THE THYROIDOLOGISTS BLOG: SEE WHAT A THYROID EXPERT WITH CREDENTIALS HAS TO SAY

Molecular Classifier saves surgery on a suspicious nodule

2011-02-22T11:45:00.000-08:00

Here is the result of an Afirma molecular classifier test done on a male patient set to go to surgery for a suspicious follicular lesion. they wanted to do a lobectomy.The Afirma sample was taken during a repeat FNA and the needle washout was sent to Veracyte for Afirma. The report shown below was benign. He was not a candidate for surgery, and will be followed with yearly examinations and ultrasound.

HMO Offers Poor and Outdated Thyroid Cancer Diagnosis and Therapy To One of Their Own Employees.

2011-02-07T20:15:00.000-08:00

45 Y/O F had a isthmus nodule felt by her GI physician. An ultrasound done by a radiologist noted more nodules and one of them was biopsied. The results were suspicious, but she refused a lobectomy until an outside opinion that she had to pay for out of her own pocket.A second biopsy was even less helpful. After it they still wanted to operate. Finally, she heard about molecular classifiers that could tell if a suspicious biopsy was benign from my website. She was asymptomatic, had 2 firm nodules on my examination. My endocrine neck diagnostic ultrasound result was dramatic. She had 3 very suspicious nodules with microcalcifications, and the whole right side of her neck lateral to the biggest suspicious nodule was full of 5-10 mm abnormal lymph nodes with all the criteria for thyroid cancer spread to local regional lymph nodes. There was no mention of the nodes in the radiology report. Ultrasound techs are not taught endocrine neck changes, such as lymph nodes or parathyroid glands, and only report the thyroid. Many biopsies done by radiology departments are done by PAs, not by radiologists. The biopsy was inferior and only suggested suspicious, because they failed to do smears and only did thin prep. This is a poor substitute for smears, and caused the endocrinologist to recommend lobectomy instead of total thyroidectomy. She did not have a pre-op ultrasound lymph node evaluation before planning to send her for surgery. The second opinion changed everything. She needed a lymph node biopsy and needle washout test for cancer marker thyroglobulin. She will surely be positive for metastatic thyroid cancer in many nodes in her right neck. She now has a pre-op Thyroglobulin test which was not planned before the surgery. She will now have a total thyroidectomy, and central compartment node dissection, but will have a complete level 2-5 node dissection. This is called a Modified radical neck dissection MRND. She was on her way to have a second right neck surgery in one year, which they would have told her it was a recurrence, but it was there all the time BEFORE the first surgery, if she did not get her own second opinion. Please, do not go in for thyroid surgery without an outside second opinion. She would have had many surgeries, and multiple doses of radioiodine as a result of an initial evaluation and therapy plan which was flawed.

Save Unnecessary Thyroid Surgery with new Afirma Molecular Marker Test

2011-01-05T14:57:00.000-08:00

Well thyroid patients heading to elective surgery for suspicious but not positive diagnosis of thyroid cancer, there is now a test, Afirma that can save you and 35,000 others this year from that surgery. It is a marker test with 143 genes, that if present on a 2 pass ultrasound guided FNA will give you a 96% chance it is benign. This is good enough to allow your thyroidologist to follow you yearly without surgery. The first soft opening 3 months of the year Veracyte Corp will do the test for you without out of pocket expense to you. They will bill your medicare,medical, and private insurance, and if there is any money due from you they will send you a letter telling you that you do not owe anything.
How does it work?
First, thyroid surgery is elective and is not an emergency no matter what the doctors tell you. Thyroid cancer is only 5% of all nodules, and it is slow growing to allow definite time for second opinions by experts.
There is time for more opinions, even when it is already on the surgery plan tommorow!
If the nodule was not called benign,or for sure cancer, then Afirma could be just the test you need to prevent a surgery, complications, and 12 weeks of recovery.

1. Call and make a consultation with me or a thyroidologist near you that offers Afirma.
2. Bring you FNA actual slides, or ask me to get them for you. If I decide the FNA is inadequate for diagnosis, which is a common occurence due to poor smearing and biopsy technique, i will repeat the biopsy and get the Afirma marker.
3. If the repeat FNA is benign or cancer I will discard the Afirma sample. However, if it is unclear as to the diagnosis,I will send the Afirma test to Veracyte. You get charged for my collection of the sample, and Veracyte will only bill your insurance if you have any. No out of pocket fees to you. If you have the 143 good genes the nodule is benign, and no surgery is needed. You can contact my office for more information on Afirma. 310-393-8860, fax 310-395-8147, or email dr.guttler@thyroid.com

Lobectomy for a Large Benign Thyroid Nodule? Second Opinion Saved the Day

2010-11-09T10:52:00.000-08:00

50 Y/O female for second opinion on a referral for a lobectomy for a very large thyroid nodule. The FNA of the nodule was benign, but because of the size her endocrinologists referred her for surgery. The ultrasound described two small insignificant nodules 7 mm each in the opposite lobe. My evaluation revealed a major historical finding not known by the first opinion physician. Her sister had thyroid cancer. My ultrasound again saw the nodules but they has 4 + Doppler blood flow in the nodules, irregular borders. My FNA of the large nodule was also benign, but because of the ultrasound findings and the family hx of thyroid cancer I biopsied the two suspicious small nodules not evaluated by the first opinion physician. Both were positive for papillary thyroid cancer. What should you learn as a thyroid patient with a nodule?
1. Get an outside second opinion from a clinical thyroidologist before going under the knife.
2. The second opinion found out during the history that she was at risk due to the fact her sister had thyroid cancer.
3. Careful evaluation of the thyroid by ultrasound revealed not 2 insignificant small nodules, but suspicious nodules for FNA.
4. The second opinion consultant had now changed the whole case from a simple lobectomy to remove a large benign nodule, to a total thyroidectomy for cancer. The lobectomy would have left her with thyroid cancer in the other side that the surgeon would not have felt as they were too small to palpate.
4. The two tests needed before surgery for thyroid cancer would not have been done. They are thyroglobulin cancer marker and an ultrasound 6 level lymph node mapping. This procedure can result in a change in the extent of surgery 30% of the time to include one or more lateral neck lymph node compartments.

It is no emergency to go to surgery for a thyroid nodule. Stop, Think, and get proactive.
Second opinion from an expert thyroidologist can save you from the wrong surgery, as in this example.

My Thyroid Ultrasound Referral Center is Certified by AIUM

2010-11-05T18:41:00.000-07:00

Endocrine Neck Ultrasound Lab of Southern California is the only referral center on the west coast that has both the certification of the physician sonographer by the American College of Endocrinology ACE, and the ultrasound lab certified by the American Institute of Ultrasound Medicine.100 endocrinologists have been certified by ACE, but only 5 have had their ultrasound equipment certified by AIUM. My referral ultrasound center is the only one double certified on the west coast. This allows us see referrals from general endocrinologists,and thyroid surgeons for specific studies. Diagnostic Endocrine neck ultrasound, lymph node mapping before and after cancer surgery, parathyroid localization, USGFNA of nodules,lymph nodes, and parathyroid adenomas. Interventional sonography for Ethanol injection treatment of benign recurrent cysts to replace surgery, and recurrent papillary, medullary cancer lymph nodes after prior neck dissection.

Clinical Thyroidologists: What we do for our patients.

2010-04-01T16:07:00.000-07:00

In the last month in cooperation with filmmaker John Lynch, I have produced 5 2 minute videos to explain what a real clinical thyroidologist, who only see patients with thyroid disease or thyroid cancer does. The first one is an introduction to my center, and an example of the careful history and physical examination that still is the key to discovering the cause of the thyroid disease. The second is my clinical thyroid nuclear medicine section to evaluate toxic nodules, Graves disease, and cancer.The video is designed to explain why the thyroid expert is the best person to treat you, not the general nuclear medicine types who spend little time with thyroid patients. I can treat the cancer patients with radio-iodine as an outpatient. The hall mark of my center is the core thyroid lab, with excellent confirmed results for T4,T3,TSH,TPO Antibodies, Thyroglobulin, thyroglobulin antibodies,and Calcitonin. The Ultrasound section is top heavy with state of the art testing and treatment for nodules and cancer.We are one of the few centers to treat thyroid/parathyroid cysts,and cancer lymph nodes with ethanol. The thyroid cytology section is a leader in the field of alerting endocrinologist of the need to quality control the results of thyroid FNA,and surgical pathology results by general pathologists concerning their own private patients before subjecting them to surgery or radiation therapy. The videos are uploaded to my twitter site and blog.
Enjoy,
Dr.G.

Iodine Induced Graves' Disease Why Treat with Iodine?

2009-06-24T17:59:00.000-07:00

48 Y/O Female with hypothyroidism was treated with iodine pills and T3 cytomel. While on high dose T3 and iodine, she developed double vision and pop eye on the right. MR= swollen eye muscles=Graves Eye Disease.The patient was hyperthyoid on examination. The thyroid was enlarged, firm, and Ultrasound showed Graves'firestorm blood flow. The iodine was stopped, as was the T3. She was started on beta blocker and a I/123 uptake was planned. No ultrasound was ever done.A real time ultrasound was positive. Several nodules were suspicious for cancer.A Biopsy was done, and it was negative for cancer.The patient was cooled off with beta blocker, and was treated with RAI/131.The eye disease stabilized and then a muscle relocation procedure cured the double vision.
What did we learn?
Always see an endocrinologist or thyroidologist if you are told by your primary MD, you have thyroid disease.
www.thyroidologists.com
www.aace.com
www.thyroid.org

Good luck,
Dr.G.

"My Physician found my TSH was high, and started me on thyroid hormone. Why am I worried about this ? Isn't there more investigation needed?"

2009-04-30T10:44:00.000-07:00

The answer to this Ask the Doctor email is yes. The finding of an elevated TSH or even a slowly increasing TSH over a few years is a clue to the onset of hypothyroidism. The abnormal TSH should be the starting point to investigate the cause of the failing thyroid and to evaluate the structure of the gland. TSH elevation even in the upper normal range has been found to be a risk factor for thyroid cancer. All newly diagnosed patients with TSH 2.5-10 are in the risk pool for cancer. The primary physician may not even feel the patient's neck before starting therapy. The thyroid gland is almost always abnormal to physical examination by a clinical thyroidologist. Firm gland with cobble stone surface is usually missed by the primary physician. Before allowing the physician to treat you, you need a complete thyroid evaluation looking for nodules. The endocrine neck ultrasonographer thyroidologist will do a detailed study of the thyroid, lymph nodes and parathyroid areas. If a suspicious nodule or lymph node is found, an ultrasound guided FNA will be done. Modern thyroidology concepts include hands on ultrasound real time done by your thyroidologist or endocrinologist, not by a radiology tech, who prints out pictures for a radiologist to look at after the fact. The original evaluation when the abnormal TSH is found is the best time to see a clinical thyroidologist, notjust start thyroid hormone.

