Tuesday, November 04, 2008

Thyroid Cancer: A Lesson in What Can Go Wrong with Multiple Unnecessary Surgeries

39 Y/O female has a lump found below her right ear. First problem. A excision biopsy was done by an ENT without any ultrasound, or fine needle biopsy. It was papillary thyroid cancer in a level 2 node. The patient was referred to an endocrinologist. He saw the results of the node biopsy, and told her she needed her thyroid out. Problem #2 There was no detailed lymph node mapping done before the referral to the surgeon.Problem #3 The surgeon, even knowing that there was a proven cancer node high up in the neck removed by the ENT, did not include a modified radical neck on the side of the cancerous node removed. Problem #4 When the surgeon took out the thyroid cancer, he was confronted with 3 lateral neck nodes that were next to the thyroid. This was his second chance to do a modified neck on that side, but he decided to take the easy way out and only cherry picked the 3 abnormal nodes. Problem #5 while removing the thyroid with the cancer, he came across 2 very abnormal nodes in the thyroid bed. They were positive for cancer, and again he failed to do the right thing and do a complete central compartment
node removal. Problem #6 After 100 MCI Radioiodine, and a negative whole body scan, she returned with elevated cancer marker, and finally the endocrinologist did an ultrasound lymph node mapping. Surprise, there were more nodes on the side of the twice cherry picked ones. Problem #7 There was no mention of the central compartment, but we already know the surgeon did not do a good job the first time only taking 2 nodes. There was surely more nodes that were crying out to make the surgeon do a central compartment along with the lateral neck. Problem # 8 Our gun shy surgeon, takes out the lateral nodes, but again fails to address the central compartment. Problem #9 She returns to the thyroid challenged endocrinologist, and recommends another dose of RAI/131, even though the last one was negative when she had all that cancer in her neck even before the first surgery. Wow, after 165 MCI I/131, and an increased risk of other cancers in the future, her Whole body scan was negative! Well, finally she had enough, and came to me for a second opinion. Even before I touched her neck, I knew she was still full on cancer nodes, especially in the central compartment, because of incomplete first thyroid surgery. There was a large scar all the way to her ear.
Ultrasound lymph node mapping revealed several abnormal nodes in the thyroid bed.
USGFNA of the biggest one was positive for cancer. Last major problem. After a lymph node excision, a total thyroidectomy with node picking, a lateral neck node surgery, she now needs a 4th surgery to clean out the central thyroid bed. These are the most dangerous, and can only be removed surgically, not with radiation.

What went wrong?
Everything, but the most problematic was the failure to do mapping BEFORE the thyroidectomy. All the nodes would have been located, and in addition to a total thyroidectomy, and central compartment node removal, the lateral neck would have been done. The second problem was the failure to do an FNA on the first node. It would have stopped the first excision surgery, and triggered a extensive investigation of the neck nodes before the first thyroid surgery. Endocrinologists, and Surgeons need to become aware of the crucial role of ultrasound lymph node mapping. 3 surgeries, and a fourth one next week, and all this could have been saved by a careful pre-op evaluation before rushing off the OR. One surgery would have been enough. Finally, the excessive use of radioiodine in a low risk young women, when surgery was needed, put her at risk for other cancers in the future.

Please, get an expert outside opinion before the first surgery.
Remember, not all endocrinologists are experts in modern thyroid cancer therapy.
They are hard working internists and diabetic specialists, and have little time for modern thyroidology.
It can save you many months of morbitity, and unnecessary radiation, and surgeries.

Good Luck,


Wednesday, October 15, 2008

Pregnant, But is Your Baby Getting Enough Iodine from Your Prenatals ?

The American Thyroid Association recommends prenatal vitamins with 150 mcg elemental iodine during pregnancy. The Institute of Medicine recommends 220 mcg iodine in pregnancy, and 290 mcg when breast feeding. There is no mandate for U.S. prenatal vitamins to have 150 mcgs of iodine. What does a pregnant women do to insure her baby is getting enough iodine?
The internet listed 127 nonprescription, and 96 prescription brands on the market in the U.S. Only 69% of non-RX brands had iodine listed. Even lower percentage of prescription brands listed iodine. 90% of them with iodine, listed > 150 mcg of iodine. 150 mcg of KI is only 114 of elemental iodine. Kelp based prenatal vitamins had >150 mcg iodine. This labeling is misleading. Researchers at Boston University measured 60 brands of prenatal vitamins for iodine content. The prenatal with KI had 119 mcgs as expected.
However, the kelp based prenatal had 33-610 mcgs of iodine. Over half had content that was different than listed on the label, including 10/25 with low iodine content. Kelp iodine content is variable, and one should stick to potassium iodide KI as the source of their prenatal iodine, not kelp.

