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.
Friday, April 27, 2007
Monday, March 26, 2007
Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protein Deficency, Hypo-TBG -emia.
40 Y/O F with a diagnosis of TBG deficency since age 16. She was noted by an endocrinologist, to have a small goiter then. No therapy was directed toward the goiter. Over the next 20+ years the patient was treated with thyroxine, T3, Triac,
Armour thyroid, and large amounts of iodine containing supplements. She had multiple CT scans with iodine contrast.The low Total T4 confused the physicians, into treating her for hypothyroidism. Her usual thyroid tests were compatible with low TBG.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in iodine induced hyperthyroidism. However,there were other periods of hyperthyroidism caused by her large iodine intake. 2 years ago, a thyroid scan showed high iodine uptake and multiple hot nodules on scanning. There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome, an unproven, and dangerous T3 therapy Rxed by a physician, that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. She had a multinodular goiter with 4 autonomous hot nodules, on repeat thyroid scan, which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency, meant she was hyperthyroid. She is now off all thyroid preparations, and clean of supplement iodine, and is about to be treated with radioactive iodine to ablate the pre-toxic autonomous nodules in her goiter.
Key to case.
Hot nodules on seen on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Rare Low TBG is not a disease, and has no effects on the patient, but it can mask real disease, and in some cases cause unnecessary treatment for hypothyroidism.
Rare high TBG can cause the opposite effect. In 30 years I have stopped 2 patients from therapy for hyperthyroidism, who had excess TBG. They had high Total T4, a simple goiter, and were not toxic hyperthyroid.
Until the next thyroid rounds,
Dr.G.
Armour thyroid, and large amounts of iodine containing supplements. She had multiple CT scans with iodine contrast.The low Total T4 confused the physicians, into treating her for hypothyroidism. Her usual thyroid tests were compatible with low TBG.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in iodine induced hyperthyroidism. However,there were other periods of hyperthyroidism caused by her large iodine intake. 2 years ago, a thyroid scan showed high iodine uptake and multiple hot nodules on scanning. There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome, an unproven, and dangerous T3 therapy Rxed by a physician, that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. She had a multinodular goiter with 4 autonomous hot nodules, on repeat thyroid scan, which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency, meant she was hyperthyroid. She is now off all thyroid preparations, and clean of supplement iodine, and is about to be treated with radioactive iodine to ablate the pre-toxic autonomous nodules in her goiter.
Key to case.
Hot nodules on seen on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Rare Low TBG is not a disease, and has no effects on the patient, but it can mask real disease, and in some cases cause unnecessary treatment for hypothyroidism.
Rare high TBG can cause the opposite effect. In 30 years I have stopped 2 patients from therapy for hyperthyroidism, who had excess TBG. They had high Total T4, a simple goiter, and were not toxic hyperthyroid.
Until the next thyroid rounds,
Dr.G.
Missed Thyroid Diagnosis Due to Confusion Caused by Thyroxine Binding Protien Deficency, Hypo-TBG -emia.
40 Y/O F with a diagnosis of TBG deficency since age 16. She was noted by an endocrinologist, to have a small goiter then. No therapy was directed toward the goiter. Over the next 20+ years the patient was treated with thyroxine, T3, Triac,
Armour thyroid, and hugh amounts of iodine contaning supplements. She had multiple CT scan with iodine contrast.The low Total T4 confused the physicians, in her being treated for hypothyroidism. Her usual thyroid tests were compatible with TBG deficency.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in hyperthyroidism.
However, there were other periods of hyperthyroidism caused by her large iodine intake.
2 years ago a thyroid scan showed high uptake and multiple hot areas on scanning.
There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome T3 therapy that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. she had multinodular with autonomous hot nodules which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency meant she was hyperthyroid.She is now off all
thyroid preparations, and clean of supplement iodine, and is about to be treated with radioiodine to ablate the toxic nodules in her goiter.
Key to case.
Hot nodules on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Untill the next thyrroid rounds,
Dr.G.
Armour thyroid, and hugh amounts of iodine contaning supplements. She had multiple CT scan with iodine contrast.The low Total T4 confused the physicians, in her being treated for hypothyroidism. Her usual thyroid tests were compatible with TBG deficency.
The low Total T4, and normal TSH resulted in several CT scans of the head looking for a pituitary tumor. Iodine contrast dye for these tests resulted in hyperthyroidism.
However, there were other periods of hyperthyroidism caused by her large iodine intake.
2 years ago a thyroid scan showed high uptake and multiple hot areas on scanning.