Surgery for Benign Thyroid Cystic Nodules? Not Anymore! There is a New Medical Treatment Using Injection of Alcohol call PEI

2009-04-28T18:27:00.000-07:00

42 year old female with a large visible mass on the right thyroid lobe. She had local symptoms and did not like the looks of the mass, as it distorted her thin neck. Her thyroid tests were normal, but a complex cyst was seen in the right lobe on ultrasound.
An FNA and drainage of the cyst fluid was done. The free hand FNA done without ultrasound guidance, was negative for cancer, but the mass recurred in 4 weeks. The endocrinologist referred her to a surgeon to remove the mass. She was referred to me for a second opinion on the need for surgery. Of course she had searched the web for alternatives to surgery, and found my website.
She learned about my Ethanol Injection Method (PEI) for recurrent Cysts. The cyst was 11 ml in size and had a complex solid component. An ultrasound guided FNA aimed directly at the solid component to R/O cystic papillary thyroid cancer was negative. The injection of ethanol after draining the cyst was successful. She had slight burning sensation as the needle was removed, but othewise there was no other side effects. She returned in a month to see the effects of the ethanol on the cyst. When she walked int the examining room, she said, "The thing is gone". The large visible mass was not seen on inspection, or was it felt on palpation. The mass was still there but was markedly reduced. From the original 11 ml to 0.6 ml. That was a >90%
reduction in size. The average reduction noted in the literature is 80%. She did not need surgery, because the reasons for surgery did not exist anymore.They are fear of cancer, obstruction,and removing an ugly mass for cosmetic reasons.

Get a second opinion before having thyroid surgery for a cyst.

Good Lck,Dr.G.

Thyroid.About.Com, the Source for Dangerous Thyroid Information has Done it Again. Now You Don't Need an Endocrinologist at All!

2009-03-16T14:57:00.000-07:00

The about.thyroid.com website, for alternative medical information has reached a new low. Patients with thyroid disease should NOT see an endocrinologist or thyroidologist. The post claims that "thyroid friendly" alternative types will listen to the patient and give them therapy based on symptoms, rather than hard thyroid hormone blood studies. The patients with cancer or needing radiation for Graves' disease are the exception, and need to see a thyroidologist. This is a very way out idea. Here is why. First, hypothyroid patients need to see a specialist at the first sign of disease. The careful examination of the neck by an expert will be able to feel a firm nodular surface of an early Hashimoto's thyroiditis. That will trigger an ultrasound. The ultrasound done real time by the endocrinologist could reveal a cancer nodule, goiter,or nodular goiter years before it can be troublesome to the patient. Waiting until the patient has cancer,or nodules that can result in a surgery is a poor concept,and is the major reason not to consider anyone other than an endocrinologist. Every patient with subclinical hypothyroidism with TSH >3.0 and slowly climbing yearly needs to see an endocrinologist,or thyroidologist PERIOD. Hashimoto's thyroiditis with progressively increasing TSH from 2.5 to 10 over 10-20 years, or has positive antibodies needs a complete endocrine/thyroid evaluation. TSH is a risk factor for thyroid cancer in patients with Hashimoto's thyroiditis.
Also TSH causes nodules to grow that are not cancer but look bad on a thyroid biopsy, and can result is surgery.Early detection of Hashimoto's can save surgeries and find cancer when it is small and curable. Also, in 35 years of practice,I have seen goiters melt away, and the antibodies disappear on T4 therapy. The disease will destroy the thyroid if you prevent the regrowth due to TSH. Failure to visit an endocrinologist to get an early diagnosis of possible troubles is a major mistake that will happen to some of those who read the posts on thyroid.about.com. Finally, that leaves only the few percent of all thyroid patients who are still complaining about symptoms when their T4, and TSH are normal, to seek those physicians, that prey on the patients ignorance and give them Armour, T3, Combo T4/T3, and compounded products, to treat symptoms totally unrelated to the thyroid disease. The impossible dream is that just treating thyroid problems will correct all the symptoms the patient have. That is not only a dream, but a pipe dream. They may feel better for a while due to the effect of T3 on the brain, but will suffer in the long run.

I challenge the website managers to allow comments, without deleting those that have a contrary opinion to it's alternative views. My comments given here in my last few blogs were sent as comments to the website. They were clearly received, but disappeared by the next day. The only comments that were allowed to appear were the "yes, I agree" type. The alternative thyroid audience will not like what I have to say, but there will be a few among them that will rethink their position.
Good Luck,
Dr.G.

A German Story of a Failed Treatment Plan for a Radiation Exposured Patient With a Toxic Nodule, and the Negative Long Term Effect on HER.

2009-03-14T12:55:00.000-07:00

A 45 Y/O female presented to my center with a thyroid nodule. The history was positive for radiation therapy for a skin problem as a child in Germany. At age 30 she had symptoms of hyperthyroidism, and was diagnosed with a single toxic nodule by thyroid uptake and scan. The endocrinologist in Berlin referred her to a surgeon, who did a lobectomy removing only the lobe with the toxic nodule. 15 years later is when she arrived at my doorstep after a CT scan, done for another unrelated problem revealed a mass in the thyroid. A large scar over the left side of her neck was secondary to the childhood irradiation. A palpable mass was noted in the right lobe. The scar from the surgery was located over the other lobe area that was removed in Berlin. Her thyroid blood tests were normal, but the high frequency ultrasound was abnormal. There was a large nodule in the right lobe, but there were 10 nodules in all ranging in size from 3-10 mm. The left lobe was also enlarged and had nodules as well. Did the surgeon do a nodule removal only or was this regrowth? The ultrasound guided FNA of all nodules > 5 mm were benign. The patients problems began when the Berlin endocrinologist and the surgeon failed to factor in the radiation history in the surgery plan for the toxic nodule. The radiation history should have been the reason to do a total thyroidectomy to remove at risk thyroid tissue along with the toxic nodule. This would have removed the risk of cancer in the future, and would have prevented the progression of her goiter to the point that now she will need careful ultrasound and blood monitoring for the rest of her life. Any one of the nodules that were not biopsied could be a cancer, and if they grow another round of biopsies will be needed. The endocrinologists should have known that patients in their area have a high incidence of iodine deficient goiters. That toxic nodules arise out of those glands. Also that needed to remember that radiation therapy for benign conditions of the head and neck causes goiters, nodules, benign and malignant tumors. Her life would have been simple if they did a total as recommended, and simple thyroid blood T4, and TSH, would have been the only followup needed. Instead she will need yearly ultrasounds to follow the massive number of nodules that are present,or go in for another surgery now.
I wish her luck in the future,

Dr.G.

Mary Shomon, and the Medical Review Board of about.thyroid.com, on their Opinion on the Top Thyroid Websites: Pros and Cons

2009-02-27T12:38:00.000-08:00

The last newsletter from Mary Shomon has her company's opinion on the top thyroid websites. I am honored to be listed alongside the Endocrine Society, and the American Thyroid Association. She has cleverly added a medical review board, since her last top websites list, probably paid by her corporation, which has 12 physicians, who are evaluating the top sites. It should be noted that not a single endocrinologists is on the panel. The way Mary Shomon and her bosses treat top level endocrinologists, as bag men and women for the drug companies, there is no wonder why she can not get a real qualified expert clinical endocrinologist to be on the panel. Headed by an internist, and without a single physician board certification in endocrinology among them, they are asked to judge the top thyroid websites. The last "top" site they reviewed was her own site, about.thyroid.com. That shows the panel's level of objectivity. The panel appears to be just a rubber stamp for all the slanted views presented on their website. What was the review panel doing allowing Mary to blow her own horn, calling it a a top site. Not only did she include about.thyroid.com on the list of top sites, but plugged her book, Living Well with Hypothyroidism, and even worse plugged another of her books on an unrelated subject. The panel mentioned the slanted, and biased qualities of the other top sites toward evidenced based conventional medicine, because of corporate money funding the sites, but failed to mention that Mary's site was extremely outside the range of objective thyroid medical opinion. There was no mention that this approach was considered by the vast majority of physicians and patients to be beyond any reasonable credible concepts of thyroid patient care. The problem with The American Thyroid Association website, was according to the panel that it was in the pocket of drug companies, that is why they only mentioned mainstream medicine, and did not cater to alternative medicine. Similar knocks on other top thyroid sites, such as the Endocrine Society, were made by the panel. Finally, let me look at the comments made about my site, Thyroid.com, which was founded by me personally in 1997. This was the first private thyroid website, and except for a short partnering deal with Amazon, we have never accepted ads. Most endocrinologists and clinical thyroidologists will not waste their breath to respond to things listed on her website as it is considered a "way out" site. Let me take a moment to respond to the inaccurate comments made about my site.
1. The concept of virtual second opinions on the web did not start with me. Her site stated that I charge excessive fees for those opinions. The Cleveland Clinic had one before me and charged more than I do. A fee of $400-500 to review all the records, actual thyroid scans, ultrasounds, pathology materials and give the patient valuable advice is not excessive. 2. The few complaints they said they received are out of thousands of thyroid patients I have treated in 35 years. The patients who are unhappy with me are the ones who are told they are properly treated and need to look elsewhere for the cause of their symptoms. I am not an internist, or even an endocrinologist, but a clinical thyroidologist. I refer them to others but many insist, after reading the slanted stories on about.thyroid.com, that it is the thyroid causing the symptoms and I, as a mainstream physician, am not treating the symptoms only the numbers. 3. My Blog, www.thyroid.blogspot.com, is my personal diary about my experiences in 35 years practicing in the thyroid field. I do not have a paid corporate spell checker or any Grey Flannel Suits with lawyers packed inside them to correct my grammar or tell me not to write things that could hurt the image of the corporation, decrease the ad revenue from the Grapefruit therapy for Graves' disease suppliers and other alternative types. I do not want anyone telling me how to inform by readers. 4. As for bedside manner, I have plenty of that. Name five other endocrine physicians in the country that see thyroid patients 5 days a week, giving me a following of 3-5,000 patients from around the world. 5. As a test, please look at thyroid.com and then look at about.thyroid.com. I think you will see who is full of corporate cash from ads on the site. Why should patients be worried about the educational grants that keep excellent thyroid websites, such as the Endocrine Society, working, but do not also question the funding of about.thyroid.com which takes all comers as long as they have ad dollars to spend. Every page is clean of ads, and no money changes hands to support my website. I have turned down all ad revenue, and refuse to be a paid hack fishing for ads to pay the bills and make a profit for myself. I have turned down 5 figure offers to buy thyroid.com by corporations eager to take it and ruin it. I have refused to sell out to drug companies.

