The Academy of Clinical Thyroidologists' Website Launched

4/19/2005

www.thyroidologists.com


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

Dr.G.

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

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

Dr.G.

Thyroid Surgery What are the risks?

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

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

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

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

Dr.G.

Who Should Do Your Thyroid Surgery?

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

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

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

Dr.G.

Black Thyroid / A Rare Complication of Acne Therapy

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

Dr.G.

Why Generic Substitution is Bad for Thyroid Patients

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

Dr.G

Levothyroid not the same drug!

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

Dr.G.

T4/T3 Combination Therapy

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

D.G.

Rehnquest is still alive

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

Dr.G.

Breast Feeding Infants at Risk from Rocket Fuel Chemical

Perclorate is a drug that can be useful in treating some forms of hyperthyroidism, and was used in the past as a test of thyroid function, in the perchlorate discharge test.
It is hard to find in the USA for treatment, but can be found all over the country in mother's breast milk. It is found in foodstuff raised with water contaminated with perchlorate. This level in breast milk is higher than in cow's milk. This is even more troubling, because the infant is the most susceptable to iodine deficiency.Perchlorate causes blockade of nutritional iodine, and thyroid hormone formation. Thyroid hormone is needed for brain, and IQ development in the infant.Because of this finding the researchers are recommending women block the bad effects of perchlorate by iodine suppliments while they breast feed.The amount of perchlorate in breast milk would give a one month old enough perchlorate to exceed a safe level, called a reference dose that was established by a panel of NAS experts last month. This should result in lowering the safe dose level to protect breast fed infants. Perchlorate levels are high in the lower Colorado river which covers 2 million acres of cropland. What should you do?
Use iodine containing vitamins to counteract the perchlorate effect in breast milk.

Dr.G.

A.C.T. A new thyroid society

I attended a thyroid meeting in Snowbird in January. The two directors of the meeting, Jack Baskin, Dan Duick, and I were talking about who in addition to ourselves are doing 100% thyroid in their private centers. We came up with a list of about 8-10 names. 2 in Detroit, one each in Texas,Florida,Arizona, California,and New York. We thought it was about time we started a clinical thyroid society as a counterpoint to the American Thyroid Association.This would be similar to the AACE, clinical endocrinologist, and the Endocrine Society.We need at least 100 clinical thyroidologists in the next 5-10 years. The criteria would be to do only thyroid, and just a small amout of adrenal, pituitary, but no Diabetes. The future thyroidologist would need to train in ultrasound, USG needle biopsy of thyroid nodules, suspect cancer neck lymph nodes, parathyroid, as well as interventional therapy, such as alcohol therapy for thyroid cysts. The future thyroidologist must train in thyroid nuclear medicine, so he or she can treat their patients with I/131 for cancer, hyperthyroidism, and simple goiter. They need to learn how to scan their patients for diagnosis of recurrent cancer, and hyperthyroid goiters. They need to train in cytopathology by taking courses offered Cytopathology, even if they do not read their own thyroid biopsy slides.They need to be able to read the slides, and if they do not report out the results,they need to know enough to review the slides and ask key questions of the pathologist. The training in Ultrasound is the cornerstone of the future thyroidologist's practice. It supplies the eyes into the thyroid gland, beyond the reach of expert thyroidologist's fingers. Anyone using small parts U.S. with 10-12.5 Mhz probe, will tell you it brings us way beyond our limited palpation
skills. We find 5-10 mm cancer nodes, in Total Body Scan negative patients with elevated Thyroglobulin cancer markers. We also can biopsy them easily with the 10-12.5 probe, and do TG washings to confirm cancer recurrence. These nodes are almost always not palpated by the thyroiologist.A recent 29 y/o female came to see me with an MR showing one nodule.She had an ultrasound done by a radiologist also showing the one nodule. She balked at my suggestion of my repeating the U.S. myself. When she heard why, she consented. My thyroidologist ultrasound result was starkly different.There were 9 nodules, ranging from 20 mmm to 3 mm in size. There were two highly suspect nodules with 4+ blood vessel penetration into the nodules by power doppler, and microcalcifications. We need to be doing our own ultrasounds for the good of the patients. We are meeting in May at the AACE meeting to jump start this society. We are looking for members, future members, and interested sponsors for out new venture.