1. 69% of non RX prenatal, and 28% of prescription prenatal vitamins have iodine.
2. Kelp is a poor source of iodine due to variable amounts of iodine.
3. KI based prenatal is more consistent but only have 76% iodine content of the labeled 150 mcg, or 120 mcgs.
4. KI prenatals should be the drug of choice.
5. However future Prenatal vitamins should have 197 mcg KI to get to the recommended 150 mcgs elemental iodine supplement needed during pregnancy, and lactation.

What should the woman do now?

Get KI based Prenatal vitamins, and add a 100 mcg KI pill, to get the extra 80 mcgs you need.

Good Luck with the pregnancy,


Iodine Content of U.S. Prenatal Multivitamins
Leung, et al
American Thyroid Association national meeting abstract #106
Thyroid supplement page S-45
October 3 2008.

Thursday, October 02, 2008

Thyroid Nodule Therapy in Patients with Insulin Resistance

Recent studies have shown that patients with high levels of insulin seen in obesity, diabetes, and in thin patients with insulin resistance have a larger thyroid gland by volume studies by ultrasound, and have a significant increased number of nodules.Thyroid vol.18(4),461-164 2008. Obese and non-obese patients with insulin resistance had increased thyroid volumes, compared to obese, and normal patients without elevated insulin levels. Also the number of nodules was increased over controls without excess insulin. Well if increased insulin is a thyroid growth factor as seen in animals studies, and suggested by these data, maybe we need to consider another medical approach to nodule therapy. Well the thyroid group from Argentina has treated patients with the drug metformin to reduce the insulin levels in patients with thyroid nodules. Metformin alone, with T4, T4 alone, and control with no therapy for 6 months. TSH was kept at 0.1-0.9 range,in the treated groups. The metformin dose was 1 gram. The patients were all from an iodine deficient country. The dramatic results were a marked reduction in the nodules with metformin alone, 73%, but this was even better with the addition on T4, 95%. The control without therapy was 26% reduction, and the T4 only was 35%. T4 only just prevented increased growth, but did not decrease nodule volume compared to controls. Insulin and TSH are growth factors for thyroid nodules. The dramatic results in Argentina is partially due to iodine deficiency, and the effects should be less in the USA. However,combination therapy may be worth a try in diabetic, obese patients, or thin patients with proven high insulin levels seen during a 75 gram glucose load test, who have benign thyroid nodules by Ultrasound Guided FNA.

6 th World Congress on Insulin Resistance Syndrome
September 25-27 2008
Los Angeles Ca
Abstract #20
Metformin Treatment of Benign Thyroid nodules in Euthyroid Patients with Insulin Resistance
H. Niepomniszcze et al.

Tuesday, September 16, 2008

Beware of Generic Substitution of Your Thyroid Hormone Therapy

160 adverse events happened in 2007 from switching sources of thyroid hormone, during an Endocrine Society and American Thyroid Association reported study. The FDA method of determining that different brands of thyroid hormone are equal is seriously flawed.
Thyroid hormone therapy requires fine tuning with TSH as an endpoint. If you get switched,the other thyroid pill may be different enough to cause you harm. The pill you were taking at the time your endocrinologist did the TSH testing should be the one you get from your drug store. If it is not, then you would need a new thyroid test in six weeks to see if this company thyroid hormone is still giving the correct amount by TSH re-testing. This is what needs to be done, and it should not be necessary if you received the same pill your were taking when you were first tested. However, the FDA in it's wisdom, has not allowed the black box warning to be added to the PDR listing of thyroid hormones. Elderly and thyroid cancer patients are most at risk for adverse results do the switching of brands. The elderly have heart problems if the dose is off.
Cancer patients can have regrowth of a dormant cancer if the thyroid hormone is inadequate, or heart problems if it is excessive.

Here is my advice:
1. Until FDA changes it's methods, the patient must be his own best advocate.
2. Demand to receive do not substitute scripts from your physician.
3. Insist on receiving the same company thyroid pill that you were tested on, from the drug store.
4. Look at the pill at the store to see if it is the same shape, color and that the store clearly informs you that it is the same as you were taking when you had the tests in your physicians office.
Good Luck,

Reference: www.endo-society.org/publicpolicy/policy/upload/Joint_Statement_Levothyroxine-Thyroxine.pdf

Tuesday, July 29, 2008

What if My Primary Physician Tells Me I have a Single Thyroid Nodule?