Thank you, and keep looking for excellent endocrinologists, with good records, to care for you.
Good Luck,
Dr.G.

The Brits are Half Right, and Mary Shomon is as Usual All Wrong

2009-02-21T19:53:00.000-08:00

The national health service NHS, of the United Kingdom, has banned the use of Armour thyroid, compounded combination thyroid preparations, Cytomel, and other products with anything but LT4 in them for treatment of hypothyroidism for all patients treated by the NHS. This is a good step by the NHS to get rid of these second tier drugs that cause more harm than good. The recent story by Ms. Shomon on about.thyroid.com was off base as usual, and aimed again at the fringe patients who feel they are not "doing well" on T4 alone, even though all the proven tests of T4, and TSH are completely normal. They are not hypothyroid, but are truly not feeling well, but for other reasons, not thyroid. As an expert in thyroid disease for 35 years, I am glad that we are finally seeing the beginning of the end of these drugs. To all the thyroid patients in the NHS, and the USA, do not pay any attention to doomsayers like Ms. Shomon, as she is not a physician, and as a hired gun for a large corporation, has an interest in appealing to the patients who are unhappy with the results of their thyroid therapy, even though it is properly treated with thyroid hormone of the T4 type. However, there are problems with the other part of the NHS guidelines. Although a TSH less than 10 is rarely associated with symptoms, as they correctly state,therefore, therapy for pure hypothyroidism is rarely needed when a TSH is less than 10. However, the problem is more complicated than that. TSH values between 2.5-10 are abnormal,and are associated with other problems than symptomatic hypothyroidism. As the TSH rises there is a increased risk of cancer of the thyroid, nodules, and goiter formation. If the NHS mandates ultrasounds for all patients with elevations of TSH above 2.5 and there is no goiter, or nodules, then follow up without thyroid therapy is reasonable. Also if the patient does not have heart disease or lipid abnormalities, then the use of TSH > 10 is a reasonable choice for symptomatic hypothyroidism for therapy. Remember, by the time the TSH rises it may be already the cause of significant nodule formation,and increased risk of thyroid cancer.
DR.G.

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

2008-11-04T14:23:00.000-08:00

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,

Dr.G.

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

2008-10-15T11:04:00.000-07:00

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.

Conclusions:
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,

Dr.G.

Reference:
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.

Thyroid Nodule Therapy in Patients with Insulin Resistance

2008-10-02T10:42:00.000-07:00

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.
Thanks,
Dr.G.

Reference:
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.

Beware of Generic Substitution of Your Thyroid Hormone Therapy

2008-09-16T12:22:00.000-07:00

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,
Dr.G.

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

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

2008-07-29T09:42:00.000-07:00

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,

Dr.G.

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

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

2008-07-17T11:42:00.000-07:00

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,

Dr.G.

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

2008-07-17T11:03:00.000-07:00

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,

Dr.G.

Why a General Endocrinologist Should Not be your Thyroid Doctor

2008-06-30T17:55:00.000-07:00

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

Dr.G.

Calcitonin Measurement in All New Thyroid Nodules

2008-06-16T13:37:00.000-07:00

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.

Thanks,

Dr.G.

Alarms Go Off in Restrooms When Radiated Thyroid Patients Urinate.

2008-06-16T11:01:00.000-07:00

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,

Dr.G.

Tajiri et al
Radioiodine and Flame sensors

P2-190
abstract Endocrine Society Annual meeting San Francisco Ca 6-15-2008.
abstract

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

2008-06-13T15:00:00.001-07:00

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,
Dr.G.

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

2008-06-13T15:00:00.000-07:00

I do not recommend the use of compounding pharmacy

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

2008-05-27T11:04:00.002-07:00

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,

Dr.G.

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

2008-05-27T11:04:00.001-07:00

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

2008-05-27T11:04:00.000-07:00

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

2008-05-25T13:37:00.000-07:00

Case Presentation:
Question:
Why are they treating 85-94 year old patients so aggressively?
Answer:
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,
Dr.G.

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

2008-05-24T15:35:00.000-07:00

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,

Dr.G.

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

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

2008-05-24T08:58:00.000-07:00

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,
Dr.G.

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

2008-05-22T08:29:00.000-07:00

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,

Dr.G

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?

2008-05-21T14:11:00.000-07:00

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,

Dr.G.

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?

2008-05-21T11:06:00.000-07:00

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

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

Good Luck,

Dr.G.

Murder by Thyroid Poisoning, or Paranoia?

2008-04-07T13:30:00.000-07:00

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

Good thyroid health,

Dr.G.

Endocrine Neck Labratory Open for Busness

2008-03-20T14:14:00.000-07:00

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.

Why Surgery Not Needed for most Goiter Patients

2008-03-11T18:51:00.000-07:00

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

Hashimotos Thyroiditis, HT: A Thyroid Cancer Risk?

2008-03-11T18:23:00.000-07:00

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

2008-03-11T17:58:00.000-07:00

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

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

2008-02-28T12:13:00.000-08:00

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

Two new tools added to treat our thyroid cancer patients

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

Dr.G.

Gangster with Graves' Disease

2008-02-21T12:35:00.000-08:00

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

Thyroid Cancer Radiation Therapy USA Today Front Page Story

2007-11-20T11:28:00.000-08:00

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.

O Oprah, Get Real About Your Thyroid

2007-10-18T13:54:00.000-07:00

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

Bloody Bad Thyroid Smears Can Lead to The Wrong Diagnosis

2007-07-29T13:28:00.000-07:00

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.

Kidney Cancer Presenting as a Thyroid Nodule

2007-04-27T12:01:00.000-07:00

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.

Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protein Deficency, Hypo-TBG -emia.

2007-03-26T14:42:00.001-07:00

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.

Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protien Deficency, Hypo-TBG -emia.

2007-03-26T14:42:00.000-07:00

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.

Rare TBG Deficiency Confuses Physicians, and They Miss Her Real Thyroid Problem.

2007-03-23T22:47:00.000-07:00

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

Seaweed Goiter, or How I Grew My Thyroid While Ingesting Large Amounts Kelp

2007-03-15T19:23:00.000-07:00

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.

A Rare Cure of Medullary Thyroid Cancer ???

2007-03-15T19:08:00.000-07:00

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.

Acute Leukemia and MCT, Medullary Thyroid Cancer

2007-03-15T18:25:00.000-07:00

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.

Medullary Thyroid Cancer: One Chance to Cure

2007-03-01T18:40:00.001-08:00

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.

Medullary Thyroid Cancer: One Chance to Cure

2007-03-01T18:40:00.000-08:00

Holistic Therapy for Graves' Disease: An 8 Year Therapy Plan that Failed, or How to Stroke Out or Die When There is Conventional Medical Therapy

2006-11-22T16:24:00.000-08:00

49 Y/O male ex- chirpractor, first sought medical care 8 years ago. He had every major symptom of Graves' Hyperthyroidism. He refused medical therapy for most of the next 8 years.6 years ago after 2 years of holistic medicine, he had Hyperthyroid induced rapid irregular heart beats called atrial fibrillation. He did nothing for 6 years! He was sent to a heart specialist this year. He was told the thyroid needed therapy and the heart problem would go away. The heart was enlarged, and he was at risk for blood clots to his brain and a stroke if the thyroid was not treated. He never took the blood thinner medicine to prevent stroke. He continued holistic therapy, even though he was told the thyroid could be easily cured by radioiodine, surgery, or antithyroid pills.

When I saw him in consultation, he had a large goiter with blood flow sounds, Atrial fib out of control, and thyroid eye disease and skin disease.

The bone density was low.
The left atrium was enlarged and at risk for an embolus to the brain.
There was decreased function of the heart.

Ultrasound showed a firestorm pattern of increased blood flow in the thyroid.
There was a very high iodine uptake, and diffuse scan consistent with Graves'
hyperthyroid 8 years after first diagnosed!

He swore to me he was finally ready to be treated by standard thyroid therapy methods.

Well, he failed to return, and was trying another holistic regimen in hopes of cure.

He is a fool, and puts himself at grave risk for no reason. Modern well known therapy
could have fixed him 8 years ago. There is no holistic therapy for Graves' Hyperthyroidism. I hope he learns this in time, before his stroke.

I sadly sent him a withdrawal letter as I did not want to be the physician of record when he became paralized from a blood clot from his heart, or when he went into heart failure.

Before 1940, there was a high mortality for untreated Graves' Disease, but that was because there was no therapy! With 3 proven therapies today, no one should stroke out or die, unless you try unproven methods in cure yourself.

Dr.G.

Distant Metastatic Disease 30 years after Partial Thyroidectomy for Thyroid Cancer

2006-11-08T17:05:00.000-08:00

I was not expecting this when a nurse called me to see her 85 Y/O father. He had a mass under the skin of his abdomen which was removed, and was found to be metastatic papillary thyroid cancer.The story gets worse. Since his surgery in his home country 30 years ago, he never knew that he had had thyroid cancer. The family did not tell him. They thought he had been cured by the partial thyroid surgery. There was no cancer follow up. With the distant cancer spread 30 years later, the family asked me to see him. He was wearing a pacemaker, had heart disease, and was not a good surgical risk. He was taking a heart drug, amioaderone, which was very high in iodine content. He had nodular masses in the lung by CT, and had significant thyroid tissue
still in the neck by ultrasound. 24 Hr uptake was 18%, the scan showed bilateral thyroid gland with cold masses in the left lobe. The thyroid tests confirmed severe hypothyroidism with TSH of 70. He had never been treated with thyroid hormone for the cancer or hypothyroidism. The TSH stimulated cancer marker TG was > 2000.
He was ready for ablation therapy, but was incontinent! No hospital would take him.
What do you do with this case?
After much thought, because he was most effected by the hypothyroidism, I elected to treat his hypothyroidism first. He had wide spread cancer with very high cancer marker, and had no local symptoms due to the cancer. I will wait for local symptoms and then treat for symptom relief with external radiation. This is a very sad case, because if he knew he had cancer, the patient might have sought medical care when there was a chance it would have help.

Why you need to see a Clinical Thyroidologist before parathyroid surgery

2006-10-17T16:57:00.000-07:00

42 Y/O female sees me for a second opinion for the need for parathyroid surgery. She has documented hyperparathyroidism by calcium and PTH testing.Prior Parathyroid scan
was negative. Ultrasound before seeing me was consistent with a parathyroid adenoma on the left, but a thyroid nodule was seen on the right. There was no change of plans when the thyroid nodule was found pre-op. That was what prompted her to get a second opinion.

