Thursday, January 05, 2006
Surgeons Need to Refer Thyroid Cancer Cases to Thyroidologists Before the Surgery
I do not operate on my thyroid cancer cases, but refer them to expert thyroid surgeons.
I do not expect surgeons to operate on cancer cases without a complete thyroid evaluation before the surgery date.
70Y/O male with Medullary Thyroid cancer found while having a PET/CT for lukemia F/U.
A positive node was found in the upper mediastinum for Medullary Ca. They biopsied the
thyroid and confirmed MCT. He had a date for surgery for the next day for a total Thyroidectomy. He was not referred to a thyroidologist. He was nervous, and came to me on his own for my opinion.
I found bilateral abnormal lymph nodes on both sides of his neck by High Frequency ultrasound. He had high blood pressure. I ordered tests to r/o a blood pressure adrenal tumor, and and sent a DNA study to a r/o family type of Medullary cancer.
I told him to cancel the surgery. that he needed to see a thyroid cancer surgeon, because he needed a very complicated surgery, that included total thyroidectomy, bilateral lymph node resection, and also opening the chest to remove the nodes found there on PET/CT. After my evaluation, he followed my advice, and went to MD Anderson in Texas for the surgery. The massive surgery went well and he returned to L.A. to be followed in my clinic.
The surgeon who wanted to rush him to surgery, would have faced a possible crisis
because he did not check the adrenals for a BP tumor. He did not know that there were bilateral nodes I found on HF US testing. The surgery would have been incomplete.
What did we learn?
Do not get rushed into surgery without a complete evaluation by a thyroidologist.
Also beware of surgeon who seem to know it all.
I do not operate, and they should not act as thyroidologists.
This surgeon who rushed the case to the OR, is considered a local thyroid surgeon, but because of his cowboy attitude toward his patients, he never gets a referral from me.
Dr.G.
www.thyroidologists.com
I do not expect surgeons to operate on cancer cases without a complete thyroid evaluation before the surgery date.
70Y/O male with Medullary Thyroid cancer found while having a PET/CT for lukemia F/U.
A positive node was found in the upper mediastinum for Medullary Ca. They biopsied the
thyroid and confirmed MCT. He had a date for surgery for the next day for a total Thyroidectomy. He was not referred to a thyroidologist. He was nervous, and came to me on his own for my opinion.
I found bilateral abnormal lymph nodes on both sides of his neck by High Frequency ultrasound. He had high blood pressure. I ordered tests to r/o a blood pressure adrenal tumor, and and sent a DNA study to a r/o family type of Medullary cancer.
I told him to cancel the surgery. that he needed to see a thyroid cancer surgeon, because he needed a very complicated surgery, that included total thyroidectomy, bilateral lymph node resection, and also opening the chest to remove the nodes found there on PET/CT. After my evaluation, he followed my advice, and went to MD Anderson in Texas for the surgery. The massive surgery went well and he returned to L.A. to be followed in my clinic.
The surgeon who wanted to rush him to surgery, would have faced a possible crisis
because he did not check the adrenals for a BP tumor. He did not know that there were bilateral nodes I found on HF US testing. The surgery would have been incomplete.
What did we learn?
Do not get rushed into surgery without a complete evaluation by a thyroidologist.
Also beware of surgeon who seem to know it all.
I do not operate, and they should not act as thyroidologists.
This surgeon who rushed the case to the OR, is considered a local thyroid surgeon, but because of his cowboy attitude toward his patients, he never gets a referral from me.
Dr.G.
www.thyroidologists.com
Tuesday, November 15, 2005
Wednesday, October 05, 2005
Very Prolonged Painful Viral thyroiditis: Why No Physicians Treated Her Neck Pains
41 Y/O female developed a sore throat, and neck discomfort. This was followed by enlarging mass in the thyroid area on the left. The mass was tender to touch, and pain began in addition to tenderness. She saw an ENT physician who gave her antiboitics, and an allergy steroid dose pack for 5 days. The pain was gone, but returned when the pack was finished. The ENT did not continue the steroids. She continued to have pain, which was only slightly relieved with Motrin. She returned crying, when the pain and mass migrated to the other side of the neck. The ENT told her it could be cancer, and did a FNA. She screamed with each of 3 needle sticks. She was told it was not cancer. She indured the pain for 4 months with only slight relief from non-steroidals, and 2 other physicians she visited for opinions did not offer a solution to her pain. Her pain finally went away on it's on, and she was euthyroid by 6 months.