Dr.G.

The Italian Thyroid Ultrasound Machine

It is 2 months since I became the 7 th thyroidologist in the USA to own the Technos Partner Biosound Esaote Small Parts ultrasound, made in Italy. The machine is awesome. I can see and biospy 5 mm suspect cancer nodes, inject saline, and alcohol in thyroid cysts,and analyze nodules for cancer characteristics. Irregular borders, vascular invasion in the nodule, as well as size and echogenicity. The picture quality is as good as the $200,000 all purpose machine they make. I am finding more suspicious neck nodes with this machine, and can biopsy them as well. The guided needle into the node can be sent for cytology, but also washed into saline for Cancer markers,thyroglobulin, and calcitonin.Small suspect parathyroid masses, and cysts can be biopsied, and needle washed for parathyroid hormone. The nodule evaluation is more refined with this machine. For example, if one faces a patient with a goiter with 6 nodules, the cancer may not be the biggest or dominant one by size.This is the one we all would have biopsied in the past. By evaluating the factors most suggestive of tumor, by ultrasound, we can pick out the nodule most likely to harbor cancer, or the "real" dominant nodule. The lower risk nodules can be followed and only biopsied if they grow. The new age of thyroid evaluation for thyroid cancer by high resolution ultrasound is here. Moved to the back bench, is the old mainstay of thyriod cancer follow up, the Total Body I/131 Scan.

Dr.G.

Amber Frey Thyroid Alert

I received a return email from Amber's lawyer, Gloria Allred, stating she would inform Amber about my observations, but did not say if Amber knew she had a thyroid problem.

Dr.G.

Miscarriage in Women with excessive Thyroid Hormone Exposure

The damaging effects of excess thyroid hormone on the fetus, independent of the mother's hyperthyroid state was studied in a family with RTH ( Thyroid Hormone Resistence Syndrome).Female members of a family with RTH, had high T4,T3, and suppressed TSH exactly like any hyperthyroid patient, but were resistent and euthyroid.
36 couples were in the study.There was an increase in miscarriage in mothers with RTH, when the fetus did not have RTH. The unaffective non-RTH fetus was exposed to excess thyroid hormone, and miscarried more frequently than the RTH babies that did not feel the excess due to their resistence syndrome. The non-RTH fetus had lower birth weights as well. This neat study shows how pure fetal toxicosis can effect the outcome,when the mother is euthyroid due to resistence. The direct effect on the fetus is clearly seen in this study by Refetoff et al.
Please remember to be checked before and after conception to make sure the thyroid hormone dose is correct. Too much or too little thyroid hormone can have deleterious effects on the fetus.

Dr.G.
Reference
JAMA 2004Nov 3;292917):2085-6 Anselmo,Cao,Karrison,Weiss,and Refetoff

Perchlorate in your drinking water. Can it harm your thyroid?

Solid rocket fuel contains perchorate, The ground water is contaminated with low levels. 10 California counties including L.A. county have leaked perchlorate into the aquifer, from chemical factories, and aerospace plants. L.A. has 138 wells with traces of perchlorate. Lettuce, and milk have traces of perchlorate as well.
Perchlorate can decrease the ability of the thyroid gland to uptake iodine. It has been used to slow down a hyperthyroid gland. However, studies on humans showed that, the level in our water is too low to effect the function of the thyroid gland. The report released today, by the National Research Council, places the acceptable levels in water below the level that may harm women with a thyroid problems, or iodine deficiency.The level would be about 2-6 ppb. They stated that perchlorate did pose a heath threat, in higher levels in drinking water, to the human thyroid gland, which controls the brain development in infancy. This "safe" level is much lower than that recommended by industry of about 200 ppb. They found no cancer risk from perchlorate.They studied 37 healthy adults. They received various doses of perchlorate in the tests.A good review of the effects of perchlorate on thyroid function is in Diseases of the Thyroid
2nd edition Louis Braverman MD editor page 320-322. 2003 Hunana Press, Totowa New Jersey

Dr.G.