I believe that real time high frequency Ultrasound done by the physician thyroidologist, is manditory in this case. Therefore, I repeated the US personally.
The 11 mm mass in the left extra-capsular area of the thyroid had a polar parathyroid like artery coming into the mass. The right lobe of the thyroid had a 6-8 mm mass with irregular border, cystic posterior enhanced views consistent with cystic fluid, and microcalcifications worrisome for papillary thyroid cancer. Also an abnormal shaped lymph node was seen on real time in level 4 lateral to the thyroid nodule in the right lobe.

You wonder if she is having surgery anyway, who cares if there is cancer, she will have her thyroid removed while doing the parathyroid.

Well, the reason is if the node is positive it can change the surgery. There will be a need to remove the lateral neck nodes as well as the total thyroid , and the parathyroid adenoma. This is called a three for one surgery. It would surely save her a relapse and surgery, and Radioiodine years later.

What happened?

The parathyroid was a single adenoma.
The right thyroid nodule was papillary thyroid cancer.
The node washing was positive for TG on FNA, and the surgeon did a right lateral neck node removal at the original surgery.

Now do you know why you need to see a clinical thyroidologist BEFORE you submit to surgery, even if it is recommended by a good endocrinologist, and surgeon. This evaluation may have saved her future surgery for cancer nodes. Pre-op physician
thyroidologist real time ultrasound and US guided FNA of nodes can change the
surgery planned for you 30-44% of the time.

Check www.thyroidologists.com or thyroid.com for details.

I will visit with you with the next great thyroid case soon,

Dr.G.

Alternative Therapy for Graves' Hyperthyroidism for 10 years: A Serious Failure

2006-10-05T18:46:00.000-07:00

46 Y/O male sees me for the first time 10 years after he was first diagnosed with hyperthyroidism. He was trying alternative therapy and refused the main stream medical therapy for his disease. Each new therapy was giving him some relief for a short time. The goiter even shrunk for a while. Herbs, therapy in Mexico, accupuncture, and other treatments only gave partial relief. He continued to try other methods without much success. He developed a dangerous irregular heart beat called atrial fibrillation,AF, 7 years ago but still refused to follow the cardiologists advice to get the thyroid treated. He was doing poorly, and finally consented to be treated, when he learned that a stroke, and even death could occur if he continued to be untreated with western medications.

He had a visible goiter from across the room. The pulse was 130, and irregular,irregular. Slight exercise caused a rapid rise to 170-180.
He had muscle wasting, elevated nail beds called Plummer's nails, Pre-tibial Graves' Dermopathy, and mild Graves' exopthalomas. I sent him to a sports store to but a sports heart rate monitor. I started him on beta blockers and ask him to monitor the dose until he was controled with mild exercise to 110-120.

The left atrium of the heart enlarges due to AF, and clots can be sent from the heart to the brain causing a stroke. I added 10 gr ASA to help stop clotting, and sent him for detailed cardiology`evaluation. I started anti-thyroid drugs to control hyperthyroidism for 6 weeks, before I give him radioiodine.

This is a rare example of the false hope given by alternative care givers to patients with clearly treatable disease. This false hope could have made him a drooling stroke victim for the rest of his life, or killed him by means of thyrocardiac disease, or liver failure.

In 32 years of private thyroid only practice, This is the worse example of the wrong headed approach to thyroid treatment, I have ever seen.

Your alternative approach works for some symptoms, but stay away from thyroid patients that have curable disease, which you put in danger when you offer half baked treatments that delay the onset of life saving western care.

Shame on all the fools that tried to treat him, with their treatment plans that have no validity, and their disrespect for the highly successful mainstream medical treatment, that has saved lives for 60 years!

Doctor, My TSH is Low, but you tell me my Thyroid dose is correct. Then Why do I feel So BAD?

2006-09-09T14:40:00.000-07:00

Patients need to be able to read the results of their tests, and know why they are taking thyroid hormone in the first place. The normal range for TSH is lower than before. It is 0.3-3.0.

There are three different dose levels depending on your disease

1. Hypothyroidism only without nodules, or goiter. The TSH should be between 0.5-2.0.

2. Suppression for nodules, or goiter in younger patients < 50 Y/O. The TSH should be between 0.1-0.5.

3. Active thyroid cancer needing maximum suppression to act as a hormonal chemotherapy.
The TSH needs to be lower than for hypothyroidism at < 0.1, and even <0.01 in active diease.

Do not let a physician change your dose without knowing what your reason for taking thyroid hormone is. The suppressed TSH is not correct for hypothyroidism, but is needed for cancer and nodule and goiter suppression. The most suppression is for cancer patients that still have active disease.

Good Luck,
Dr.G.

Traumatic Damage, with painful bloody cyst formation, due to a child's blunt blow to the mother's neck

2006-09-08T20:14:00.000-07:00

After an incident where the mother received a blow to the neck by her child, she began to experience pain and tenderness and marked swelling of her neck. She did not realize the trauma caused the swelling and was fearful of cancer, because it was rapid in onset and very large. She noted that the swelling deceased in size but was still painful. She had a large visible mass from across the examining room. The ultrasound confirmed a 5 cm cystic mass. The rest of the thyroid confirmed a diffuse goiter was present. Thyroid tests were normal. The ultrasound guided FNA produced 5.6 cc of bloody fluid. The attempt to biopsy the mass was unable to confirm an underlying cancer. She returned in 1 week. The mass was not visible and was decreased in size due to the decompression and fluid removal. The repeat US revealed a reduction of 60% in the size of the cyst. There was no pain or tenderness now. She was placed on thyroid hormone to suppress the goiter. If the cyst recurs, she will be a candidate for percutaneous ethanol injection, or PEI. This has replaced surgery as the primary therapy for non-cancerous recurrent cysts. There is an average 80% reduction in size with PEI.

If you have a recurrent cyst, please consider a visit to my center instead of a major surgical intervention for a minor cyst.

The Return of a Pituitary Tumor Patient

2006-09-06T20:19:00.000-07:00

Today, I saw the man I diagnosed with pituitary hypothyroidism 6 months ago. He had secondary hypothyroidism. That means his hypothyroidism was due to the failure of the pituitary to send enough TSH to sustain normal thyroid function. An MR of the head revealed a large tumor that was interfering the normal gland function. He had low testosterone for several years. A 3-4 cm mass was seen on the MR. The surgery was long and difficult. However he returned to see me after the surgery, with normal pituitary function. The clue to his diagnosis was a low Free T4, and a normal TSH. This was not the usual numbers for primary thyroid failure and suggested a central cause for his failure. His testosterone normalized, and he was markedly improved. He does not need replacement or stress steroids!

Great case,
Good result.

Until next time,
Dr.G.

40 Heathy Years after So Called Papillary Thyroid Cancer Surgery: Serious Recurrence due to Undiagnosed Medullary Thyroid Cancer

2006-08-08T19:12:00.000-07:00

60 Y/O female had a total thyroidectomy, lymph node removal from the neck, and superior mediastinum, and a mutilating radical removal of all neck structures on the right. Why?
The pathologic report, I tracked down from 1960's called it a very, very agressive papillary thyroid cancer. She had mytosis in some areas, and spindle cell formation, but no signs of papillary structures, but many spindle cell groups. Her parents elected at age 18, not to tell her about the cancer, until age 24. They told her she was cured, but had to take thyroid hormone for life. She never saw an endocrinologist, and was fine until 37 years later, when she developed diarrhea. Specialist Gastroenterologist did not find a reason for the diarrhea, but had drawn a calcitonin, which was markedly elevated, at 4000, normal< 20. This was ignored, and never sent to the her primary physician. 38 years after the surgery, she developed dysphagia. An MR revealed a mass in the thyroid bed and in the mediastinum. It circled the carotid, esophagus, and some great vessels in the mediastinum. The calcitonin was still in the 4000 range and the CEA was 2 fold elevated. She saw experts on the east coast, and they were reluctant to intervene surgically. When I saw her, I was able to obtain the pathology report from 1960's. She had exactly the same disease as in the 1960's. The diagnosis of Medullary Cancer of the thyroid was not widely known, and usually called atypical aggressive papillary cancer then. Ultrasound guided FNA diagnosed Medullary adenocarcinoma in the masses in the thyroid bed.

Wow, I am impressed that something looking so aggressive in 1960, had not killed her in 40 years!

Armed with the knowledge that it was an extremely indolent cancer, I began to lobby for a debulking surgery to decrease tumor burden, and decrease diarrhea due to tumor bulk. I sent her to MD Anderson in Texas to see a extreme surgeon to operate.

I will update as this story unfolds.

Dr.G.

Strip Searched at the White House, Airport, and Courthouse

2006-08-04T18:56:00.000-07:00

If you receive radioiodine therapy for thyroid cancer, or hyperthyroidism, you may be strip searched at security check points because the therapy will cause detectors to go off months after the radiation is safe. It still will set off the scanners for up to 12 weeks. You need to get a form from your physician stating, you were treated and are not a risk. Please do not go to areas of secure detectors, such as airports without a formal letter from the treating physician. White House guards have strip searched a man, and 4 patients have been strip searched at Banks,and airports because they had no documentation of the therapy.

Dr.G.

The Best Thyroid Patients in My Clinic Last Week

2006-07-27T20:18:00.000-07:00

The first patient of the week was from Italy, and had pain and tenderness in her neck area by the left lobe. She was treated for iodine deficient nodular goiter from Italy. The Ultrasound confirmed a cystic nodule. she must have bled into her goiter. An US guided FNA confirmed no cancer in the cystic nodular goiter.

A 14 Y/O male from a family, where many members have autoimmune thyroid disease, had a goiter for several years, but because the TSH was normal, no therapy had been given by the child's physician. By the time I saw him he had a larger goiter, positive TPO, and Tg antibodies, and a 1.8 cm nodule in the right lobe. He now will need a needle biopsy, because the physician did not get an endocrine consult 2 years earlier. Thyroid therapy,then, may have prevented the nodule formation.

An 85 Y/O with a long standing goiter that was never treated, developed apathetic toxic nodular goiter, which was noted on routine yearly physical,by low TSH. The only abnormal finding was lid lag. She had no symptoms to report.

77 Y/O female with Hurtle Cell Follicular Carcinoma treated 7 years ago by lobectomy only, and no radiation I/131 ablation, presents with a new nodule in the other lobe not removed at the first surgery.

A patient from Chicago was told after a six hour thyroid surgery for a nodule, that all was well. She sent me all the material including the orginal surgery slides. On the slides I noted a cancer which was not reported on the original report. She was very upset and came out to LA to see me. She had papillary thyroid cancer, but had no abnormal cancer nodes on my neck node ultrasound.She will follow up yearly with me.

Have a good week,

Dr.G.

The Best Thyroid Patients in My Clinic Last Week

2006-07-16T15:42:00.000-07:00

The week was full of unusual cases.

