Case Presentation:
Question:
Why are they treating 85-94 year old patients so aggressively?
Answer:
Because they have the tools to do it.
88 Y/O male with a 4 cm mass, which was proven to be a follicular variant of papillary cancer. After total thyroidectomy, he was subjected to hormone withdrawal at his age. Well it is no surprise that he was developed cardiac complications. The TSH >100, and TG was 88. He was stabilized, and cardiac failure treated, and was given 150 MCI I/131. The expected survival of 88 year old male is 4-5 years. After therapy the Neck ultrasound and TG, cancer marker were negative. Even with cardiac disease the oncologist pushed thyroid to suppress TSH. Also they did a Thyrogen stimulated TG, which was elevated to 15 from 3.7. He was given another 150MCI radioiodine, but alas the post therapy scan was negative. He developed side effects of the radiation. Dry mouth, hypotension, throat pain, nose bleed. He developed pseudogout, and more admissions followed. More studies were done including a PET/CT. A 7 mm nodule in the lung was seen. Symptoms of excess thyroid continued to occur do to suppressed TSH. More problems, this time a fracture again put him in the hospital. The rising TG was now 500. A PET positive mass in the lung and chest wall was found. The TG was now 1500. External beam radiation was given to the chest wall, even though there was no chest wall pain. The radiation caused more symptoms. TG went from 420 post EBRT to 1200. He lived for 8 years, but most of the time he was not well. We need to think about what we do to elderly patients with a tumor that slow growing and stop treating the TG numbers. As one smart thyroidologist once said at a meeting, "You never die from an elevated thyroglobulin. This patient was treated with external beam radiation at age 94! Now the oncologist was bragging about the fact he did not die of the cancer, but what about all the morbitity inflicted on the poor elderly gentleman, when the cancer was progressing in the expected slow course. The idea should be to do no harm, and only treat symptomatic lesions, or ones that could cause airway blockage or bleeding in the neck.
The second dose of I/131 was not helpful. The side effects were debilitating. Did the oncologist ever suffer cotton mouth symptoms, which this second dose I/131 of unlikely value, caused? The external beam to the chest wall did not relieve any chest wall pain as there was no pain. The oncologist was over eager to do something, when the best thing to do was to be conservative with a chronically ill octigenerian. Only 1600 thyroid cancer patients ever die from the disease in any year, but too many suffer early and late complications due to over-eager physicians chasing the thyroglobulin, with I/131, EBRT, PET/CT Scans, and morbitity inducing thyroid hormone withdrawal. He was too old to get cancers from the 300 millicuries given, but many younger patients are given 150 routinely after low risk thyroid cancer. They will by at risk for other cancers years later. There is a new generation of endocrine-oncologists that have available to them the most advanced methods to treat high risk thyroid cancers, but need to think twice before doing this to many 95 year olds.
Good Luck,
Dr.G.
Sunday, May 25, 2008
Saturday, May 24, 2008
What Should You do if your Primary Care, or Endocrinologist tell You that Your Blood Calcium is Elevated and you need Surgery to Remove a Parathyroid
The most common cause is over-active parathyroid gland activity. Usually a single non cancerous tumor called a parathyroid adenoma. The screening testing is easy. Calcium, parathyroid hormone, and urine studies for calcium and creatine. But once the diagnosis is made the next step is not as easy. The location of the tumor can be anywhere in the neck, and may even be in the chest. Also, there may be co-existent thyroid tumors as well. The standard approach is to do a Parathyroid scan.They are hard to read and will negative even when the tumor is present. Do not go to surgery, without a high frequency parathyroid ultrasound. The experience of the parathyroid ultrasonographer is crucial to the success in finding the tumor. They can be found behind the esophagus, down in the thymic ligament and even in the thyroid. Incidental tumor nodules in the thyroid can be treated at the same time if positive for cancer. The parathyroid adenoma has a distinct look on US. It will be hypoechoic and have many shapes as it is soft. There will be a distinctive polar artery coming to the tumor. The parathyroid ultrasonographer will be able to biopsy the tumor with extremely small needles, and usually needs only one or two passes into the tumor. The chances for fibrosis are rare to none. The sample will be sent for cytology, and the needle washing for PTH. The cytology is not diagnostic, as it looks similar to a thyroid adenoma, but the PTH washing will be very elevated in most cases. With the knowledge that there is only one tumor, and the thyroid is not harboring a cancer nodule, the surgeon can do a quick 15 minute operation to remove the single adenoma. If the thyroid ultrasonographer finds more than one adenoma, or a mass is found in the thyroid, then the usual parathyroid exploration and thyroid removal would be needed. Also, if you have a recurrence after the first surgery, you need to see a expert parathyroid ultrasonographer, to find the abnormal gland. There can be a second adenoma missed on the first surgery, or it can be down in the chest. A CT of the Chest can help find that rare variation.