Amber Frey has a Goiter?

The 15 minute of fame witness, Amber Frey, in the Scott Peterson conviction was on Fox News talking about her new book. While she was being interviewed, I noted a fullness in her long swan neck that moved up, and down when she talked or swallowed. This is most likely a goiter. I emailed the show to pass on my observation to her. Most people look into a person's eyes, but I look at their neck! An occupational habit. Most people wear their thyroid like a bow tie, and this can usually be seen if one makes a point to look. Family doctors need to learn that skill, if they are ever going to diagnose thyroid goiter early.

Dr.G.

Rehnquist Returns to Work / Glaucoma : thyroid Link?

I am very surprised that the Justice has returned to work part time, after missing 25 court arguments since October 22,2004.
However, he is very tough, and if anyone can keep going it is the Chief Justice.

University of Alabama researchers studied 600 men with glaucoma, and compared them to 6000 men without glaucoma.
They were all older than 50.The incidence of hypothyroidism was significantly higher in the glaucoma group. Further studies are needed to better understand the possible link. Because women are 5 times more likely to get glaucoma than men studies need to be done in women. This study is not enough to say there really is a link, but does demand further study.
reference:
Christopher Girkin M.D.
< http://www.macleans.ca/topstories/health/article.jsp?content=20050105 124535 5316>

Dr.G.

The Diagnosis of the Recurrent Thyroid Cancer in Neck Nodes

The 35 Y/O female patient had total thyroidectomy and Radioiodine ablation one year ago. She had a low risk 2 cm well differentiated papillary cancer without spread and no positive Lymph nodes. She was on TSH suppression with LT4 for the year. Her neck exam was negative to palpation, however her thyroid cancer ultrasound found two nodes. One
in the lateral neck, and the other at the angle of the jaw. Both were on the side of ther original surgery. Ultrasound Guided biopsy of the nodes, included a washing of the needle into saline for Thyroglobulin,( TG ). Tg is the cancer marker for thyroid cancer. The needle biopsy slides were negative for thyroid cancer in both nodes, however, the Tg was 19,000, for the node by the thyroid bed, but was < 0.3 in the node at the angle on the jaw. The washings helped decide that surgery was indeed, needed. Washing the needle for thyroglobulin is a new and necessary part of biopsy protocol for suspected thyroid cancer lymph nodes.

Dr.G.

Rhenquist/ Norville Updates

The Justice has removed himself from ruling on the first 12 cases the court heard after the election. He still may vote if it is a 4-4 tie. His absence without disclosure of the exact diagnosis of his thyroid cancer, continues to point to anaplastic Cancer of the thyroid.

Also, I still have not heard from Deborah Norville, or her agents at MSNBC. She was on the news last night, and I still see something moving in the thyroid area. I hope she knows there is a problem, but does not want to tell me, rather than denial.

Dr.G.

Goya Painting of a Noble Lady with a Goiter at the Getty

My son Antonio needed to visit a museum for his art class.
I packed up the whole family, on a very rainy day and visited the new Getty in West L. A. After his school assignment was completed, we visited the painting gallery.
I was not expecting to see any thyroid related art today.
However, I was wrong. There was a lifesize painting of a noble woman with an extra-ordinary enlarged neck. When I looked closer,the neck was the home of a large goiter.
Francisco Jose' Goya Y Lucientes, Spanish painter, who lived from 1746-1828, had painted the Marquesa de Santiago in 1804. She was goitrous, probably due to iodine deficiency, which was common in Spain. Why did he paint her? Besides the money, it was considered a sign of beauty to have a large curvy neck. The goiter was usually seen in women, and was just another "curve" on a women's body that was different from a man's body. It was not known that the goiter was a disease of iodine deficiency, for many years after Goya painted the Marquesa. Well, the museum trip was completed with an excellent meal at the Getty Restaurant. I can't get away even for one day from the thyroid gland.

Happy New Year,

Dr.G.

Vist the Marquesa at www.getty.edu/art/collections/objects/o823.html