1. 30 Y/O singer with a lingual thyroid. The patient had a sore throat and went to an ENT.
When they looked down the throat they saw a whitish mass at the back of the tongue. MR confirmed a 2.5 cm mass. The TSH was elevated to 5.6. The possibility of a rare congenital undecended thyroid at the base of the tongue was confirmed by thyroid imaging with 123/Iodine.There was no uptake in the neck where the thyroid usually is located, but was very hot in the posterior pharynx. The image showed uniform uptake without cold areas. The ultrasound showed coarse calcifications in the gland but no nodules. He was treated with thyroid hormone to keep the lingual thyroid from enlarging.

2. 6 month retired special forces policeman, developed Graves' Disease after a severe stress related to a murder of a rapist who was holding hostages at a clinic where the people worked.His eyes were swollen and reddened from thyroid eye disease.

3. A 2 Y/O infant developed Graves' disease and even on proper therapy had global retardation in growth, speach and motor co-ordination. The infant had a goiter, and was tall for it's age.
The infant "flew around the room" with the mother chasing after. This is the youngest patient I ever saw in 30+ years as a consultant with Graves'.

4. A thyroid cancer patient who refused surgery for an ultrasound FNA proven recurrence in a lymph node. The node had 400+ ng/ml Thyroglobulin Tg cancer marker in the node washings. She allowed me to inject Ethanol by ultrasound guidance directly into the cancerous node. She returned in 4 weeks, and the node was now 50% smaller, but the doppler blood flow was gone! The blood TG went from 2.0 to 0.9 after the Ethanol therapy. She allowed me to repeat the procedure called Percutaneous Ethanol Injection, PEI again.

Well it was a big week at my thyroid center, and we will see what is in store for me next week.

Dr.G.

Parathyroid Adenoma Cured by FNA, not Surgery

2006-05-28T17:31:00.000-07:00

47 Y/O female has biochemical hyperparathyroidism. She saw me for evaluation of a thyroid nodule. While doing the ultrasound with high frequency probe, a 10 mm mass was seen in the area of the upper pole parathyroid, posterior and medial to the thyroid on the left. The thyroid
gland had positive antibodies and a USGFNA biopsy of the thyroid nodule confirmed Hashimoto's Thyroiditis. The suspicious parathyroid mass on the left with central polor artery
seen on power Doppler, was biopsied and had a thyroid follicular neoplasia pattern. Microfollicular without background colloid. The PTH washing from the mass is pending, However, the Calcium before the biopsy was 10.5, and one hour post biopsy was 7.9. It appears that the biopsy has necrosed the adenoma. There are reports of this happening after a biopsy. There have been attempts to do this in elderly patients who are not surgucal candidates. One 90 Y/O had Calcium of 12.5 , and the thyroidologist spent a few extra passes to try to infarct the adenoma. The calcium dropped to normal, and stayed normal until she died from other causes. We will check my patient to see if the Calcium stays normal. Ethanol injection, which is so successful for thyroid cysts has not been able to cure parathyroid nadenomas.

What does it mean?

In some patients a biopsy of a suspect parathyroid adenoma, may cure them, rather than just locate the specific abnormal gland for the surgeon.

Come to see me to locate the adenoma before you have surgery.
We may, even if unlikely, cure you!

Dr.G.

Rare Central Hypothyroidism, But What is the Cause?

2006-05-12T22:20:00.000-07:00

The male patient from an endemic goiter area of eastern Europe, sees me for a goiter.
The goiter is multinodular, but no Ultrasound suspicious nodules, and all below 10 mm.
No history of radiation exposure.

He is thin, and has muscle weakness. He complains of fatigue. His wife states he has had decreased libido since 1 1/2 years ago.

He has a multinodular goiter, and a BP 100/70. Normal pubic and axillary hair.
Normal male genitalia.

Prior testing 1, and 2 years ago by an internist had euthyroid FT4I and TSH, but lower
level Testosterone with low FSH/LH . a prolactin was also normal. He had a low normal repeat Testosterone one year ago.

FT4 0.6 TSH 2.9 Free T4 by dialysis 0.6.
Repeat FT4 0.3 TSH 0.69

The Head MR revealed a pituitary tumor. This non-cancerous tumor is replacing the normal pituitary gland. It is 3 cm in size. It is the cause of a rare cause of hypothyroidism.
Secondary hypothyroidism due to pituitary failure, caused by the tumor compressing the normal gland, and causing decreased TSH secretion. The patient is on the way to consultations to determine what the best therapy is for his tumor.

It is rare to see this , but the clues are low T4 with inapproprate normal TSH.
The free T4 by dialysis confirmed hypothyroidism, and the failure to see a rise in TSH as is usual with primary thyroid failure, was a major clue. The clincher was the wife's statement he had recent onset of decreased libido.
Also he had sexual problems and flabby muscle and weakness.

Beware of abnormal thyroid tests that do not match.
Get help from an expert.
www.thyroidologists.com

Six Hour Surgery / No Problem??? / Wrong!

2006-05-10T19:58:00.000-07:00

I was asked to do a second opinion on a prestige medical center in Chicago. The patient was sent to sugery because of suspicious biopsy result of a thyroid nodule. The patient was told she had normal thyroid tests and a normal gland except for the nodule. Her family sat out in the waiting room 6 hours! They thought the worst, when they were told the surgery only would take 90-120 minutes. An Endocrine surgeon did the surgery. When she woke up, they told her everything was O.K. She was shocked the surgery was 6 hours long, and they found no cancer, only thyroiditis. She was suspicious because they told there was no abnormality of her thyroid before the surgery. They sent her home on thyroid hormone. She continued to be upset that the surgery was so long, and no cancer was found. She was troubled enough to request I do a virtual second opinion, on thyroid.com. She sent me all the records and the slides from the surgery. After looking at the records, it was clear there was evidence she had Chronic Thyroiditis before the surgery that was missed, because her TSH's were all above 2.5, and she had mildly positive anti-TG antibody. I was just about to tell her the long surgery was due to the severe inflammation that occurs around the thyroid in Hashimoto's thyroidtitis, and not to worry, and all was well, when I looked at the surgical pathology. The pathology department
failed to note a follicular variant of Papillary thyroid cancer. I called the pathologist, and told him what I found. They did recuts, and agreed with my diagnosis. The cancer was nothing to worry about the surgeon told her. Obviously, she had lost all trust in her university physicians, and requested they send me all the recuts. She has an appointment to see me in Los Angeles to go over her opinions now that she knows she has cancer.

It is never to late to have a thyroidologist do a second opinion, even after the surgery! Check www.thyroidologists.com for one of us near you.

Be Proactive.
It is your Thyroid Gland.
Remember, Endocrinologists may be too busy with diabetes to be up to date with all the modern advances in clinical thyroidology. Go to the fountainhead of knowledge
in clinical thyroidology, your local expert clinical thyroidologist.
Be cautious and always get expert help before surgery, or as in this case after the result was smelling very fishy.

Dr.G.

Thyroid Nodules: Why the Radiologist's Criteria is Wrong

2006-05-08T20:02:00.000-07:00

Terry Davies, editor of the Thyroid Journal, had a word to say about the recent
Radiology consensus conference result on ultrasound for thyroid nodules. He states that consensus means no one agrees.

First, he makes a definitive statement on who should do thyroid ultrasound. "all thyroid ultrasonography should be done in real time by a thyroidologists, where the clinical history, examination, and be combined into a sensible plan."

The second big time comment by Dr Davies was " One thing to be sure of is the days of planting ones expert fingers on the neck and pronouncing the lack of thyroid nodules to the patient is gone".

Third is the fact that he states the disturbing fact that cancer is just as common in multinodular goiter as single nodule or worse. Also the biggest dominant nodule is not always the cancer.

The radiologist when all was said and done fell back on the size as the criteria for FNA. This goes against all logic as cancer starts small.

Dr. Jack Baskin and Dan Duick, clinical thyroidologists, founding members of the Academy of Clinical Thyroidologists, had an editorial which clearly showed the obvious defects of using size as a major criteria. They went as far to say size was irrelevant. The Ultrasound operator has to be experienced in USG/FNA of small nodules.

Finally, for all that are interested go to www.thyroidologists.com for the Academy of Clinical Thyroidologists position paper on US criteria for FNA of thyroid nodules and
suspicious cancer neck lymph nodes. You will find a different answer than the size only by the radiologists.

Dr.G.

Who Should Take Care of Your Nodule or Thyroid Cancer

2006-04-21T18:57:00.000-07:00

Who Should Take Care of Your Thyroid Nodule or Cancer?

2006-04-13T19:02:00.000-07:00

There has been a big shift in the way thyroid cancer should be treated, and nodules evaluated. Before your primary care physician, referred you for studies, and only when it was obvious it was a nodule or cancer, did they refer you to others. In the past it was felt the obvious referral was to an endocrinologist, even though many PMD's sent you directly to a surgeon. The endocrinologist sent you for an ultrasound at the hospital radiologist's office. He sent you for a scan at the nuclear medicine department, and did a biopsy without ultrasound guidance in the office. The Endocrinologist sent the slides to the hospital for review. Then if the diagnosis was suspicious, atypical, or indeterminate, or frank cancer, he sent you to his local general surgeon. After the surgery, the endocrinologist deferred to the nuclear medicine physician, or the radiologist about the need and extent of radiation therapy. The NM physician almost always recommended Therapy.
The physicians treating you would return you to your primary care, who would monitor your thyroid hormone therapy.

What is wrong with this?

There is defects in the care of the thyroid nodule or cancer patient at each and every phase of this protocol.