An endocrine neck lab such as mine, or a referral to a clinical thyroidologist with expert ultrasound experience in handling parathyroid localization procedures and biopsies can help your endocrinologist find your tumor.
Do it right the first time, and avoid an unnecessary long exploratatory surgery, or at least know that it is necessary because you had multiple parathyroid masses, or had a tumor nodule in the thyroid as well.
Case Presentation:
46Y/O Female with high Calcium and Blood PTH has parathyroid disease.
A second opinion was requested by her endocrinologist to help locate the adenoma.
Prior para thyroid scan was negative. Neck High frequency ultrasound was negative for locating it until I put 2 pillows under her back and with her neck hyperextended, I was able to see the right upper parathyroid which had been displaced to the area behind the esophagus. The thyroid gland was also abnormal. A 1.6 cm nodule was located in the right lobe.It had abnormal ultrasound changes suggestive of cancer. The biopsy of the parathyroid was done first. a washing for PTH was 56,000, and the cytology was consistent but not diagnostic,resembling a follicular neoplasm.The biopsy for the thyroid nodule was positive for papillary thyroid cancer. Prior to surgery, a lymph node mapping was done to see if neck nodes were invaded by thyroid cancer. The neck node ultrasound mapping was negative. The surgeon was told that because of the thyroid cancer the minimal surgery was not indicated, and a total thyroidectomy and central compartment node removal had to be done. The single adenoma was easily located behind the esophagus and the patient continues to have normal calcium 6 months after surgery.
We call that a "TWOfer". Two diseases with one surgery!
Good Luck,
Dr.G.
Endocrine Neck Lab of Southern California
Dr.G. is the thyroid and parathyroid ultrasonographer
www.endocrineneck.com
An endocrine neck lab such as mine, or a referral to a clinical thyroidologist with expert ultrasound experience in handling parathyroid localization procedures and biopsies can help your endocrinologist find your tumor.
Do it right the first time, and avoid an unnecessary long exploratatory surgery, or at least know that it is necessary because you had multiple parathyroid masses, or had a tumor nodule in the thyroid as well.
Case Presentation:
46Y/O Female with high Calcium and Blood PTH has parathyroid disease.
A second opinion was requested by her endocrinologist to help locate the adenoma.
Prior para thyroid scan was negative. Neck High frequency ultrasound was negative for locating it until I put 2 pillows under her back and with her neck hyperextended, I was able to see the right upper parathyroid which had been displaced to the area behind the esophagus. The thyroid gland was also abnormal. A 1.6 cm nodule was located in the right lobe.It had abnormal ultrasound changes suggestive of cancer. The biopsy of the parathyroid was done first. a washing for PTH was 56,000, and the cytology was consistent but not diagnostic,resembling a follicular neoplasm.The biopsy for the thyroid nodule was positive for papillary thyroid cancer. Prior to surgery, a lymph node mapping was done to see if neck nodes were invaded by thyroid cancer. The neck node ultrasound mapping was negative. The surgeon was told that because of the thyroid cancer the minimal surgery was not indicated, and a total thyroidectomy and central compartment node removal had to be done. The single adenoma was easily located behind the esophagus and the patient continues to have normal calcium 6 months after surgery.