She had a classic case of Viral Subacute Thyroiditis SAT. She became hyperthyroid first, TSH 0.01, and then hypothyroid TSH 6, and was normal TSH 2.1 by 6 months. Her goiter disappeared as well.
The only thing one can do for this type of patient is to relieve the pain! This was not done. The pain of SAT is quickly treated with Prednisone, and the dose may be needed for weeks to a few months. The band aid of a 5 day dose pack was inadequate to help her overcome the painful symptoms of SAT.
Also a biopsy is the last resort in this disease because it is very painful!
None of the physicians offered her prednisone or even an endocrine consultation to help treat her.
Dr.G.
She had a classic case of Viral Subacute Thyroiditis SAT. She became hyperthyroid first, TSH 0.01, and then hypothyroid TSH 6, and was normal TSH 2.1 by 6 months. Her goiter disappeared as well.
The only thing one can do for this type of patient is to relieve the pain! This was not done. The pain of SAT is quickly treated with Prednisone, and the dose may be needed for weeks to a few months. The band aid of a 5 day dose pack was inadequate to help her overcome the painful symptoms of SAT.
Also a biopsy is the last resort in this disease because it is very painful!
None of the physicians offered her prednisone or even an endocrine consultation to help treat her.
Dr.G.
Thursday, September 29, 2005
Laser Thermocoagulation of Benign Solid Thyroid Nodules: A New Therapy
We now put alcohol into recurrent cysts, as an alternative to surgery. Now there are studies published in Clinical Thyroidology 2003;15:11 on the effective use of another form of destruction of thyroid tissue. The use of a laser to "cook" the inside of solid FNA proven benign nodules that cause local symptoms in the neck, or appearance issues. Randomly assigned 30 females to Laser or no therapy for six months. The method involves Ultrasound Guided 18 G needle into the nodule.Then a o.4 mm wire is inserted into the center of the nodule.The needle is withdrawn.Then 2.5-3.0 W output power is given to the nodule. Vapor is seen in the area of the wire on ultrasound, and the area becomes hypoechoic. Two more 2.5-3.0 W outputs complete the therapy, for a total median energy of 2007 J.
The results:
The median volume decreased from 8.2 to 4.8 ml, while the volume increased from 7.5 to 9.0 ml in the untreated patients. A 44% reduction. The controls increased 9 %. There was a 53% difference between the two groups at 6 months. 7/15 in the laser group had neck pain, or tenderness for up to seven days. However, all would have the therapy again if needed. No serious complications occurred, such as vocal cord paralysis. 13/15 laser group patients had pressure symptoms before, and 10/13 had marked relief after the therapy. Cosmetic symptoms also decreased. There was no change in symptoms in the control group, even though the size increased an average of 9%.
Hegedus et al Eur J Endocrol 2005; 152:341-5
Dr Robert Utiger, editor of Clinical thyroidology, states that this seems to be a reasonable way to reduce nodules.
Even though the nodules did not disappear, they decreased enough to reduce symptoms and appearance problems. Usually symptomatic nodules were referred to surgery, but now this is a reasonable alternative.
Clinical thyroidologists will be offering this in the near future. Check www.thyroidologists.com to see if any are offering this now.
Dr.G.
The results:
The median volume decreased from 8.2 to 4.8 ml, while the volume increased from 7.5 to 9.0 ml in the untreated patients. A 44% reduction. The controls increased 9 %. There was a 53% difference between the two groups at 6 months. 7/15 in the laser group had neck pain, or tenderness for up to seven days. However, all would have the therapy again if needed. No serious complications occurred, such as vocal cord paralysis. 13/15 laser group patients had pressure symptoms before, and 10/13 had marked relief after the therapy. Cosmetic symptoms also decreased. There was no change in symptoms in the control group, even though the size increased an average of 9%.
Hegedus et al Eur J Endocrol 2005; 152:341-5
Dr Robert Utiger, editor of Clinical thyroidology, states that this seems to be a reasonable way to reduce nodules.
Even though the nodules did not disappear, they decreased enough to reduce symptoms and appearance problems. Usually symptomatic nodules were referred to surgery, but now this is a reasonable alternative.
Clinical thyroidologists will be offering this in the near future. Check www.thyroidologists.com to see if any are offering this now.
Dr.G.
Recurrent Thyroid Cysts Surgery or PEI
The standard therapy for a benign recurrent thyroid cyst is to remove it at surgery.
However, there are now alternative therapies for recurrent symptomatic thyroid cysts.