1. The PMD should seek expert help ASAP, and not waste time with testing that is not needed or a waste. Feel a lump = refer! The best expert is a clinical thyroidologist, or endocrinologist with certified training in the personal use of ultrasound and nuclear medicine.
2. The PMD, or the patient needs to learn who is available with training in
interventional thyroidology, and refer direct to that physician. The main clue, is the endocrinologist trained in US, and USG biopsy by American College of Endocrinology? Radiologist, and nuclear medicine physicians, with their technicians are not the ones to be doing studies on your patients. The personal hands on clinical thyroidologist, or endocrinologist that is certified by ACE is the right person for your patient.
3. Before sending the patient to surgery, request a second opinion on the pathologist. There is a very wide variation in their ability to read thyroid biopsies. The overuse of a suspicious report, has resulted in too many needless surgeries.Even pathologists will tell you that thyroid is one of the hardest slides to read for them. Beware, and get another opinion.
4. Before surgery, you need to have several things done. First, a pre-op Cancer marker. That is a thyroglobulin TG. Make sure it was drawn BEFORE or 30 after the FNA, as it can be elevated by the trauma of the FNA biopsy.
5. Then, if the biopsy is positive, or very stronly suggestive of cancer, be sure to have a pre-op Lymph node evaluation by ultra-sensitive ultrasound, done by your trusty clinical thyroidologist, or US certified endocrinologist. The finding of abnormal cancer nodes, proven by cytology, and or washings for thyroglobulin will change the extent of the surgery needed 40% of the time.
4. If you are satified that your patient has a high likelyhood of cancer, then research to find the closest thyroid surgeon. A thyroid surgeon is one who dose 50-150 thyroidectomies a year, and certifies that a central compartment node removal will be standard in all his cancer cases. It will be worth a drive or flight to the nearest real expert. Failure to remove the central compartment nodes will result in an increased recurrence rate for years afterward. Finding lateral neck nodes on the pre-op node US will result in a lateral neck node removal at the time of the initial surgery.
5. Post surgery care is not the place to rely on the oncologist, surgeon,radiologist, or nuclear medicine physician. Oncologist treat other cancers, not thyroid cancer, which is a hormonal cancer, best treated by thyroid experts. NM types are still passing out high doses of radiation, and making people sick with thyroid hormone withdrawal for useless total body scans in low risk cases. Radiation is no cure, and can cause solid tumors and blood tumors years later, when it is unnecessary in low risk cases. Yearly bouts of severe symptoms of thyroid withdrawal, to get a total body scan, when they are clearly not needed, in most cancer cases is cruel and unnecessary today. Cancer markers,and Ultrasensitive US done by real thyroid cancer experts is the best way to follow thyroid cancer today.
Careful staging by the thyroidologist will be the first step to decide the extent of the further therapy.
6. The therapy with radiation, and the use of thyroid hormone as "chemotherapy, not just replacement, is and should always be under supervision of the clinical thyroidologist, until there is clear indication that the disease is under control.
That is when the TG is non-detectable on TSH suppression, and in in some expert's hands, stays that way after Thyrogen stimulation ( rh TSH ). TSH must be suppressed until it is clear the patient is safe. It is not O.K. to have a TSH in the normal range, if there is clear evidence of disease, by elevated TG.
7. No one cares more about the status of the cancer, and nodule patients under their care, than a hands on clinical thyroidologist, or a ACE certified US endocrinologist.
8. Failure to seek the new age clinical endocrinologist or thyroidologist may result in future problems for your patients.

Good Luck,

Richard B. Guttler, MD,FACE
President,
Academy of Clinical Thyroidologists
www.thyroidologists.com
Clinical Professor of Medicine
Keck School of Medicine
University of Southern California
Director,
Sanatr Monica Thyroid Center
www.thyroid.com

The Return of TRH / Another Scam?

2006-04-01T16:21:00.000-08:00

The TRH Stimulation test was the best way to look at accurate assessment of thyroid
function for 20 years. This was because the TSH was not accurate in the low range.
The TSH presently used by most labs,is able to read very low TSH values. I used TRH testing until the baseline TSH was able to replace the TRH Stimulation test. The TRH Stimulation Test is never used by experts anymore except for rare pituitary or hypothalmic disorders. There is no need for it now that it's value as a sensitive testing agent has been replaced by a newer, better baseline TSH.
The drug disappeared from sight. The Drug company that makes it does not even mention it on it's USA, or world website. The company is in the UK.

Mary Shomon of about.thyroid.com, in her article "The Return of TRH Stimulation Test", showcases a physician of unknown credentials, who states every physician needs to know how to do this test. Mary does not know that this test was found to be unnecessary in our modern world. TRH is similar to museum quality drugs such desicated thyroid. They have served their purpose well, but are outdated and not needed anymore.Please ask Mary, or the physician who wants to test you with TRH, why the drug company does not plaster ads all over the TV, with this exciting breakthrough! This is another example why smart patients will learn to live without reporting of this quality by MS.

Mary, as usual you are wrong again.

I will only comment on her site when she really tries to pull a fast one on thyroid patients.

Dr.G.

Why a Thyroid Scan can save you from Unnecessary surgery

2006-03-23T19:51:00.000-08:00

A 65 Y/O F patient was referred for biopsy for a 2.5 cm nodule.
She came from Cleveland on the Great Lakes, a known goiter area in the past from iodine deficiency. The ultrasound was eu-echioc, with significant 2 vessel blood penetration. She was told that benign nodules can have significant blood flow. She was not excited to be biopsied unless absolutely necessary. Even though the ATA guidelines call for biopsy, I elected to scan her first. The thyroid experts feel that if the TSH is normal you won't find a hot nodule on scan. Well her TSH was normal at 0.89.
She had increased uptake in the nodule with decrease in the rest of the gland. There were no nodules in the opposite lobe. I told her she had a hot nodule.It was not toxic yet, but was going in that direction. We talked about surgery, Radioiodine, or observation therapy. I told her it was not cancer, and she did not need a biopsy.Hot nodules are never cancer. She elected to be treated with radioiodine in the next few weeks.

We are too needle happy in the pursuit of cancer, when only 5 % of all nodules are cancer.

The longer I practice thyroidology, the less needle happy I have become.
We need to look at the whole patient and try to stop excessive surgery.

Dr.G.

The Thyroid Biopsy Report. Why it is a Big Problem for Those with a Nodule, or The Pathologists are either The Good, the Bad or the Ugly

2006-02-13T18:59:00.000-08:00

When your doctor tells you the report from the thyroid biopsy was atypical, suspicious, and recommends a surgery, what do you do next? Well, the answer will not be, see a surgeon. Why not? Because the reading of your biopsy is a very difficult thing to do
well for pathologists. It is the hardest thing a pathologist has to do.

If it is hard, then why should you take the result as a fact. Maybe, the pathologist is not sure what you have, and covering his own a.. . Well, there are real thyroid cancer experts out there to help you out of this fix.

Do not consider the surgery recommendation by your doctor, until you get the slides
reviewed by an expert. The best way to assure yourself that the surgery is really needed, is to see a thyroidologist. He will review your slides and help you decide if surgery is needed. Check our website for one. www.thyroidologists.com

Remember, pathologists come in 3 distinct groups.

The Good, the Bad and the Ugly. you want the good ones only!

Your only chance to avoid unnecessary surgery, and complications, is to demand another opinion, before you put your neck on the line at surgery.

Make sure your nodule biopsy is reviewed by the first group, not the last two.

The best approach is to be a Doubting Thomas when they recommend surgery based on a report from pathologists that are trying to read slides from the thyroid gland, when they admit it is their toughest gland to get right.

Remember, 95% of nodules are not cancer, but the bad, and ugly pathologists will send many more for unnecessary surgery, because they do not understand thyroid cytology.

Dr.G.

Surgeons Don't Need to be Cowboys

2006-01-05T13:02:00.000-08:00

Surgeons Need to Refer Thyroid Cancer Cases to Thyroidologists Before the Surgery

2006-01-05T10:09:00.000-08:00

I do not operate on my thyroid cancer cases, but refer them to expert thyroid surgeons.
I do not expect surgeons to operate on cancer cases without a complete thyroid evaluation before the surgery date.

70Y/O male with Medullary Thyroid cancer found while having a PET/CT for lukemia F/U.
A positive node was found in the upper mediastinum for Medullary Ca. They biopsied the
thyroid and confirmed MCT. He had a date for surgery for the next day for a total Thyroidectomy. He was not referred to a thyroidologist. He was nervous, and came to me on his own for my opinion.

I found bilateral abnormal lymph nodes on both sides of his neck by High Frequency ultrasound. He had high blood pressure. I ordered tests to r/o a blood pressure adrenal tumor, and and sent a DNA study to a r/o family type of Medullary cancer.

I told him to cancel the surgery. that he needed to see a thyroid cancer surgeon, because he needed a very complicated surgery, that included total thyroidectomy, bilateral lymph node resection, and also opening the chest to remove the nodes found there on PET/CT. After my evaluation, he followed my advice, and went to MD Anderson in Texas for the surgery. The massive surgery went well and he returned to L.A. to be followed in my clinic.
The surgeon who wanted to rush him to surgery, would have faced a possible crisis
because he did not check the adrenals for a BP tumor. He did not know that there were bilateral nodes I found on HF US testing. The surgery would have been incomplete.

What did we learn?

Do not get rushed into surgery without a complete evaluation by a thyroidologist.
Also beware of surgeon who seem to know it all.
I do not operate, and they should not act as thyroidologists.
This surgeon who rushed the case to the OR, is considered a local thyroid surgeon, but because of his cowboy attitude toward his patients, he never gets a referral from me.
Dr.G.
www.thyroidologists.com

HMO Refuses Patient's Request for A Thyroid Surgeon. Also Does Not Biopsy the Nodule Before Surgery.

2005-11-15T13:13:00.000-08:00

Very Prolonged Painful Viral thyroiditis: Why No Physicians Treated Her Neck Pains

2005-10-05T14:47:00.000-07:00

Very Prolonged Painful Viral thyroiditis: Why No Physicians Treated Her Neck Pains

2005-10-05T14:13:00.000-07:00

41 Y/O female developed a sore throat, and neck discomfort. This was followed by enlarging mass in the thyroid area on the left. The mass was tender to touch, and pain began in addition to tenderness. She saw an ENT physician who gave her antiboitics, and an allergy steroid dose pack for 5 days. The pain was gone, but returned when the pack was finished. The ENT did not continue the steroids. She continued to have pain, which was only slightly relieved with Motrin. She returned crying, when the pain and mass migrated to the other side of the neck. The ENT told her it could be cancer, and did a FNA. She screamed with each of 3 needle sticks. She was told it was not cancer. She indured the pain for 4 months with only slight relief from non-steroidals, and 2 other physicians she visited for opinions did not offer a solution to her pain. Her pain finally went away on it's on, and she was euthyroid by 6 months.

She had a classic case of Viral Subacute Thyroiditis SAT. She became hyperthyroid first, TSH 0.01, and then hypothyroid TSH 6, and was normal TSH 2.1 by 6 months. Her goiter disappeared as well.

The only thing one can do for this type of patient is to relieve the pain! This was not done. The pain of SAT is quickly treated with Prednisone, and the dose may be needed for weeks to a few months. The band aid of a 5 day dose pack was inadequate to help her overcome the painful symptoms of SAT.

Also a biopsy is the last resort in this disease because it is very painful!

None of the physicians offered her prednisone or even an endocrine consultation to help treat her.

Dr.G.