We call that a "TWOfer". Two diseases with one surgery!
Good Luck,
Dr.G.
Endocrine Neck Lab of Southern California
Dr.G. is the thyroid and parathyroid ultrasonographer
www.endocrineneck.com
What is Thyroid Cancer Ultrasound Lymph Node Mapping, and why do I need to have one BEFORE my Cancer Surgery?
Prior to the new approach to thyroid cancer, the radio-iodine whole body scan WBS, was the mainstay of diagnostic cancer studies. Along came highly sensitive cancer markers, Thyroglobulin TG, and the TG antibody. The WBS was poor at detecting recurrence. The addition of the newer high frequency ultrasound was better at finding recurrences, than the WBS. With Cancer markers and Ultrasound we can find the cancer that is missed with WBS, and even after a post treatment scan. The lymph node mapping by high frequency ultrasound can find tumor recurrence even when the WBS, TG and PET/CT are negative! Well if it is that good after the surgery, maybe it is good PRIOR to the original surgery. In fact if you have a qualified clinical thyroidologist, and thyroid ultrasonographer map your neck BEFORE the original surgery, it will expand the scope of the first surgery in 20-30% of the patients with a positive needle biopsy confirming cancer or is suspicious of thyroid cancer. The expanded surgery would include the lateral neck nodes on the side of the positive node biopsy. Modern thyroid cancer pre-op should include a lymph node mapping. INSIST on one before the surgery.It will save you another surgery in 1-5 years. The first surgery is the most important. Recurrences will be less likely if positive nodes, which would be still left in the neck were not removed at the original surgery. The use of MR,CT or PET/CT will not be as accurate as Ultrasound in the right operators hands at finding your neck node disease. Ask your endocrinologist or internist to refer you to an endocrine neck ultrasound lab where a clinical thyroidologist, and ultrasonographer can help him. My referral endocrine neck ultrasound lab website is www.endocrineneck.com.
Case Presentation:
56 Y/O female was seen 6 weeks after total thyroidectomy for a needle biopsy proven papillary thyroid cancer. The internist sent her for management of the cancer, after the surgery. The cancer marker on Thyroid hormone was <0.1, and the TSH was 0.09. However the lymph node mapping found cancer nodes in the right neck. The ultrasound guided FNA biopsy was negative for cytology, but was positive for TG in the washings from the largest node. It is common that the cytology will miss the tumor , but the TG will be found in the node. Any TG in the node is abnormal.The patient was shocked that a node study was not done before the first surgery. I told her it was relatively new information,and not well known by non-specialists. The patient was sent back to surgery to do a modified neck dissection. 4/15 nodes were positive for metastatic thyroid cancer in the neck.
The best time to send a patient to the clinical thyroidologist is when the nodule is first found, not after the biopsy, and surely not after the crucial first surgery.
Good Luck,
Dr.G.
Case Presentation:
56 Y/O female was seen 6 weeks after total thyroidectomy for a needle biopsy proven papillary thyroid cancer. The internist sent her for management of the cancer, after the surgery. The cancer marker on Thyroid hormone was <0.1, and the TSH was 0.09. However the lymph node mapping found cancer nodes in the right neck. The ultrasound guided FNA biopsy was negative for cytology, but was positive for TG in the washings from the largest node. It is common that the cytology will miss the tumor , but the TG will be found in the node. Any TG in the node is abnormal.The patient was shocked that a node study was not done before the first surgery. I told her it was relatively new information,and not well known by non-specialists. The patient was sent back to surgery to do a modified neck dissection. 4/15 nodes were positive for metastatic thyroid cancer in the neck.
The best time to send a patient to the clinical thyroidologist is when the nodule is first found, not after the biopsy, and surely not after the crucial first surgery.
Good Luck,
Dr.G.