The use of alcohol injection, called Percutaneous Ethanol Injection PEI, have been very effective alternative to thyroidectomy. A 5 year study from Italy of 58 patients with cysts found about 90% had volume reduction. Baseline Volume was 13.7 cc, Ethanol injected 7.3 cc.Volume after 5 years was 2.3 cc. There were only 2 recurrences.
PEI is offered at centers around the country. Check www.thyroidologists.com for one near you. Go in for an evaluatuion to see if you are a candidate for this alternative to surgery.
Dr.G.
However, there are now alternative therapies for recurrent symptomatic thyroid cysts.
The use of alcohol injection, called Percutaneous Ethanol Injection PEI, have been very effective alternative to thyroidectomy. A 5 year study from Italy of 58 patients with cysts found about 90% had volume reduction. Baseline Volume was 13.7 cc, Ethanol injected 7.3 cc.Volume after 5 years was 2.3 cc. There were only 2 recurrences.
PEI is offered at centers around the country. Check www.thyroidologists.com for one near you. Go in for an evaluatuion to see if you are a candidate for this alternative to surgery.
Dr.G.
Friday, September 23, 2005
Thursday, September 22, 2005
30 Year Follow Up of Toxic Psychosis Secondary to Hyperthyroid Graves' disease
63 Y/O Female returns for her yearly examination, S/P subtotal thyroidectomy 30 years ago, for Graves' hyperthyroidism, on T4 replacement therapy. Her story is amazing.
At age 33 she had a 50 pound weight loss, and severe anxiety to the point of admission for psychosis. While being treated on the Psych ward, a total T4 was drawn and was 20. n 4.2-12.
She was paranoid, and stated 3 men broke into her house. One of them was a well known
actor. People were talking about her outside her window all night. She was mad all the time, and lost her temper, and could not work. Her employer stated she was a very normal employee for 10 years with no sick days. She had other Sx of hyperthyroidism, such as tremo.. Smooth soft skin, muscle weakness, sweats, and palpitations. There was no FH of thyroid disease, but her dad killed himself after returning from army combat.
I saw her 10 days after admission, and she had a dull stare, drooling from the mouth, and a coarse tremor. She had smooth soft skin, pulse of 136, and a diffuse smooth goiter 2-3 times normal size.
She was on large doses of Thorazine. She was under the care of a conservator due to her acute
mental illness. She was considered an endocrine emergency, and under Inderal blockade, she had an uneventful total thyroidectomy. She was kept on Thorazine for 6 week post surgery, became euthyroid and was never treated again for mental illness.Not even a tranquilizer, for 30 years! She had a recurrence of hyperthyroidism 3 years later, that was treated with radioiodine, but there was no flare up of mental illness. She return to her job, and has spent the last 30 years mentally "normal".
She had examinations by experts in mental illness after her recovery, and they found no abnormal thought processes. I have seen her twice a year since 1976, and she is a very normal lady.
Dr.G.
At age 33 she had a 50 pound weight loss, and severe anxiety to the point of admission for psychosis. While being treated on the Psych ward, a total T4 was drawn and was 20. n 4.2-12.
She was paranoid, and stated 3 men broke into her house. One of them was a well known
actor. People were talking about her outside her window all night. She was mad all the time, and lost her temper, and could not work. Her employer stated she was a very normal employee for 10 years with no sick days. She had other Sx of hyperthyroidism, such as tremo.. Smooth soft skin, muscle weakness, sweats, and palpitations. There was no FH of thyroid disease, but her dad killed himself after returning from army combat.
I saw her 10 days after admission, and she had a dull stare, drooling from the mouth, and a coarse tremor. She had smooth soft skin, pulse of 136, and a diffuse smooth goiter 2-3 times normal size.
She was on large doses of Thorazine. She was under the care of a conservator due to her acute
mental illness. She was considered an endocrine emergency, and under Inderal blockade, she had an uneventful total thyroidectomy. She was kept on Thorazine for 6 week post surgery, became euthyroid and was never treated again for mental illness.Not even a tranquilizer, for 30 years! She had a recurrence of hyperthyroidism 3 years later, that was treated with radioiodine, but there was no flare up of mental illness. She return to her job, and has spent the last 30 years mentally "normal".
She had examinations by experts in mental illness after her recovery, and they found no abnormal thought processes. I have seen her twice a year since 1976, and she is a very normal lady.
Dr.G.
Thursday, September 08, 2005
Tango and Thyroid
Well, I am off to Argentina in October to learn the tango, and have one of my thyroid cancer studies presented as an oral presentation at the International Thyroid Congress.