Laser Thermocoagulation of Benign Solid Thyroid Nodules

2005-09-29T12:42:00.000-07:00

Laser Thermocoagulation of Benign Solid Thyroid Nodules: A New Therapy

2005-09-29T11:53:00.000-07:00

We now put alcohol into recurrent cysts, as an alternative to surgery. Now there are studies published in Clinical Thyroidology 2003;15:11 on the effective use of another form of destruction of thyroid tissue. The use of a laser to "cook" the inside of solid FNA proven benign nodules that cause local symptoms in the neck, or appearance issues. Randomly assigned 30 females to Laser or no therapy for six months. The method involves Ultrasound Guided 18 G needle into the nodule.Then a o.4 mm wire is inserted into the center of the nodule.The needle is withdrawn.Then 2.5-3.0 W output power is given to the nodule. Vapor is seen in the area of the wire on ultrasound, and the area becomes hypoechoic. Two more 2.5-3.0 W outputs complete the therapy, for a total median energy of 2007 J.

The results:
The median volume decreased from 8.2 to 4.8 ml, while the volume increased from 7.5 to 9.0 ml in the untreated patients. A 44% reduction. The controls increased 9 %. There was a 53% difference between the two groups at 6 months. 7/15 in the laser group had neck pain, or tenderness for up to seven days. However, all would have the therapy again if needed. No serious complications occurred, such as vocal cord paralysis. 13/15 laser group patients had pressure symptoms before, and 10/13 had marked relief after the therapy. Cosmetic symptoms also decreased. There was no change in symptoms in the control group, even though the size increased an average of 9%.

Hegedus et al Eur J Endocrol 2005; 152:341-5

Dr Robert Utiger, editor of Clinical thyroidology, states that this seems to be a reasonable way to reduce nodules.
Even though the nodules did not disappear, they decreased enough to reduce symptoms and appearance problems. Usually symptomatic nodules were referred to surgery, but now this is a reasonable alternative.

Clinical thyroidologists will be offering this in the near future. Check www.thyroidologists.com to see if any are offering this now.

Dr.G.

Recurrent Thyroid Cysts: Surgery or PEI ?

2005-09-29T10:15:00.000-07:00

Recurrent Thyroid Cysts Surgery or PEI

2005-09-29T08:55:00.000-07:00

The standard therapy for a benign recurrent thyroid cyst is to remove it at surgery.
However, there are now alternative therapies for recurrent symptomatic thyroid cysts.
The use of alcohol injection, called Percutaneous Ethanol Injection PEI, have been very effective alternative to thyroidectomy. A 5 year study from Italy of 58 patients with cysts found about 90% had volume reduction. Baseline Volume was 13.7 cc, Ethanol injected 7.3 cc.Volume after 5 years was 2.3 cc. There were only 2 recurrences.
PEI is offered at centers around the country. Check www.thyroidologists.com for one near you. Go in for an evaluatuion to see if you are a candidate for this alternative to surgery.

Dr.G.

30 Year Follow Up of Toxic Psychosis Secondary to Hyperthyroid Graves' disease

2005-09-23T10:53:00.000-07:00

30 Year Follow Up of Toxic Psychosis Secondary to Hyperthyroid Graves' disease

2005-09-22T14:44:00.000-07:00

63 Y/O Female returns for her yearly examination, S/P subtotal thyroidectomy 30 years ago, for Graves' hyperthyroidism, on T4 replacement therapy. Her story is amazing.

At age 33 she had a 50 pound weight loss, and severe anxiety to the point of admission for psychosis. While being treated on the Psych ward, a total T4 was drawn and was 20. n 4.2-12.
She was paranoid, and stated 3 men broke into her house. One of them was a well known
actor. People were talking about her outside her window all night. She was mad all the time, and lost her temper, and could not work. Her employer stated she was a very normal employee for 10 years with no sick days. She had other Sx of hyperthyroidism, such as tremo.. Smooth soft skin, muscle weakness, sweats, and palpitations. There was no FH of thyroid disease, but her dad killed himself after returning from army combat.

I saw her 10 days after admission, and she had a dull stare, drooling from the mouth, and a coarse tremor. She had smooth soft skin, pulse of 136, and a diffuse smooth goiter 2-3 times normal size.

She was on large doses of Thorazine. She was under the care of a conservator due to her acute
mental illness. She was considered an endocrine emergency, and under Inderal blockade, she had an uneventful total thyroidectomy. She was kept on Thorazine for 6 week post surgery, became euthyroid and was never treated again for mental illness.Not even a tranquilizer, for 30 years! She had a recurrence of hyperthyroidism 3 years later, that was treated with radioiodine, but there was no flare up of mental illness. She return to her job, and has spent the last 30 years mentally "normal".
She had examinations by experts in mental illness after her recovery, and they found no abnormal thought processes. I have seen her twice a year since 1976, and she is a very normal lady.

Dr.G.

Tango and Thyroid

2005-09-08T18:24:00.000-07:00

Well, I am off to Argentina in October to learn the tango, and have one of my thyroid cancer studies presented as an oral presentation at the International Thyroid Congress.
The LAC/Keck/USC Thyroid Cancer Group has a paper on the cancer marker thyroglobulin, TG. The study will look at the value of improved TG sensitivity in the long term followup of well differentiated papillary thyroid cancer.Some of our members are Carole Spencer, John Lopresti,and Peter Singer. On the way back, I stop in Dallas to attend the AACE's New advances in the use of Ultrasound for thyroid. This will include interventional ultrasound techniques.

Dr.G.

Thyroid Cancer Occuring with Graves' Disease. Is it More Aggressive?

2005-09-07T19:10:00.000-07:00

At LAC/USC Thyroid Conference, a patient was presented and discussed, who had papillary thyroid Cancer and newly diagnosed Graves' Disease with hyperthyroidism. A paper from Italy was presented, and it claimed that the cancers were more aggressive in Graves' patients. I discussed my experience with this rare combination. My 5 cases were not more aggressive than the typical papillary cancer. No one of the experts present had more than one or two cases to talk about.Prior studies have not always agreed with the more aggressive concept.

What can you do to make sure your Graves' patient does not harbor a rare cancer as well?
Any palpable nodule needs ultrasound, I/123 imaging for cold nodules, and possible FNA biopsy. Ultrasound will find any non-palpable significant nodules, and it can help guide the needle into the mass.Significant nodules would be hypoechoic, irregular borders, vascular, and micro-calcifications. If the biopsy is suspicious or positive for cancer, than surgery will be the ideal therapy for both diseases. A rare medical "two for one". After a 4-6 week course of anti-thyroid drug therapy total thyroidectomy needs to be done.

Dr.G.

Thyroid Nodular Goiter in a Horse:Is it Cancer, or Just Too Much or Too Little Iodine?

2005-09-06T20:34:00.000-07:00

I have treated two horses in my life with thyroid disease. In 1972, a physician friend ask me to look at her horse. It had recently been purchased, and was noted on arrival to have an enlarged thyroid gland. I felt a 3-4 times enlarged nodular goiter.The blood testing of T4 was very low. I first thought the horse was hypothyroid, but after consultation with vet endocrine experts, I was told the horse's total T4 thyroid blood test will seem low by human standards, but the free T4 will be normal. The most likely cause was either a benign tumor, or enlargement secondary to either excess iodine in supplements, or iodine deficiency. There was no use of iodine supplements, so I diagnosed iodine deficiency.
Iodine salt lick was added to the horses diet, and the goiter markedly reduced in size.
The second horse had a large nodule, and after ultrasound studies , it was not consistent with a follicular tumor which is common in horses, but was more likely to be part of a diffuse goiter with a nodule. This time the owner did use kelp supplements,
which contained large amounts of iodine. Fortunately, with removal of the kelp, the nodular goiter reduced in size. Cancer of the thyroid is rare in horses.

Even horses can develop a goiter from excess or deficient iodine in their diet.
Humans in the USA, have a higher chance to develop excess iodine goiter from supplements, as iodine deficiency is rare in the USA.

My daughter's horse, Casey, does not have a goiter, thank God, or I would have had to treat my third horse in 31 years!

I will stick to human thyroid disease, as horses can not tell me what bothers them.

Dr.G.

Free Questions Answered By "Ask the Thyroid Doctor", for Katrina, and Flood Victims

2005-09-03T20:44:00.000-07:00

Any thyroid patients in the New Orleans, Mississippi, or Alabama areas, who are displaced and wondering about the status of their thyroid condition, or about thyroid medications they are taking, you can get answers from The Thyroid Home Page. Just bypass the usual pay site that includes Paypal credit card section, and go to my thyroid.com email address: dr.guttler@thyroid.com. Be sure to state you are a Katrina victim, as there is usual fee of $35 for all others, at the official "Ask The Thyroid Doctor" site on www.thyroid.com.

Here is a two thyroid patient points to remember:

1. The thyroid hormone used to treat hypothyroidism is not an emergency hormone. You have several weeks to get a new supply, without serious effects.

2. However, the drugs used to treat hyperthyroidism such as Graves' Disease have a short life in your body.Tapazole has an 8 hour half life, and PTU is even shorter. This means your condition will worsen after 1-2 weeks. If you are taking one of these drugs, please notify the nearest medical facilities you come to, that you need this drug refilled, if you lost them in the storm surge, or flood.

The Ask The Thyroid Doctor service has helped many thyroid patients get help all over the world. We want to help you. Please email me if you need thyroid help.

God Bless you all,

Dr.G.

Anaplastic Thyroid Cancer Claims Chief Justice Rehnquist

2005-09-03T20:24:00.001-07:00

September 3, 2005, After a 10 month battle with the most
aggressive form of thyroid cancer, he has passed away at home. The patients with his cancer usually live 3-6 months, but he battled the cancer for 10 months. He swore in the president for a second term. He continued on the court , when lesser men would have resigned. In October, we in the thyroid medical field predicted he had this lethal form of thyroid cancer. He did not have his thyroid removed, but only had a a hole put into his air-pipe to breath. This was the major clue he did not have much time left. He was able to continue to vote on cases before the court, and with difficulty swore in President Bush. He lived to see his clerk, Roberts nominated to the court.
He outlived every one of my own cases of anaplastic thyroid cancer, by 4 months! He was a brave man with a mission, and even a thyroid death sentence did not stop him, from achieving his last goals. No matter what your political goals for the new court, we need to salute his brave, and classy exit.

Bravo to the Chief

Dr.G.

2005-08-11T13:34:00.000-07:00

Iodine from Large Amounts of Kelp Causes Goiter Progression in a Young Lady

2005-08-11T13:14:00.000-07:00

Women Smokers have higher incidence of Graves' Disease

2005-08-11T13:11:00.000-07:00

Iodine from Large Amounts of Kelp Causes Goiter Progression in a Young Lady

2005-08-08T11:38:00.000-07:00

36 year old female is seen in consultation for goiter, referred by her family physician. Prior work up included an FNA that was read as colloid goiter. Ultrasounds have shown progressive enlargement. There is a family hx of goiter in a sibling.
She as a history of ingesting a large amount of iodine containing supplements. She eats seaweed, kelp, and powdered seaweed at each meal. Bilateral nodular goiter is noted on neck examination. TFT's were borderline with TSH of 2.8 N 0.4-2.5,FT4 0.89 N 0.8-2.0 FT3 2.6 N 1.9-5.1 TG 154, TPO <10.1 TG AB <1,0. 24 hour urine free iodine was 3002 mcgs N 100-400.