Thursday, May 22, 2008
What is Methylene Blue Dye Localization, and why do I need to know about it if I have recurrent thyroid cancer after multiple surgeries?
Case Presentation:
69 Y/O female with an aggressive form of papillary thyroid cancer called Tall Cell Variant. She has had total thyroidectomy, and central compartment node removal.. 150 MCI was given after the first surgery. The first recurrence was in the right lateral neck. Another surgery was done. 200 Millicuries of I/131 was given. Over 12 months her
thyroglobulin,TG rose from 0.36 to 6.5 with suppressed TSH. The last Whole body scan was negative. The ultrasound lymph node mapping revealed central compartment abnormal nodes. The USGFNA biopsy was positive for recurrence, and the TG Cancer marker was 35,000 in the needle washing from the largest node. Because of the aggressive nature of the cancer a PET/CT was done to make sure there was distant spread to the lungs or bones. The scan was positive only for the nodes seen on ultrasound in the central compartment. The patient had suffered a right vocal cord injury at the first surgery, and therefore re-entry in the central compartment was more risky. The thyroid surgeon agreed to go in only if I could localize the nodes for him before the surgery. One hour before she went to the hospital, she came to the thyroid center, and under US guidance I placed a drop of dye on the anterior surface of the largest node. The surgery was uneventful. There was no changes in her voice or the blood calcium post surgery. However when she returned for the 4 week post surgery visit her cancer marker was markedly decreased from 6.5 to just above the lower limit of <0.15, at 0.23. There were 3 positive nodes clustered around the blue dye marked node. The surgeon had no problem finding the PET positive nodes with my dye marker.
Thyroid cancer, Tall Cell Variant, thyroid ultrasound lymph node marking, Thyroid ultrasound Guided lymph node FNA biopsy, Thyroglobulin washing for the cancer node, Methylene blue dye cancer lymph node localization procedure prior to surgery.
Good Luck,
Dr.G
69 Y/O female with an aggressive form of papillary thyroid cancer called Tall Cell Variant. She has had total thyroidectomy, and central compartment node removal.. 150 MCI was given after the first surgery. The first recurrence was in the right lateral neck. Another surgery was done. 200 Millicuries of I/131 was given. Over 12 months her
thyroglobulin,TG rose from 0.36 to 6.5 with suppressed TSH. The last Whole body scan was negative. The ultrasound lymph node mapping revealed central compartment abnormal nodes. The USGFNA biopsy was positive for recurrence, and the TG Cancer marker was 35,000 in the needle washing from the largest node. Because of the aggressive nature of the cancer a PET/CT was done to make sure there was distant spread to the lungs or bones. The scan was positive only for the nodes seen on ultrasound in the central compartment. The patient had suffered a right vocal cord injury at the first surgery, and therefore re-entry in the central compartment was more risky. The thyroid surgeon agreed to go in only if I could localize the nodes for him before the surgery. One hour before she went to the hospital, she came to the thyroid center, and under US guidance I placed a drop of dye on the anterior surface of the largest node. The surgery was uneventful. There was no changes in her voice or the blood calcium post surgery. However when she returned for the 4 week post surgery visit her cancer marker was markedly decreased from 6.5 to just above the lower limit of <0.15, at 0.23. There were 3 positive nodes clustered around the blue dye marked node. The surgeon had no problem finding the PET positive nodes with my dye marker.
Thyroid cancer, Tall Cell Variant, thyroid ultrasound lymph node marking, Thyroid ultrasound Guided lymph node FNA biopsy, Thyroglobulin washing for the cancer node, Methylene blue dye cancer lymph node localization procedure prior to surgery.
Good Luck,
Dr.G
Wednesday, May 21, 2008
PEI: What is Percutaneous Ethanol Injection, and why do I need to know about it, if I have had multiple surgeries for papillary thyroid cancer?