First of all do not panic. 31% of the time the palpation is NOT accurate. 16% of the time there is no nodule at all! The referral to the radiologist for an USGFNA may result in a biopsy even if there is no nodule present, as they are only doing what the physician orders. Ask for a referral to an endocrinologist that does their own high frequency Ultrasound. Check www.thyroidologists.com for a clinical thyroidologist near you. Also, 15% of patients with a worrisome single nodule will actually have a multinodular goiter. The thyroidologist ultrasonographer will confirm if there is a nodule, detect additional nodules, that may need FNA biopsy, and identify the ultrasound characteristics of the nodules. The present guidelines tell us that not all nodules need biopsy, especially <10 mm nodules. If the nodule is <10 mm there must be abnormal lymph nodes found, or radiation history or family history of thyroid cancer.
>10 mm nodules there are solid, hypoechoic or have micro-calcifications, need FNA biopsy. >1.0-1.5cm cm nodules that are solid and either iso,or hypoechoic need FNA biopsy. If they want to biopsy all your nodules or the ones that are not listed here, ask for a second opinion BEFORE you let them do the biopsy. >1.5-2.0 cm complex nodule, with another suspicious feature, such as vascularity, irregular margins,,micro-calcifications need a biopsy.
>2 cm Predominantly cystic without suspicious US features should be biopsied.

What about multiple nodules?
DO NOT allow them to Biopsy all the nodules. Prioritize based of Ultrasound findings. If there are multiple similar, coalescent nodules without suspicious features, they can biopsy the largest one.

Thyroid Ultrasound In summary,
Palpable Nodule
1. Assess if it is the same nodule seen on ultrasound, and look for suspicious findings. Review the ultrasound for other non-palpable nodules and their suspicious findings and select for USGFNA biopsy if indicated.

Non-palpable nodules seen on ultrasound.
1. Assess for need for Biopsy by suspicious findings, or history of radiation or family history.

Multiple Nodules
1. Select the nodules for biopsy based on suspicious findings or size.

All Nodules
1.Assess the lymph nodes for clues to the presence of thyroid cancer.

Always ask to see the actual diagnostic ultrasound and the report before allowing a biopsy to be done.

Good Luck,


Frontiers in Thyroid Cancer
ATA Guidelines in Clinical Practice
July 11-12 2008
Boston Mass.

Thursday, July 17, 2008

What do I Need to do Before my Thyroid Cancer Surgery?

If you are told you have a positive cancer FNA biopsy result on a thyroid nodule, or they say it is suspicious for cancer, what do you neeed to be done BEFORE the surgery?
First, if you are not seeing a thyroidologist, or an endcrinologist with an interest in thyroid cancer, request a referral.
The Pre-operative screening should include a cancer marker test, thyroglobulin.
A detailed thyroid ultrasound to determine if there is tumor on the other lobes.
The thyroidologist should do an ultrasound lymph node mapping of your neck. 20-80% of patients already have mets in the local nodes around the thyroid. If abnormal nodes are found, an USGFNA for cytology, and Thyroglobulin cancer marker washings should be done.
If positive the original surgery plan will be changed in at least 20-30% of the cases, to include the lateral neck area of the cancer nodes.
Now you can go to surgery, and have the definitive first surgery, and save yourself from the recurrence and need for a second surgery in 1-5 years.
Good Job,


What is a Low Risk Thyroid Cancer, and Do I Need Radiation?

How do I know if I am very, low risk?
If you are <45 years old,
Get your pathology report from your surgery.
Look for these items:
Very Low Risk is a patient has a single < 1 cm cancer nodule.
No lymph node mets.
The cell type is not an aggressive type, such as Tall Cell.
There is no extension beyond the capsule of the thyroid gland.
Then there is no family history of thyroid cancer, and no radiation exposure.

What needs to be done to treat you?
You will only need lobectomy, as there is no benefit from total thyroidectomy.
Also there is no benefit from Radioiodine ablation therapy with any dose.
Death 0% Recurrence by 20 years 8%

How do I know if I am low risk?
If you are <45 years old.

Again get the pathology report.
Papillary Ca 1-4 cm without nodes or distant spread.
No local invasion outside of the thyroid gland.

Follicular CA <2 cm

Minimal capsule invasion, but no vascular invasion.
What needs to be done if I am low risk?
Total thyroidectomy is definitely needed.
Radioiodine therapy is controversial.
May be only on a select few rather than knee jerk use in everyone.
Careful discussion with a thyroidologist before you accept the radiation therapy.

<40 years old Death 0%
<40 years old <3 cm RAI Dubious

Remnant Ablation with RAI/131?
All high risk patients, but not all very low, or most of the young low risk patients.

