 cm left lobe nodule. The cells and staining for calcitonin on the slides confirmed MCT. What do I need to do to help him. First, I did an ultrasound of 1-6 levels lymph nodes on both sides of the neck. He had many abnormal shaped nodes. Because the nodule was on the left, and his RET DNA did not show family MCT, the surgeon was only going to do the lymph nodes on that side of the nodule. I called the surgeon, and informed him that there were nodes on Both sides, and if he hoped to give him the best chance for cure he needed to do complete lymph node removal on the right, left, and central compartment. He agreed to do this extensive surgery to try to cure him. There were cancer nodes on both sides of the neck. He took out everything, and sent him back to me on thyroid hormone to see what the MCT cancer marker, Calcitonin was after complete bilateral neck disection. He is recovering well without major side effects. Stay turned for a post surgery follow tests in 4 weeks.
DR.G.
DR.G.
Medullary Thyroid Cancer: One Chance to Cure
I saw a 50 Y/O male for second opinion with a Biopsy proven DX of Medullary Thyroid Carcinoma MCT. He had prior FNA of a 2 cm left lobe nodule. The cells and staining for calcitonin on the slides confirmed MCT. What do I need to do to help him. First, I did an ultrasound of 1-6 levels lymph nodes on both sides of the neck. He had many abnormal shaped nodes. Because the nodule was on the left, and his RET DNA did not show family MCT, the surgeon was only going to do the lymph nodes on that side of the nodule. I called the surgeon, and informed him that there were nodes on Both sides, and if he hoped to give him the best chance for cure he needed to do complete lymph node removal on the right, left, and central compartment. He agreed to do this extensive surgery to try to cure him. There were cancer nodes on both sides of the neck. He took out everything, and sent him back to me on thyroid hormone to see what the MCT cancer marker, Calcitonin was after complete bilateral neck disection. He is recovering well without major side effects. Stay turned for a post surgery follow tests in 4 weeks.
DR.G.
DR.G.
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