Case Presentation:
70 Y/O Japanese female with multiple surgeries in the lateral neck after total thyroidectomy for papillary thyroid cancer. Her cancer marker rose again, and she was given another thyroid cancer lymph node mapping. There was a 7 mm tall and 6 mm wide node in level 4 on the right side. The node had abnormal Doppler blood flow suggestive of another recurrence. She was given an USG FNA of the node, and cancer marker was collected from the needle washings. The cytology was negative, but the cancer marker in the washings from the lymph node was 156,000. This was diagnostic of metastatic papillary thyroid cancer. She was told it was too risky to operate again due to scarring and high complication rate. The surgeon recommended she have radio-iodine instead. Her endocrinologist had heard about alternatives to surgery, and knew radio-iodine was not helpful to kill lymph nodes. He referred her to me for evaluation for PEI. I called the surgeon and suggested he might want to do the surgery, if I could mark the cancerous node , by placing a small dot of blue dye on the abnormal node one hour before surgery to reduce the risk of complications. He refused my request. I was left with PEI as the only other treatment. I injected ethanol directly into the cancerous node under ultrasound guidance. She had no complications, but did note a slight tingling along the tract of the needle when I pulled it out. The return visit in 4 weeks was notable for a complete loss of blood flow by Doppler, and a 67% reduction of the node. Also the cancer marker dropped 3 fold to <0.1. 2 more sessions resulted in a small remnant node with no blood flow. The yearly ultrasound follow exams have shown no recurrence of the node in question, and the cancer marker is still non-detectable.
PEI is a new method for treatment of recurrent thyroid cancer in the neck. It is operator dependent and should only be done by expert thyroid interventional ultrasonographers.
Good Luck,
Dr.G.
70 Y/O Japanese female with multiple surgeries in the lateral neck after total thyroidectomy for papillary thyroid cancer. Her cancer marker rose again, and she was given another thyroid cancer lymph node mapping. There was a 7 mm tall and 6 mm wide node in level 4 on the right side. The node had abnormal Doppler blood flow suggestive of another recurrence. She was given an USG FNA of the node, and cancer marker was collected from the needle washings. The cytology was negative, but the cancer marker in the washings from the lymph node was 156,000. This was diagnostic of metastatic papillary thyroid cancer. She was told it was too risky to operate again due to scarring and high complication rate. The surgeon recommended she have radio-iodine instead. Her endocrinologist had heard about alternatives to surgery, and knew radio-iodine was not helpful to kill lymph nodes. He referred her to me for evaluation for PEI. I called the surgeon and suggested he might want to do the surgery, if I could mark the cancerous node , by placing a small dot of blue dye on the abnormal node one hour before surgery to reduce the risk of complications. He refused my request. I was left with PEI as the only other treatment. I injected ethanol directly into the cancerous node under ultrasound guidance. She had no complications, but did note a slight tingling along the tract of the needle when I pulled it out. The return visit in 4 weeks was notable for a complete loss of blood flow by Doppler, and a 67% reduction of the node. Also the cancer marker dropped 3 fold to <0.1. 2 more sessions resulted in a small remnant node with no blood flow. The yearly ultrasound follow exams have shown no recurrence of the node in question, and the cancer marker is still non-detectable.
PEI is a new method for treatment of recurrent thyroid cancer in the neck. It is operator dependent and should only be done by expert thyroid interventional ultrasonographers.
Good Luck,
Dr.G.
PEI: What is PEI and why do I need to know about it, if I have a thyroid cyst, or parathyroid cyst, and have been told to have surgery?
Case Presentation:
50 Y/O Chinese male was told in Shanghai, that the only therapy for his recurrent thyroid cyst was surgery. A modern Chinese male hits the web to research this, before submitting for surgery. He found thyroid,com, and emailed me about coming to the USA for a consultation. He was euthyroid, on no medications, and had a 15 cc pure cyst.