The LAC/Keck/USC Thyroid Cancer Group has a paper on the cancer marker thyroglobulin, TG. The study will look at the value of improved TG sensitivity in the long term followup of well differentiated papillary thyroid cancer.Some of our members are Carole Spencer, John Lopresti,and Peter Singer. On the way back, I stop in Dallas to attend the AACE's New advances in the use of Ultrasound for thyroid. This will include interventional ultrasound techniques.
Dr.G.
The LAC/Keck/USC Thyroid Cancer Group has a paper on the cancer marker thyroglobulin, TG. The study will look at the value of improved TG sensitivity in the long term followup of well differentiated papillary thyroid cancer.Some of our members are Carole Spencer, John Lopresti,and Peter Singer. On the way back, I stop in Dallas to attend the AACE's New advances in the use of Ultrasound for thyroid. This will include interventional ultrasound techniques.
Dr.G.
Wednesday, September 07, 2005
Thyroid Cancer Occuring with Graves' Disease. Is it More Aggressive?
At LAC/USC Thyroid Conference, a patient was presented and discussed, who had papillary thyroid Cancer and newly diagnosed Graves' Disease with hyperthyroidism. A paper from Italy was presented, and it claimed that the cancers were more aggressive in Graves' patients. I discussed my experience with this rare combination. My 5 cases were not more aggressive than the typical papillary cancer. No one of the experts present had more than one or two cases to talk about.Prior studies have not always agreed with the more aggressive concept.
What can you do to make sure your Graves' patient does not harbor a rare cancer as well?
Any palpable nodule needs ultrasound, I/123 imaging for cold nodules, and possible FNA biopsy. Ultrasound will find any non-palpable significant nodules, and it can help guide the needle into the mass.Significant nodules would be hypoechoic, irregular borders, vascular, and micro-calcifications. If the biopsy is suspicious or positive for cancer, than surgery will be the ideal therapy for both diseases. A rare medical "two for one". After a 4-6 week course of anti-thyroid drug therapy total thyroidectomy needs to be done.
Dr.G.
What can you do to make sure your Graves' patient does not harbor a rare cancer as well?
Any palpable nodule needs ultrasound, I/123 imaging for cold nodules, and possible FNA biopsy. Ultrasound will find any non-palpable significant nodules, and it can help guide the needle into the mass.Significant nodules would be hypoechoic, irregular borders, vascular, and micro-calcifications. If the biopsy is suspicious or positive for cancer, than surgery will be the ideal therapy for both diseases. A rare medical "two for one". After a 4-6 week course of anti-thyroid drug therapy total thyroidectomy needs to be done.
Dr.G.
Tuesday, September 06, 2005
Thyroid Nodular Goiter in a Horse:Is it Cancer, or Just Too Much or Too Little Iodine?
I have treated two horses in my life with thyroid disease. In 1972, a physician friend ask me to look at her horse. It had recently been purchased, and was noted on arrival to have an enlarged thyroid gland. I felt a 3-4 times enlarged nodular goiter.The blood testing of T4 was very low. I first thought the horse was hypothyroid, but after consultation with vet endocrine experts, I was told the horse's total T4 thyroid blood test will seem low by human standards, but the free T4 will be normal. The most likely cause was either a benign tumor, or enlargement secondary to either excess iodine in supplements, or iodine deficiency. There was no use of iodine supplements, so I diagnosed iodine deficiency.
Iodine salt lick was added to the horses diet, and the goiter markedly reduced in size.
The second horse had a large nodule, and after ultrasound studies , it was not consistent with a follicular tumor which is common in horses, but was more likely to be part of a diffuse goiter with a nodule. This time the owner did use kelp supplements,
which contained large amounts of iodine. Fortunately, with removal of the kelp, the nodular goiter reduced in size. Cancer of the thyroid is rare in horses.
Even horses can develop a goiter from excess or deficient iodine in their diet.
Humans in the USA, have a higher chance to develop excess iodine goiter from supplements, as iodine deficiency is rare in the USA.
My daughter's horse, Casey, does not have a goiter, thank God, or I would have had to treat my third horse in 31 years!
I will stick to human thyroid disease, as horses can not tell me what bothers them.
Dr.G.
Iodine salt lick was added to the horses diet, and the goiter markedly reduced in size.
The second horse had a large nodule, and after ultrasound studies , it was not consistent with a follicular tumor which is common in horses, but was more likely to be part of a diffuse goiter with a nodule. This time the owner did use kelp supplements,
which contained large amounts of iodine. Fortunately, with removal of the kelp, the nodular goiter reduced in size. Cancer of the thyroid is rare in horses.