There was multiple FNA biopsies of the 10 + nodules seen on ultrasound. They were all benign. She tried Wilson's Syndrome T3 therapy that put her in the emergency room with T3 induced rapid heart beats. Finally, she saw me for a consultation. she had multinodular with autonomous hot nodules which were ripe for induction to hyperthyroidism with introduction of excess iodine. She had "normal" total T4 and suppressed TSH which in TBG deficiency meant she was hyperthyroid.She is now off all
thyroid preparations, and clean of supplement iodine, and is about to be treated with radioiodine to ablate the toxic nodules in her goiter.
Key to case.
Hot nodules on scan can be induced to over produce T4 when presented with excess iodine, and will surely become hyperthyroid if put on thyroid hormone.
Untill the next thyrroid rounds,
Dr.G.
Friday, March 23, 2007
Rare TBG Deficiency Confuses Physicians, and They Miss Her Real Thyroid Problem.
40 Y/O F with 24 year history of decreased TBG. This rare harmless defect, should not mask other thyroid disorders. Her initial exam revealed a goiter. Nothing was done until testing confirmed a multinodular R>L. She had periods of transient hyperthyroidism after iodine supplements for a CT cscan, or kelp liquid drops, or even low dose thyroid hormone. She had multiple suppressed TSH values, off or on Thyroid hormone therapy. Over the counter Triac, caused Hyperthyroidism. The goiteer and all the nodules continued to grow. The total T4 is always low in TBG deficiency.
However hyperthyroidism exists when the total T4 is normal or high with suppressed TSH. A 6/24 Hour uptake and scan was abnormal. The uptake was high, and the scan showed hot nodules. The diagnosis of Toxic Nodular Goiter with masking effects of TBG deficiency was made, and after multiple benign FNA samples, under US guidence, it was elected to treat with RAI/131.
Clues included normal TT4 with suppressed TSH. The TT4 is always low in TBG deficiency.
Radioiodine 131 was used to control the thyrotoxicosis
However hyperthyroidism exists when the total T4 is normal or high with suppressed TSH. A 6/24 Hour uptake and scan was abnormal. The uptake was high, and the scan showed hot nodules. The diagnosis of Toxic Nodular Goiter with masking effects of TBG deficiency was made, and after multiple benign FNA samples, under US guidence, it was elected to treat with RAI/131.
Clues included normal TT4 with suppressed TSH. The TT4 is always low in TBG deficiency.
Radioiodine 131 was used to control the thyrotoxicosis
Thursday, March 15, 2007
Seaweed Goiter, or How I Grew My Thyroid While Ingesting Large Amounts Kelp
50 Y/O F had a small nodule 6 years ago which was biopsied and told it was benign. She refused thyroid hormone suppression, and when it continued to grow, she even refused surgery. She treated the goiter nodule with her own home plan as suggested by the internet.If you have thyroid problems,it stated, take iodine supplements.She did that for the next 5 years as the nodular goiter continued to grow! She had multiple biopsies and she claimed that biopsies caused the goiter to grew. She finally saw me last week. She is euthyroid with a large bilateral goiter with her trachea moved to one side to make room for the larger right lobe. The US showed another big nodule on the other lobe. Now she needs to stop the iodine supplements, and Kelp, and have yet another biopsy of the new nodule.
What did she learn?
Iodine is not only not good for goiters in the USA, because we have enough iodine in our diet, but it can be down right harmful.
Do Not Take Iodine Supplements without being informed of the dangers if you have a goiter, Hashimoto's thyroiditis, or nodules.
See you next time on Thyroid Rounds at Santa Monica Thyroid Center,
Good Day,
Dr.G.
What did she learn?
Iodine is not only not good for goiters in the USA, because we have enough iodine in our diet, but it can be down right harmful.
Do Not Take Iodine Supplements without being informed of the dangers if you have a goiter, Hashimoto's thyroiditis, or nodules.
See you next time on Thyroid Rounds at Santa Monica Thyroid Center,
Good Day,
Dr.G.
A Rare Cure of Medullary Thyroid Cancer ???
This is a follow up of the patient with MCT, who had the best chance for cure.
After a 6 hour surgery, and total removal of the thyroid, central compartment nodes, and right and left neck node removal, he had a post op calcitonin on <2, N<2.
Is this a cure? Time will tell as there is 0.0-0.19 under the curve. I am hopeful his calcitonin will remain undetectable in the future. The surgeon operated for 6 hours to remove all the nodes and the thyroid gland. Yearly neck lymph node real time ultrasound, and calcitonin cancer marker testing will needed for years to finally answer the cure question.
Bravo!
See you next time on rounds at the Santa Monica thyroid Center.