The ultrasound guided FNA biopsy confirmed the cyst was indeed thyroid in nature, and the biopsy was negative for cancer. When he next visited the USA, under US guidance I
withdrew 15 cc of cyst fluid and re-injected 7.5 cc of medical grade ethanol. There was no pain or complications. He returned to see me 6 weeks later. The cyst was not visible anymore, and the ultrasound confirmed it was >99% ablated. There was a 1-2 mm residual seen on ultrasound.He had his wish come true to fix the cyst, but without major surgery, and hospitalization.
This PEI procedure can be used as primary treatment for non-functioning parathyroid cysts, and thyroglossal ducts that have recurred and failed surgery. It is mandatory to rule out cancer in mixed cysts of any nature before PEI is considered as a therapy option. It has another major use in the treatment of recurrent cancer lymph nodes in thyroid cancer patients,after a recurrence and prior neck explorations.
Good Luck,
Dr.G.
50 Y/O Chinese male was told in Shanghai, that the only therapy for his recurrent thyroid cyst was surgery. A modern Chinese male hits the web to research this, before submitting for surgery. He found thyroid,com, and emailed me about coming to the USA for a consultation. He was euthyroid, on no medications, and had a 15 cc pure cyst.
The ultrasound guided FNA biopsy confirmed the cyst was indeed thyroid in nature, and the biopsy was negative for cancer. When he next visited the USA, under US guidance I
withdrew 15 cc of cyst fluid and re-injected 7.5 cc of medical grade ethanol. There was no pain or complications. He returned to see me 6 weeks later. The cyst was not visible anymore, and the ultrasound confirmed it was >99% ablated. There was a 1-2 mm residual seen on ultrasound.He had his wish come true to fix the cyst, but without major surgery, and hospitalization.
This PEI procedure can be used as primary treatment for non-functioning parathyroid cysts, and thyroglossal ducts that have recurred and failed surgery. It is mandatory to rule out cancer in mixed cysts of any nature before PEI is considered as a therapy option. It has another major use in the treatment of recurrent cancer lymph nodes in thyroid cancer patients,after a recurrence and prior neck explorations.
Good Luck,
Dr.G.
Monday, April 07, 2008
Murder by Thyroid Poisoning, or Paranoia?
A 40+ Y/O male presented to the ER with a rapid pulse and insomnia for a week.
He told the ER physician that he felt he was being poisoned by a female friend.
He stated that for 6 weeks he has been eating at her condo, and became progressively sicker in the last 2 weeks. He developed insomnia, anxiety and rapid heart beat which was confirmed
at the ER at 160/minute.The thyroid was mildly enlarged. He described the poison plot to the physician, who had the patients stomach pumped. He described a grifter scam to get his money and his paid up house, by making him weak, and signing over all his assets. The scam was worked by the female age 35, and her boy friend. The thyroid hormone was ground up and put in his food. The delayed symptoms occurred 30 days after he began eating at her condo. When I first saw him, I asked how did he know he was being poisoned, with Synthroid, a brand name for thyroxine. He said it was a well known grifter scam listed on websites about scam artists. His heart rate was normal 4 days after the ER visit. No tremor, but still complained of insomnia. His thyroid was enlarged and nodular. However, the T4,T3, TSH, and antibodies were all normal.
The thyroglobulin TG was drawn at first to make sure it was exogenous induced hyperthyroidism, not Graves disease. When the TG came back normal, not suppressed, I knew he was not being poisoned by thyroid hormone placed in his food. His story was very strange. He has a goiter and small nodule which needs my follow up, but what about this poisoning story? When confronted with the news, he was shocked that his imagined poisoning was not real. I told him he had serious problem with reality, and needed to get help. He had planned to get the police to arrest the female, but I found no smoking gun. His paranoid thoughts were out of control. His small goiter was not enough to suspect poisoning. Also his I/123 thyroid uptake was normal. He said he would see a therapist, but did not go to the one I recommended.
Until next time,
Good thyroid health,
Dr.G.
He told the ER physician that he felt he was being poisoned by a female friend.