The excessive use of iodine containing products such as seaweed will cause progressive thyroid enlargement as in this case.It can cause hypothyroidism in patients with autoimmune thyroid disorders, such as Hashimoto's thyroiditis. Non-toxic goiters can become toxic goiters. Even a normal thyroid that has 1/2 left after lobectomy may fail under the pressure of high dose iodine supplements.

Dr.G.

Wilson's Syndrome: A Bogus Thyroid Diagnosis Trips up another Physician

2005-07-30T07:00:00.000-07:00

A physician Naturopath, was following E.Denis Wilson's
methods to treat functional hypothyroidism in over 200 patients in a western state.
In 1994, he began treating a patient by online contact, with just a history form , and no physical examination from another western state. He sent instructions to take tempatures, and send them to him. After looking at the hx and temp. charts he diagnosed Wilson's syndrome. He did not do any lab testing. He odered T3, cytomel which was sent via mail from his local pharmacy. By 1995, he was treating 100 long distance patients, via online,telephone, and mail.
T3, cytomel is normally used at doses of 25-75 mcgs. He gave up to 300 mcgs. 25% were on > 200 mcgs. Overmedication with T3, can be very dangerous and cause death. Even his claim that he saw tests from the patient's primary care group was not factual, as the records release came after he started treating the patient. In 1992, Wilson was suspended and fined and has not returned to practice in Florida. He was ordered to receive metal health assistance as part of the order. His website is still up, and caught this naturapath, in it's bogus web.
1998, the naturapath was fined $3,000, and given a 30 month suspension. He was ordered not to treat out of state patients, without a physical examination, and only with the help of tandem physician in the state of the residence of the patient. He had to submit to audits of his patient records for an additional 2 years after suspension.

The American Thyroid Association stated:
1.Wilsons is inconsistent with known facts about the thyroid gland.
2. Diagnosis is imprecise, using non-specific symptoms and body temperature.
3. T3 is no better than placebo in treating non-specific symptoms, of patients with normal thyroid hormone concentrations.
4.T3 results in wide swings in blood levels, and can produce symptoms, and cardiovascular complications in some patients, that can be potentially dangerous.

Wilson's Syndrome as described by Denis Wilson is a bogus diagnosis, but there is a real Wilson's disease , but it is a rare disease of copper metabolism.

Ref:

Disciplinary actions: E.Denis Wilson MD #0048922
Longwood FL. 2/12/92 Board of Medicine 8(2):10,1992
FL.Depart. of Professional Regulations Tallahassee FL.

TSH, and usually T4, will be abnormal BEFORE you have symptoms of hypothyroidism. Throw away the thermometer, unless you need it for your child's fever, mom!

Even with the new TSH upper normal of 2.5-3.0, you need to have the TSH > 5-10 before symptoms occur.

Dr.G

Women Smokers have higher incidence of Graves' Disease

2005-07-28T12:49:00.000-07:00

115,000 women's lifestyles were studied to see the effect on the incidence of Graves' Disease. 543 women developed Graves' Disease. Heavy smokers > 25/day, were 3 times more likely to develop Graves' Disease. The rate decreased if they quit 10-15 years ago. However, even past smokers were still more likely to develop Graves'. Archives of internal Medicine, July 25 2005 vol.165, pp.1606-1611.

Now, besides worsening thyroid eye disease, we now know we have more Graves' Disease in smoking women!

Dr.G.

Book Review: Overcoming Thyroid Problems by Dr.Jeffery R. Garber: The Harvard Medical School Guide Series

2005-07-26T09:27:00.000-07:00

Overcoming Thyroid Problems: A Great New Book from Harvard Medical School Guide Series. A Book Review.

2005-07-25T16:45:00.000-07:00

Dr.Jeffery R.Garber,assistant clinical professor, Harvard Medical School, and a fellow member of the Academy of Clinical Thyroidologists ACT, www.thyroidologists.com, American Thyroid Association ATA thyroid.org, and American Association of Clinical Endocrinologists AACE,www.aace.com, has written a thyroid patient book for the Harvard Medical School Guide series.
The introduction compares thyroid disease to the auto part you never heard of until your car breaks down. This is a good start. He has contact to the laymen, by this simple, but apt analogy.He states the thyroid is undervalued, and it is normal for patients, to not know it's basic functions. He tells the reader thyroid works behind the scenes, and can effect every organ if it is malfunctioning. The only thing most people know is that thyroid failure causes obesity, and that is wrong.

The chapters are well written, and have great side bars.
An example is the one on Kelp, Myth or Fact:
The myth is that kelp is good for you if you have thyroid problems, while the fact is just the opposite, it can harm you. He includes excessive kelp or iodine under risk factors for hypothyroidism, nodular goiter, Hashimoto's thyroiditis, and hyperthyroidism.
The use of the myth or fact approach is seen next in the thyroid medication section.No, it does not cause osteoporosis if the the dose of thyroid hormone is normal. No, hypothyroidism does not cause obesity. And, no, it is not a good therapy to cause significant long term weight loss. No, animal thyroid products, or T4/T3 combinations are not better than T4 alone.
The section on ultrasound for nodules is very up to date.
He describes changes seen on ultrasound that point to cancer, and the need for FNA. However, I think he needed to tell the patients, that ultrasound results depend on the person doing the examination. Clinical thyroidologists, doing their own ultrasound can yield better information to help manage patients with a the thyroid nodule.
The section on pregnancy is excellent, and a must read for pregnant thyroid patients.The need for iodine in prenatal vitamins, and the need to take thyroid hormone at a different time than the prenatals with iron. The present day feelings that ATD's for treating hyperthyroidisms, can be given to breast feeding mothers is discussed.
Finally, he brings up the most important issues.
Who do you see about your thyroid problem? He talks about the thyroid surgeon with a high number of thyroid surgeries/ year, and the endocrinologist with extra training, and experience with thyroid problems. He calls them clinical thyroidologists. He talks about finding out if the physician sees a high percentage thyroid patients, and are less active in diabetic care. Because, the new clinical thyroidolgists society ACT, was just formed , he failed to put the thyroidologists website as a source of referrals to endocrinologists that practice 50-100% thyroidology. The site,www.thyroidologists.com, I hope will be listed in his revised edition in the future.

In conclusion, I will recommend this book to my patients,
and hope to see it become a classic in thyroid patient
literature.It is an excellent book, to give to all my new thyroid patients at the initial consultation. The book is available at the bookstore section on thyroid.com, or at Amazon.com. It is worth the $14.95 retail price in the USA, $19.95 Canadian, or 8.99
English Pounds in the UK.

Dr.G.

The Thyroid Home Page is First!

2005-07-25T13:33:00.000-07:00

The Thyroid Home Page, the official website for Santa Monica Thyroid Center, was recently re-evaluated by a company that ranks websites by visitor traffic. They only rank the first 900,000 websites. Any lower ranking, is listed as "not ranked".

Thyroid.com was ranked first for pure thyroid websites at 156,000.
Only endocrineweb.com was ranked higher at 47,000, but it had wider draw as it included all of endocrinology. American Thyroid Association, thyroid.org, was ranked 195,000, or second. Thyroid Foundation of America was not ranked, nor was thyca.org. Stats were not available for thyroid.about.com , because it was part of a large corporation website, about.com. AACE website was ranked 164,000, but it was a general endocrine website. Canadian Thyroid Website, thyroid.ca was ranked 322,000.

Even though thyroid.com may be googled at 2nd through the 5th position, it still is the most visited pure thyroid website.

Thanks for all your support,

Dr.G.

Visit to Ireland: Birthplace of The Physician who was one of the first to describe Hyperthyroid Graves' Disease

2005-07-13T15:04:00.000-07:00

We just returned from Ireland, home of Sir Robert Graves. He was born in Dublin in 1796. He graduated from Trinity College in medicine when he was 22. He was a dynamic fellow. In a severe storm when the ship he was traveling on, was about to sink, due to damaged pump values, he took an axe to the lifeboat, because he knew they would all perish in it.He then took over command of the ship, and using his own boot leather, repaired the pumps.He published "Newly observed afflection of the thyroid gland in females" in the London Medical Journal in 1853. He detailed the clinical features of what is now recognized as Graves' disease, even though it was described earlier by Caleb Perry in 1825. It is remarkable that it is the one contribution that is most remembered today. Few call it Perry's Disease today!

In 9 days traveling throughout Ireland, I did not see a single goiter.

My daughter rode horses in western Galway, and at Castle Leslie in the northern Irish Republic, she rode cross-country on the castle's 1000 acre eventing course.

My Irish wife searched out her clans, the Delaneys, and McMonagles.
We found her family McMonagle homestead in Meenagoland,Donegal and the graveyard with 26 McMonagles in nearby Finn Town. There were 600 Delaney's in the Kilkenny phonebook!

It is good to be back.

Dr.G.

Ireland on Horseback: Sir Robert Graves, Here We Come

2005-07-01T21:16:00.000-07:00

Well, it is the time of the year to get away from the
usual daily exposure to the many problems associated
with caring for thyroid patuents, and lay back and relax.
However, my 14 Y/O daughter A.J. is an eventer. That means she rides horses over fixed objects, such as stone fences, logs, and water holes. We are going to the land of Sir Robert Graves, one of the first physicians to describe the disease of hyperthyroidism. A.J. will be riding Irish Horses all across western Ireland, and will
then travel to Castle Leslie to jump 150 fixed sites in 5 days. Thyroid clinic is less stressful, than watching her, in a titanium helmut, and flack jacket, jump irsh stonewalls. However, because my wife is second generation 100% Irish, we will search for her roots in Donnigal,in Northwest Ireland, for the McMonigle homestead. We will also look in Killkenny for signs of the Delaney clan. I will research the exact location of the famous man who
has his name on one of my most common disorders, Graves' Disease, I see in my center. It should be fun, if all goes well with my little horse mad daughter. Delaney, my wife, and a private chef, www.delaneyfoods.net, will get a few cooking tips from Darina Allen. She is the most famous chef in Ireland, and has a cooking school just outside of Cork. We will stay in the Red Room at Castle Leslie on the last night in Ireland.
This is for me. I am half Italian from Umbria Italy.The Red Room is decked out in rare items from Umbria.
Paul McCartney was married there to his second wife.
I will return on July 13, 2005. I will post a blog, if I find anything about Sir Robert Graves.

Dr.G.