Stage I Age <45 Size <2cm No LN NO Radiation Ablation Needed
Stage II Age >45 Size >2 cm + LN rhTSH Stimulated Remnant ablation

Good Luck,


Monday, June 30, 2008

Why a General Endocrinologist Should Not be your Thyroid Doctor

10-15 years ago, a referral for thyroid second opinion from an internist, and from a general endocrinologist would show that the endocrinologist knew more about the thyroid condition than the internist. Sadly, it is not the case today. With diabetes and general medicine taking up the majority of the waking hours for the endocrinologist, there is now a loss of thyroid specific expertise by the endocrinologist. He is little better than a general internal medicine physician. He is still the king of diabetes, but not thyroid.

Case History

51 Y/O female seeks my opinion on the thyroid condition she is not sure she has, or the therapy that is needed.2 years ago the endocrinologist, while treating her type one diabetes, noted an upper normal TSH, 5.61 and commented on her enlarged thyroid on his physical. He did nothing to evaluate the goiter, and told her to return in a year.
He did not offer therapy. She had a family with autoimmune disease of the thyroid.
Aunts with Graves' disease, and papillary thyroid cancer. No antibodies were drawn or was an ultrasound done to evaluate the goiter.Next year the TSH was 6.32 and he offered her thyroid hormone, but no work up. This resulted in her getting a second opinion with me. The thyroid was visible from across the room.There was a large 2 cm nodule on the right. The ultrasound found 6 nodules of which two were > 1.5 cm.
One was 3 cm.It had an irregular border, and 3 deep penetrating blood vessels on power Doppler. There was a papillary thyroid cancer in the larger nodule by USGFNA, and she was studied for abnormal nodes,which was negative. She had surgery, and is disease free with undetectable Cancer marker 6 weeks post surgery. She is lucky to have sought another opinion on her very excellent endocrinologist taking care of her type one diabetes, but learned that his knowledge was less that needed to care for her thyroid diease.

Good Luck


Monday, June 16, 2008

Calcitonin Measurement in All New Thyroid Nodules

Is Calcitonin screening of all thyroid nodules cost Effective? A recent study by Cheung and associates in the JCEM 93:2173-2180,2008, suggests it is worth the expense. They found it was comparable to screening with TSH,colonoscopy,and mammography. Two groups were studied. One following the guidelines for nodule evaluation by the American thyroid Association ATA, and the other the same ATA except a calcitonin was added to the work up.The results of the added calcitonin to the ATA guidelines were:
The main outcome measures C/E, or dollars per life years saved LYS. $11,793 per LYS for the a calcitonin group. US screening with calcitonin would yield an additional 113,000 life years saved. at a cost increase above current ATA guidelines of 5.3 %. The calcitonin screening is most cost effective in young males with larger nodules, but is still cost effective in screening of the whole thyroid nodule population. The lack of studies on the cost effective nature of screening was the reason the ATA guidelines did not include calcitonin. Now this recent study would suggest it should be added to the nodule work up.

Calcitonin is a marker for Medullary thyroid cancer. It is a rare thyroid cancer that can occur in families. Family screening is done with DNA studies, not calcitonin.



Alarms Go Off in Restrooms When Radiated Thyroid Patients Urinate.

A 30 Y/O female with Graves' hyperthyroidism was treated with 15 Millicuries of radioiodine. The next day she entered the restroom at her workplace, and an alarm of a flame sensor sounded. This happened everyday for 6 days, whenever she went to the restroom to urinate,the sensor went off and stopped when the toilet was flushed, and the radiation in the toilet was washed away. The sensor was 10 feet away from the toilet in the ceiling. The flame sensors are usually installed in restrooms in department stores, airports, shopping centers and movie theaters. Another Graves' patient activated the flame sensor in a department store restroom 2 days after treatment with 30 Millicuries of I/131. A flame sensor was studied. A patient was with Graves' set off the alarm 3 days after treatment when she passed urine. Also the flame sensor could sense I/131 gamma rays, even when a I/131 capsule was covered by a UV light interception seal. Airport radiation detectors are known to go off when a patient is treated with RAI/131. The fact that alarms can go off in restrooms all over the world when a thyroid patient urinates gamma rays into the toilet water has not been reported before. Any physician using Radioiodine to treat thyroid patients should inform them about this malfunction of restroom sensors after they are treated.

Wow, one more thing to tell my patients after radioiodine therapy. The best thing to do is flush the toilet, and the alarm will stop! Don't panic and run out without flushing.

Good Luck,


Tajiri et al
Radioiodine and Flame sensors

abstract Endocrine Society Annual meeting San Francisco Ca 6-15-2008.