He stated that for 6 weeks he has been eating at her condo, and became progressively sicker in the last 2 weeks. He developed insomnia, anxiety and rapid heart beat which was confirmed
at the ER at 160/minute.The thyroid was mildly enlarged. He described the poison plot to the physician, who had the patients stomach pumped. He described a grifter scam to get his money and his paid up house, by making him weak, and signing over all his assets. The scam was worked by the female age 35, and her boy friend. The thyroid hormone was ground up and put in his food. The delayed symptoms occurred 30 days after he began eating at her condo. When I first saw him, I asked how did he know he was being poisoned, with Synthroid, a brand name for thyroxine. He said it was a well known grifter scam listed on websites about scam artists. His heart rate was normal 4 days after the ER visit. No tremor, but still complained of insomnia. His thyroid was enlarged and nodular. However, the T4,T3, TSH, and antibodies were all normal.
The thyroglobulin TG was drawn at first to make sure it was exogenous induced hyperthyroidism, not Graves disease. When the TG came back normal, not suppressed, I knew he was not being poisoned by thyroid hormone placed in his food. His story was very strange. He has a goiter and small nodule which needs my follow up, but what about this poisoning story? When confronted with the news, he was shocked that his imagined poisoning was not real. I told him he had serious problem with reality, and needed to get help. He had planned to get the police to arrest the female, but I found no smoking gun. His paranoid thoughts were out of control. His small goiter was not enough to suspect poisoning. Also his I/123 thyroid uptake was normal. He said he would see a therapist, but did not go to the one I recommended.
Until next time,
Good thyroid health,
Dr.G.
Thursday, March 20, 2008
Endocrine Neck Labratory Open for Busness
Modern thyroid care for patients is vastly more complicated now than 20 years ago.
Most internists and endocrinologists would and could care for thyroid patients. However, the new skills needed to care for thyroid cancer patients and patients with nodules and goiters, are not universally available at your local endocrinologists office. They still use nuclear medicine types at the local hospitals to advise them on the need for radiation therapy for their thyroid cancer patients.They send the patients to radiologists to do ultrasound guided FNA. A new concept in thyroid care is the Endocrine Neck Lab. It will offer thyroid studies performed by a clinical thyroidologist, and thyroid ultrasonographer, Dr.Richard Guttler. Any physician caring for thyroid patients can have Dr.Guttler perform studies for them.These include:1.Diagnostic thyroid/parathyroid/lymph node studies 2. Ultrasound Guided Fine Needle Aspiration biopsy 3. Pre-op and follow-up lymph node mapping in thyroid cancer patients 4.Percutaneous Ethanol injections to cure thyroid cysts 5.PEI for cancer nodes. 6. Node Localizations by US guided blue dye injection pre-operatively to aid the surgeon.
Most internists and endocrinologists would and could care for thyroid patients. However, the new skills needed to care for thyroid cancer patients and patients with nodules and goiters, are not universally available at your local endocrinologists office. They still use nuclear medicine types at the local hospitals to advise them on the need for radiation therapy for their thyroid cancer patients.They send the patients to radiologists to do ultrasound guided FNA. A new concept in thyroid care is the Endocrine Neck Lab. It will offer thyroid studies performed by a clinical thyroidologist, and thyroid ultrasonographer, Dr.Richard Guttler. Any physician caring for thyroid patients can have Dr.Guttler perform studies for them.These include:1.Diagnostic thyroid/parathyroid/lymph node studies 2. Ultrasound Guided Fine Needle Aspiration biopsy 3. Pre-op and follow-up lymph node mapping in thyroid cancer patients 4.Percutaneous Ethanol injections to cure thyroid cysts 5.PEI for cancer nodes. 6. Node Localizations by US guided blue dye injection pre-operatively to aid the surgeon.
