Hashimotos Thyroiditis, HT: A Thyroid Cancer Risk?

The TSH may be elevated for years before the patient is diagnosed with chronic thyroiditis.Thyroid cancer cells have receptors for TSH. There is a 3 fold increase in cancer if Thyroiditis is present. How many family physicians,internists, and even endocrinologists know that,and do a High frequency ultrasound on their patients with Hashimoto's Thyroidits? Even small nodules not palpable by your physician, but seen on ultrasound can be as dangerous as a larger one that was felt by your physician.If you have thyroiditis, insist on a thyroid ultrasound.

Use of Radioiodine for Thyroid cancer is not needed in Low Risk Patients

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

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

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

Two new tools added to treat our thyroid cancer patients

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

Dr.G.

Gangster with Graves' Disease

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

Thyroid Cancer Radiation Therapy USA Today Front Page Story

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

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

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

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.

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.

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.

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

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 ???

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

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

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

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.

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.

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.

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.

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!