Friday, June 13, 2008

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not use compounding pharmacy thyroid hormone for my patients. There are pure thyroid hormones made by companies such as Abbott, that makes Synthroid. Errors have been found with other medications from these pharmacies. Recently, errors have occurred when they have compounded thyroid hormone.
Case History:

46 Y/O male admitted the hospital with 22 pound weight loss,palpitations, but he did not have thyroid enlargement on physical exmination. He had a history of hypothyroidism, and had been taking thyroid hormone replacement therapy with Synthroid for 10 years. However, recently he changed physicians and the new PMD, switched him to compounded T4/T3 combination. Prior to the switch he had complained of fatique, but the first physician told him the thyroid tests were normal on his Synthroid. TSH was 1.5 N0.3-3.0. He sought a second opinion and that is when the new physician told him that he needed T3 along with the T4. 6 weeks later he was admitted. The thyroid tests were off the chart, T4 75 N 4-12, T3 1541 N 70-170. The pills were made in error, and had 11 times the dose per pill. The patient was treated in the hospital until the pulse rate was normal and discharged on beta blockers. He was clinically improved , had gained weight, and felt better by 3 weeks. Off thyroid he became hypothyroid. He was switched back on his old dose of Synthroid and the TSH was returned to normal. The pharmacy denied using that dose on any other patient. Well, why use them at all, when, safe commercially available pure thyroid hormones are available by Rx from your physician. Stay away from physicians that tout compounded hormones for treating your thyroid conditions.

Good Luck,

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not recommend the use of compounding pharmacy

Tuesday, May 27, 2008

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

There are not many therapy alternatives to surgery if you have a goiter. The large goiter may be causing obstructive symptoms, or harbor a cancer.
The obstructive component can be evaluated by MR, and pulmonary function testing, including flow loop to see if there is any upper airway obstruction. Any suspicious nodules found on ultrasound need to be biopsied. If no obstruction or cancer is found, then alternatives are available. The most widely used is low dose Radio-iodine therapy.
In Europe and special centers, Laser has been used to shrink goiters. However, experience with this method is limited at present, although it seems promising.
Thyroid hormone is effective if the goiter responds to suppression.However, it usually dose not work on very large goiters. Ethanol Injections, PEI, are not for treatment of a whole gland, but for single cystic nodules. The best method now is Radio-iodine therapy.

Case Presentation:

69 Y/O female with coronary artery disease, bypass surgery, and mild heart failure was noted to have a large goiter causing tracheal deviation, and symptoms of obstruction. The MR showed mild tracheal narrowing, and the breathing test showed an abnormal flow loop consistent with upper airway obstruction due to the enlarged goiter. The treatment of choice is surgery, but because of her heart condition, alternatives were sought. Thyroid hormone was considered dangerous with heart disease. She was referred to me for consideration for ethanol, laser, or Radio-iodine. As listed above RAI was the best alternative for her. The goiter was visible from across the room.The trachea was deviated, and the ultrasound found two suspicious nodules in the goiter.They were biopsied and were benign colloid nodules. Thyroid blood testing was normal for TSH, T4, and Antibodies. The thyroid uptake was not elevated, but was to the lower normal range of 11% at 24 hours. Normal 8-32. After informed consent, including all about off label use of Thyrogen, rhTSH stimulation to boost the low uptake, she was put on a low iodine diet for two weeks. The single injection of rhTSH was given, and the TSH rose to 32. A repeat Thyrogen Stimulated thyroid uptake was positive for a significant increase in uptake to 56%. The image showed diffuse increased uptake throughout the goiter. The radiation safety instructions were reviewed with the patient and her urinary continence was assessed. There were no children in her house and she was told to stay away from her grandchildren. The arrival of the iodine dose was followed by confirming the correct dose was sent, checking for leaks, and preparing a paper for her to keep with her when she traveled by air to see her brother in 3 weeks. This will explain to the security at the airport that see has been treated with radiation, and is not a terrorist! The 30 Millicuries was given in my office as an outpatient and she was sent home. She was told to suck on lemon drops, and drink water, and avoid close contact with people for 5 days. She could go for her morning walks as usual. She could watch TV with her husband if she sat 3-5 feet away from him. She returned in one week and her thyroid goiter was firmer, but not tender.Thyroid blood tests revealed slight decrease in TSH, but no change in T4, or T3. By 12 weeks there was an obvious decrease in goiter size. Thyroid tests returned to normal, and the goiter had continued to decrease at 6 months. Repeat MR confirmed shrinkage, and the Flow loop study improved. The trachea was not narrowed, and the mild obstructive pattern on the flow loop was also better. She has noted improvement in her symptoms as well. She is followed twice yearly, and is doing well without ever having thyroid surgery.

When Surgery is offered as a treat option for your goiter, consider looking into alternative therapy with radio-iodine.

Good Luck,


Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

Sunday, May 25, 2008

88 Year Old with Recurrent Papillary Thyroid Cancer: Do No Harm or Treat?

Case Presentation:
Why are they treating 85-94 year old patients so aggressively?
Because they have the tools to do it.