Tuesday, March 11, 2008
Why Surgery Not Needed for most Goiter Patients
Why take the risk of a hospital visit to remove a non-cancerous goiter. Hospital induced secondary diseases, and the real risk of complications from the surgery makes many turned off by surgery. The alternative use of low dose radio-iodine, 30 Millicuries is a great way to reduce goiter size, and stop complications from the knife and all it's ramifications. With a small booster shot of TSH, to increase thyroid iodine uptake, you can deliver enough radiation to decrease the gland by about 50%.Doses below 80 Millicuies are not associated with secondary cancers of other organs, such breast cancer. Call your local thyroidologist for details before you listen to the physician how recommends surgery as the only option.
www.thyroidologists.com
www.thyroidologists.com
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.
ablation therapy for most if not all their patients, regardless of the level of prognostic risk. Two major medical centers with top ten ratings, still have high rates of hospital treated high dose >75 Millicurie therapy for even low risk patients. One uses 150 MCI as standard therapy! 80 MCi or more have increased incidence of solid tumors of the stomach,bladder,prostate,penis, breast,and many more. Why is this happening even though the literature has no evidence it is helpful? The answer is found in the referral patterns of a given center. Busy diabetes and internal medicine endocrinologists and surgeons, commonly defer radiation decisions to the nuclear physician. It is like Little Red Riding Hood asking the wolf for his opinion on the best thing for dinner that night. The need for a new leader to decide the need for adjunct therapy should be a clinical thyroidologist, not the nuclear medicine physician. A clinical thyroidologist with the ability to do lymph node mapping, thyroglobulin, USGFNA of suspect cancer nodes, and can develop an endocrine neck lab to help the many endocrinologists who are too busy to master the skills to be expert at lymph node FNA, percutaneous ethanol injections of cancer nodes, would be the ideal new player in this field. The days of routine use of total body scan and radiation therapy by nuclear medicine is in decline, and that of thyroid ultrasonographers are in ascendancy.
Thursday, February 28, 2008
What to Do about Recurrent Cancer Neck Nodes, When You have had Multiple Surgeries, or Have Contraindications to Further Radioiodine or Surgery?
The patient has papillary thyroid cancer. She had originally a total thyroidectomy, and central compartment node removal. 2/6 nodes were positive.
This was followed by radio-iodine therapy. She developed recurrence in the left lateral neck, treated by modified neck removal of 26 nodes. 12/26 were positive for cancer. She had a second course of I/131, and still had detectable cancer marker, which was followed until it began to rise 2 years later. The lymph node mapping by high frequency ultrasound found abnormal nodes in the left neck again, and new abnormal node in the central compartment. Both areas were sites of a previous surgery. They would be difficult to open again without a risk to her parathyroids or recurrent nerves. The thyroid surgeon, the patient and I decided it was safe to go after the central compartment node, if I could mark the location by injecting a small amount of methylene blue on the surface of the node, by ultrasound guidance one hour before surgery. The left neck was left to me to use Percutaneous Ethanol Injections to "kill" those few nodes, rather than risk a second surgery on the left neck.The surgery was fast and without complications. The surgeon found the node easily with my blue mark. The left neck node was "killed" by injecting small amount of ethanol directly into the cancer node. The blood flow by power Doppler was destroyed by the ethanol. The cancer marker decreased and she was followed yearly for 2 years without recurrence.
Two new tools added to treat our thyroid cancer patients
PEI for treating cancer nodes
USG Methylene Dye for localization of cancer nodes for the surgeon.
Dr.G.
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.
Thursday, February 21, 2008
Gangster with Graves' Disease
Jimmy Breslin's new book "The Good Rat" tells the story that Salvatore "The Bull" Gravano developed Graves'Disease. He became quite sick with hyperthyroid symptoms, after ratting out mob boss John Gotti. He had pulled out his hair, and left a head that was bald and pink.Folds of flesh hung around his eyes.Because Mr.Breslin feels politicians are as crooked as mobsters, he would not be surprised that the first President Bush had Graves' disease during the first Gulf War.
Tuesday, November 20, 2007
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.
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.
Thursday, October 18, 2007
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
The many years of weight problems well documented on all her shows.lij
Sunday, July 29, 2007
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.
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.
Friday, April 27, 2007
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.
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.
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
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