Good Day,
Dr.G.
After a 6 hour surgery, and total removal of the thyroid, central compartment nodes, and right and left neck node removal, he had a post op calcitonin on <2, N<2.
Is this a cure? Time will tell as there is 0.0-0.19 under the curve. I am hopeful his calcitonin will remain undetectable in the future. The surgeon operated for 6 hours to remove all the nodes and the thyroid gland. Yearly neck lymph node real time ultrasound, and calcitonin cancer marker testing will needed for years to finally answer the cure question.
Bravo!
See you next time on rounds at the Santa Monica thyroid Center.
Good Day,
Dr.G.
Acute Leukemia and MCT, Medullary Thyroid Cancer
One year ago I saw a a 60 Y/O M with a thyroid nodule. He was in remission from Leukemia, and wanted to explore the reason for the nodule. He had only Chemotherapy.
No External beam radiotherapy.The USGFNA was consistent with MCT. The pre-op calcitonin was about 1000 N <2. There was nodes in the central compartment, and down into the upper chest. USGFNA of lateral neck nodes was negative for cytology and calcitonin washings. The DNA studies confirmed sporadic, not family MCT. He had extensive surgery. The total thyroid was removed, as well as a node removal down into the upper chest by opening the chest. Both lateral neck node compartments were negative. Post op calcitonin was 40. He had worse problems with a recurrence of the leukemia. One year later after another remission and 4 weeks after the last round of chemotherapy, he presented himself in my office with a calcitonin of 81. The lymph node mapping of his neck was positive for abnormal shaped nodes on both sides. USGFNA of nodes in 4 lateral neck compartment was negative! Hunting for the Calcitonin rise, I did a thin slice PET/CT. The liver was PET/CT negative. He had nodes everywhere, but only one was PET positive. It was in a difficult position for FNA, and only 11 mm in size. I was able to due the biopsy, and show it was the probable source of the calcitonin rise. The surgeon was worried about finding the node group at the time of surgery. One hour before surgery, I injected 1% methylene blue dye on the anterior surface of the node to help in localization. There were smaller nodes near the PET positive one. The surgeon removed 3/12 nodes that were positive.The recovery was uneventful, and the calcitonin post op was 35.
What did we learn?
1. The prior leukemia caused generalized inflammation of nodes throughout his body, confusing me as to the initial place for USGFNA of nodes. The PET/CT was able to find the active MCT cancer node, and the CT slice number allowed us to find the right node to biopsy.
2. Calcitonin washings of the needle after smearing for cytology was the best way to diagnose lymph node mets from MCT.
3. Though MCT is more likely to cause death,than Papillary thyroid cancer, finding early recurrences before they spread to the liver can prolong life.
4.All areas of node surgery in the initial surgery were clear except the very posterior positive node found in Level IIb.
5. The best chance for survival and even cure is a radical surgery with removal of the thyroid, the central nodes and right and left lateral node compartments.
6. The surgeon must be expert in this type of surgery. I sent the patient to a world expert in Houston Texas at MD Anderson Cancer Center.
Until next time on thyroid rounds, at the Santa Monica Thyroid Center,
Good Day,
Dr.G.
No External beam radiotherapy.The USGFNA was consistent with MCT. The pre-op calcitonin was about 1000 N <2. There was nodes in the central compartment, and down into the upper chest. USGFNA of lateral neck nodes was negative for cytology and calcitonin washings. The DNA studies confirmed sporadic, not family MCT. He had extensive surgery. The total thyroid was removed, as well as a node removal down into the upper chest by opening the chest. Both lateral neck node compartments were negative. Post op calcitonin was 40. He had worse problems with a recurrence of the leukemia. One year later after another remission and 4 weeks after the last round of chemotherapy, he presented himself in my office with a calcitonin of 81. The lymph node mapping of his neck was positive for abnormal shaped nodes on both sides. USGFNA of nodes in 4 lateral neck compartment was negative! Hunting for the Calcitonin rise, I did a thin slice PET/CT. The liver was PET/CT negative. He had nodes everywhere, but only one was PET positive. It was in a difficult position for FNA, and only 11 mm in size. I was able to due the biopsy, and show it was the probable source of the calcitonin rise. The surgeon was worried about finding the node group at the time of surgery. One hour before surgery, I injected 1% methylene blue dye on the anterior surface of the node to help in localization. There were smaller nodes near the PET positive one. The surgeon removed 3/12 nodes that were positive.The recovery was uneventful, and the calcitonin post op was 35.
What did we learn?