88 Y/O male with a 4 cm mass, which was proven to be a follicular variant of papillary cancer. After total thyroidectomy, he was subjected to hormone withdrawal at his age. Well it is no surprise that he was developed cardiac complications. The TSH >100, and TG was 88. He was stabilized, and cardiac failure treated, and was given 150 MCI I/131. The expected survival of 88 year old male is 4-5 years. After therapy the Neck ultrasound and TG, cancer marker were negative. Even with cardiac disease the oncologist pushed thyroid to suppress TSH. Also they did a Thyrogen stimulated TG, which was elevated to 15 from 3.7. He was given another 150MCI radioiodine, but alas the post therapy scan was negative. He developed side effects of the radiation. Dry mouth, hypotension, throat pain, nose bleed. He developed pseudogout, and more admissions followed. More studies were done including a PET/CT. A 7 mm nodule in the lung was seen. Symptoms of excess thyroid continued to occur do to suppressed TSH. More problems, this time a fracture again put him in the hospital. The rising TG was now 500. A PET positive mass in the lung and chest wall was found. The TG was now 1500. External beam radiation was given to the chest wall, even though there was no chest wall pain. The radiation caused more symptoms. TG went from 420 post EBRT to 1200. He lived for 8 years, but most of the time he was not well. We need to think about what we do to elderly patients with a tumor that slow growing and stop treating the TG numbers. As one smart thyroidologist once said at a meeting, "You never die from an elevated thyroglobulin. This patient was treated with external beam radiation at age 94! Now the oncologist was bragging about the fact he did not die of the cancer, but what about all the morbitity inflicted on the poor elderly gentleman, when the cancer was progressing in the expected slow course. The idea should be to do no harm, and only treat symptomatic lesions, or ones that could cause airway blockage or bleeding in the neck.

The second dose of I/131 was not helpful. The side effects were debilitating. Did the oncologist ever suffer cotton mouth symptoms, which this second dose I/131 of unlikely value, caused? The external beam to the chest wall did not relieve any chest wall pain as there was no pain. The oncologist was over eager to do something, when the best thing to do was to be conservative with a chronically ill octigenerian. Only 1600 thyroid cancer patients ever die from the disease in any year, but too many suffer early and late complications due to over-eager physicians chasing the thyroglobulin, with I/131, EBRT, PET/CT Scans, and morbitity inducing thyroid hormone withdrawal. He was too old to get cancers from the 300 millicuries given, but many younger patients are given 150 routinely after low risk thyroid cancer. They will by at risk for other cancers years later. There is a new generation of endocrine-oncologists that have available to them the most advanced methods to treat high risk thyroid cancers, but need to think twice before doing this to many 95 year olds.

Good Luck,

Saturday, May 24, 2008

What Should You do if your Primary Care, or Endocrinologist tell You that Your Blood Calcium is Elevated and you need Surgery to Remove a Parathyroid

The most common cause is over-active parathyroid gland activity. Usually a single non cancerous tumor called a parathyroid adenoma. The screening testing is easy. Calcium, parathyroid hormone, and urine studies for calcium and creatine. But once the diagnosis is made the next step is not as easy. The location of the tumor can be anywhere in the neck, and may even be in the chest. Also, there may be co-existent thyroid tumors as well. The standard approach is to do a Parathyroid scan.They are hard to read and will negative even when the tumor is present. Do not go to surgery, without a high frequency parathyroid ultrasound. The experience of the parathyroid ultrasonographer is crucial to the success in finding the tumor. They can be found behind the esophagus, down in the thymic ligament and even in the thyroid. Incidental tumor nodules in the thyroid can be treated at the same time if positive for cancer. The parathyroid adenoma has a distinct look on US. It will be hypoechoic and have many shapes as it is soft. There will be a distinctive polar artery coming to the tumor. The parathyroid ultrasonographer will be able to biopsy the tumor with extremely small needles, and usually needs only one or two passes into the tumor. The chances for fibrosis are rare to none. The sample will be sent for cytology, and the needle washing for PTH. The cytology is not diagnostic, as it looks similar to a thyroid adenoma, but the PTH washing will be very elevated in most cases. With the knowledge that there is only one tumor, and the thyroid is not harboring a cancer nodule, the surgeon can do a quick 15 minute operation to remove the single adenoma. If the thyroid ultrasonographer finds more than one adenoma, or a mass is found in the thyroid, then the usual parathyroid exploration and thyroid removal would be needed. Also, if you have a recurrence after the first surgery, you need to see a expert parathyroid ultrasonographer, to find the abnormal gland. There can be a second adenoma missed on the first surgery, or it can be down in the chest. A CT of the Chest can help find that rare variation.