1. The prior leukemia caused generalized inflammation of nodes throughout his body, confusing me as to the initial place for USGFNA of nodes. The PET/CT was able to find the active MCT cancer node, and the CT slice number allowed us to find the right node to biopsy.
2. Calcitonin washings of the needle after smearing for cytology was the best way to diagnose lymph node mets from MCT.
3. Though MCT is more likely to cause death,than Papillary thyroid cancer, finding early recurrences before they spread to the liver can prolong life.
4.All areas of node surgery in the initial surgery were clear except the very posterior positive node found in Level IIb.
5. The best chance for survival and even cure is a radical surgery with removal of the thyroid, the central nodes and right and left lateral node compartments.
6. The surgeon must be expert in this type of surgery. I sent the patient to a world expert in Houston Texas at MD Anderson Cancer Center.
Until next time on thyroid rounds, at the Santa Monica Thyroid Center,
Good Day,
Dr.G.
Thursday, March 01, 2007
Medullary Thyroid Cancer: One Chance to Cure
I saw a 50 Y/O male for second opinion with a Biopsy proven DX of Medullary Thyroid Carcinoma MCT. He had prior FNA of a 2 cm left lobe nodule. The cells and staining for calcitonin on the slides confirmed MCT. What do I need to do to help him. First, I did an ultrasound of 1-6 levels lymph nodes on both sides of the neck. He had many abnormal shaped nodes. Because the nodule was on the left, and his RET DNA did not show family MCT, the surgeon was only going to do the lymph nodes on that side of the nodule. I called the surgeon, and informed him that there were nodes on Both sides, and if he hoped to give him the best chance for cure he needed to do complete lymph node removal on the right, left, and central compartment. He agreed to do this extensive surgery to try to cure him. There were cancer nodes on both sides of the neck. He took out everything, and sent him back to me on thyroid hormone to see what the MCT cancer marker, Calcitonin was after complete bilateral neck disection. He is recovering well without major side effects. Stay turned for a post surgery follow tests in 4 weeks.
DR.G.
DR.G.
Medullary Thyroid Cancer: One Chance to Cure
I saw a 50 Y/O male for second opinion with a Biopsy proven DX of Medullary Thyroid Carcinoma MCT. He had prior FNA of a 2 cm left lobe nodule. The cells and staining for calcitonin on the slides confirmed MCT. What do I need to do to help him. First, I did an ultrasound of 1-6 levels lymph nodes on both sides of the neck. He had many abnormal shaped nodes. Because the nodule was on the left, and his RET DNA did not show family MCT, the surgeon was only going to do the lymph nodes on that side of the nodule. I called the surgeon, and informed him that there were nodes on Both sides, and if he hoped to give him the best chance for cure he needed to do complete lymph node removal on the right, left, and central compartment. He agreed to do this extensive surgery to try to cure him. There were cancer nodes on both sides of the neck. He took out everything, and sent him back to me on thyroid hormone to see what the MCT cancer marker, Calcitonin was after complete bilateral neck disection. He is recovering well without major side effects. Stay turned for a post surgery follow tests in 4 weeks.
DR.G.
DR.G.
Wednesday, November 22, 2006
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
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.
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.
Wednesday, November 08, 2006
Distant Metastatic Disease 30 years after Partial Thyroidectomy for Thyroid Cancer
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.
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.
Tuesday, October 17, 2006
Why you need to see a Clinical Thyroidologist before parathyroid surgery
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.
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.
Thursday, October 05, 2006
Alternative Therapy for Graves' Hyperthyroidism for 10 years: A Serious Failure
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!
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!
Saturday, September 09, 2006
Doctor, My TSH is Low, but you tell me my Thyroid dose is correct. Then Why do I feel So BAD?
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.
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.
Friday, September 08, 2006
Traumatic Damage, with painful bloody cyst formation, due to a child's blunt blow to the mother's neck
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.
If you have a recurrent cyst, please consider a visit to my center instead of a major surgical intervention for a minor cyst.
Wednesday, September 06, 2006
The Return of a Pituitary Tumor Patient
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.
Great case,
Good result.
Until next time,
Dr.G.
Tuesday, August 08, 2006
40 Heathy Years after So Called Papillary Thyroid Cancer Surgery: Serious Recurrence due to Undiagnosed Medullary Thyroid Cancer
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.
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.
Friday, August 04, 2006
Strip Searched at the White House, Airport, and Courthouse
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.
Dr.G.
Thursday, July 27, 2006
The Best Thyroid Patients in My Clinic Last Week
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.
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.
Sunday, July 16, 2006
The Best Thyroid Patients in My Clinic Last Week
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.
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.
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