An endocrine neck lab such as mine, or a referral to a clinical thyroidologist with expert ultrasound experience in handling parathyroid localization procedures and biopsies can help your endocrinologist find your tumor.

Do it right the first time, and avoid an unnecessary long exploratatory surgery, or at least know that it is necessary because you had multiple parathyroid masses, or had a tumor nodule in the thyroid as well.
Case Presentation:
46Y/O Female with high Calcium and Blood PTH has parathyroid disease.
A second opinion was requested by her endocrinologist to help locate the adenoma.
Prior para thyroid scan was negative. Neck High frequency ultrasound was negative for locating it until I put 2 pillows under her back and with her neck hyperextended, I was able to see the right upper parathyroid which had been displaced to the area behind the esophagus. The thyroid gland was also abnormal. A 1.6 cm nodule was located in the right lobe.It had abnormal ultrasound changes suggestive of cancer. The biopsy of the parathyroid was done first. a washing for PTH was 56,000, and the cytology was consistent but not diagnostic,resembling a follicular neoplasm.The biopsy for the thyroid nodule was positive for papillary thyroid cancer. Prior to surgery, a lymph node mapping was done to see if neck nodes were invaded by thyroid cancer. The neck node ultrasound mapping was negative. The surgeon was told that because of the thyroid cancer the minimal surgery was not indicated, and a total thyroidectomy and central compartment node removal had to be done. The single adenoma was easily located behind the esophagus and the patient continues to have normal calcium 6 months after surgery.
We call that a "TWOfer". Two diseases with one surgery!

Good Luck,


Endocrine Neck Lab of Southern California
Dr.G. is the thyroid and parathyroid ultrasonographer

What is Thyroid Cancer Ultrasound Lymph Node Mapping, and why do I need to have one BEFORE my Cancer Surgery?

Prior to the new approach to thyroid cancer, the radio-iodine whole body scan WBS, was the mainstay of diagnostic cancer studies. Along came highly sensitive cancer markers, Thyroglobulin TG, and the TG antibody. The WBS was poor at detecting recurrence. The addition of the newer high frequency ultrasound was better at finding recurrences, than the WBS. With Cancer markers and Ultrasound we can find the cancer that is missed with WBS, and even after a post treatment scan. The lymph node mapping by high frequency ultrasound can find tumor recurrence even when the WBS, TG and PET/CT are negative! Well if it is that good after the surgery, maybe it is good PRIOR to the original surgery. In fact if you have a qualified clinical thyroidologist, and thyroid ultrasonographer map your neck BEFORE the original surgery, it will expand the scope of the first surgery in 20-30% of the patients with a positive needle biopsy confirming cancer or is suspicious of thyroid cancer. The expanded surgery would include the lateral neck nodes on the side of the positive node biopsy. Modern thyroid cancer pre-op should include a lymph node mapping. INSIST on one before the surgery.It will save you another surgery in 1-5 years. The first surgery is the most important. Recurrences will be less likely if positive nodes, which would be still left in the neck were not removed at the original surgery. The use of MR,CT or PET/CT will not be as accurate as Ultrasound in the right operators hands at finding your neck node disease. Ask your endocrinologist or internist to refer you to an endocrine neck ultrasound lab where a clinical thyroidologist, and ultrasonographer can help him. My referral endocrine neck ultrasound lab website is www.endocrineneck.com.

Case Presentation:

56 Y/O female was seen 6 weeks after total thyroidectomy for a needle biopsy proven papillary thyroid cancer. The internist sent her for management of the cancer, after the surgery. The cancer marker on Thyroid hormone was <0.1, and the TSH was 0.09. However the lymph node mapping found cancer nodes in the right neck. The ultrasound guided FNA biopsy was negative for cytology, but was positive for TG in the washings from the largest node. It is common that the cytology will miss the tumor , but the TG will be found in the node. Any TG in the node is abnormal.The patient was shocked that a node study was not done before the first surgery. I told her it was relatively new information,and not well known by non-specialists. The patient was sent back to surgery to do a modified neck dissection. 4/15 nodes were positive for metastatic thyroid cancer in the neck.

The best time to send a patient to the clinical thyroidologist is when the nodule is first found, not after the biopsy, and surely not after the crucial first surgery.

Good Luck,

Thursday, May 22, 2008

What is Methylene Blue Dye Localization, and why do I need to know about it if I have recurrent thyroid cancer after multiple surgeries?

Case Presentation:
69 Y/O female with an aggressive form of papillary thyroid cancer called Tall Cell Variant. She has had total thyroidectomy, and central compartment node removal.. 150 MCI was given after the first surgery. The first recurrence was in the right lateral neck. Another surgery was done. 200 Millicuries of I/131 was given. Over 12 months her
thyroglobulin,TG rose from 0.36 to 6.5 with suppressed TSH. The last Whole body scan was negative. The ultrasound lymph node mapping revealed central compartment abnormal nodes. The USGFNA biopsy was positive for recurrence, and the TG Cancer marker was 35,000 in the needle washing from the largest node. Because of the aggressive nature of the cancer a PET/CT was done to make sure there was distant spread to the lungs or bones. The scan was positive only for the nodes seen on ultrasound in the central compartment. The patient had suffered a right vocal cord injury at the first surgery, and therefore re-entry in the central compartment was more risky. The thyroid surgeon agreed to go in only if I could localize the nodes for him before the surgery. One hour before she went to the hospital, she came to the thyroid center, and under US guidance I placed a drop of dye on the anterior surface of the largest node. The surgery was uneventful. There was no changes in her voice or the blood calcium post surgery. However when she returned for the 4 week post surgery visit her cancer marker was markedly decreased from 6.5 to just above the lower limit of <0.15, at 0.23. There were 3 positive nodes clustered around the blue dye marked node. The surgeon had no problem finding the PET positive nodes with my dye marker.

Thyroid cancer, Tall Cell Variant, thyroid ultrasound lymph node marking, Thyroid ultrasound Guided lymph node FNA biopsy, Thyroglobulin washing for the cancer node, Methylene blue dye cancer lymph node localization procedure prior to surgery.

Good Luck,


Wednesday, May 21, 2008

PEI: What is Percutaneous Ethanol Injection, and why do I need to know about it, if I have had multiple surgeries for papillary thyroid cancer?

Case Presentation:

70 Y/O Japanese female with multiple surgeries in the lateral neck after total thyroidectomy for papillary thyroid cancer. Her cancer marker rose again, and she was given another thyroid cancer lymph node mapping. There was a 7 mm tall and 6 mm wide node in level 4 on the right side. The node had abnormal Doppler blood flow suggestive of another recurrence. She was given an USG FNA of the node, and cancer marker was collected from the needle washings. The cytology was negative, but the cancer marker in the washings from the lymph node was 156,000. This was diagnostic of metastatic papillary thyroid cancer. She was told it was too risky to operate again due to scarring and high complication rate. The surgeon recommended she have radio-iodine instead. Her endocrinologist had heard about alternatives to surgery, and knew radio-iodine was not helpful to kill lymph nodes. He referred her to me for evaluation for PEI. I called the surgeon and suggested he might want to do the surgery, if I could mark the cancerous node , by placing a small dot of blue dye on the abnormal node one hour before surgery to reduce the risk of complications. He refused my request. I was left with PEI as the only other treatment. I injected ethanol directly into the cancerous node under ultrasound guidance. She had no complications, but did note a slight tingling along the tract of the needle when I pulled it out. The return visit in 4 weeks was notable for a complete loss of blood flow by Doppler, and a 67% reduction of the node. Also the cancer marker dropped 3 fold to <0.1. 2 more sessions resulted in a small remnant node with no blood flow. The yearly ultrasound follow exams have shown no recurrence of the node in question, and the cancer marker is still non-detectable.

PEI is a new method for treatment of recurrent thyroid cancer in the neck. It is operator dependent and should only be done by expert thyroid interventional ultrasonographers.

Good Luck,


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,


Monday, April 07, 2008

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,


Thursday, March 20, 2008

Endocrine Neck Labratory Open for Busness

Modern thyroid care for patients is vastly more complicated now than 20 years ago.
Most internists and endocrinologists would and could care for thyroid patients. However, the new skills needed to care for thyroid cancer patients and patients with nodules and goiters, are not universally available at your local endocrinologists office. They still use nuclear medicine types at the local hospitals to advise them on the need for radiation therapy for their thyroid cancer patients.They send the patients to radiologists to do ultrasound guided FNA. A new concept in thyroid care is the Endocrine Neck Lab. It will offer thyroid studies performed by a clinical thyroidologist, and thyroid ultrasonographer, Dr.Richard Guttler. Any physician caring for thyroid patients can have Dr.Guttler perform studies for them.These include:1.Diagnostic thyroid/parathyroid/lymph node studies 2. Ultrasound Guided Fine Needle Aspiration biopsy 3. Pre-op and follow-up lymph node mapping in thyroid cancer patients 4.Percutaneous Ethanol injections to cure thyroid cysts 5.PEI for cancer nodes. 6. Node Localizations by US guided blue dye injection pre-operatively to aid the surgeon.

Tuesday, March 11, 2008

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.

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.

Thursday, February 28, 2008

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.


Thursday, February 21, 2008

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.