Even horses can develop a goiter from excess or deficient iodine in their diet.
Humans in the USA, have a higher chance to develop excess iodine goiter from supplements, as iodine deficiency is rare in the USA.
My daughter's horse, Casey, does not have a goiter, thank God, or I would have had to treat my third horse in 31 years!
I will stick to human thyroid disease, as horses can not tell me what bothers them.
Dr.G.
Saturday, September 03, 2005
Free Questions Answered By "Ask the Thyroid Doctor", for Katrina, and Flood Victims
Any thyroid patients in the New Orleans, Mississippi, or Alabama areas, who are displaced and wondering about the status of their thyroid condition, or about thyroid medications they are taking, you can get answers from The Thyroid Home Page. Just bypass the usual pay site that includes Paypal credit card section, and go to my thyroid.com email address: dr.guttler@thyroid.com. Be sure to state you are a Katrina victim, as there is usual fee of $35 for all others, at the official "Ask The Thyroid Doctor" site on www.thyroid.com.
Here is a two thyroid patient points to remember:
1. The thyroid hormone used to treat hypothyroidism is not an emergency hormone. You have several weeks to get a new supply, without serious effects.
2. However, the drugs used to treat hyperthyroidism such as Graves' Disease have a short life in your body.Tapazole has an 8 hour half life, and PTU is even shorter. This means your condition will worsen after 1-2 weeks. If you are taking one of these drugs, please notify the nearest medical facilities you come to, that you need this drug refilled, if you lost them in the storm surge, or flood.
The Ask The Thyroid Doctor service has helped many thyroid patients get help all over the world. We want to help you. Please email me if you need thyroid help.
God Bless you all,
Dr.G.
Here is a two thyroid patient points to remember:
1. The thyroid hormone used to treat hypothyroidism is not an emergency hormone. You have several weeks to get a new supply, without serious effects.
2. However, the drugs used to treat hyperthyroidism such as Graves' Disease have a short life in your body.Tapazole has an 8 hour half life, and PTU is even shorter. This means your condition will worsen after 1-2 weeks. If you are taking one of these drugs, please notify the nearest medical facilities you come to, that you need this drug refilled, if you lost them in the storm surge, or flood.
The Ask The Thyroid Doctor service has helped many thyroid patients get help all over the world. We want to help you. Please email me if you need thyroid help.
God Bless you all,
Dr.G.
Anaplastic Thyroid Cancer Claims Chief Justice Rehnquist
September 3, 2005, After a 10 month battle with the most
aggressive form of thyroid cancer, he has passed away at home. The patients with his cancer usually live 3-6 months, but he battled the cancer for 10 months. He swore in the president for a second term. He continued on the court , when lesser men would have resigned. In October, we in the thyroid medical field predicted he had this lethal form of thyroid cancer. He did not have his thyroid removed, but only had a a hole put into his air-pipe to breath. This was the major clue he did not have much time left. He was able to continue to vote on cases before the court, and with difficulty swore in President Bush. He lived to see his clerk, Roberts nominated to the court.
He outlived every one of my own cases of anaplastic thyroid cancer, by 4 months! He was a brave man with a mission, and even a thyroid death sentence did not stop him, from achieving his last goals. No matter what your political goals for the new court, we need to salute his brave, and classy exit.
Bravo to the Chief
Dr.G.
aggressive form of thyroid cancer, he has passed away at home. The patients with his cancer usually live 3-6 months, but he battled the cancer for 10 months. He swore in the president for a second term. He continued on the court , when lesser men would have resigned. In October, we in the thyroid medical field predicted he had this lethal form of thyroid cancer. He did not have his thyroid removed, but only had a a hole put into his air-pipe to breath. This was the major clue he did not have much time left. He was able to continue to vote on cases before the court, and with difficulty swore in President Bush. He lived to see his clerk, Roberts nominated to the court.
He outlived every one of my own cases of anaplastic thyroid cancer, by 4 months! He was a brave man with a mission, and even a thyroid death sentence did not stop him, from achieving his last goals. No matter what your political goals for the new court, we need to salute his brave, and classy exit.
Bravo to the Chief
Dr.G.
Thursday, August 11, 2005
Monday, August 08, 2005
Iodine from Large Amounts of Kelp Causes Goiter Progression in a Young Lady
36 year old female is seen in consultation for goiter, referred by her family physician. Prior work up included an FNA that was read as colloid goiter. Ultrasounds have shown progressive enlargement. There is a family hx of goiter in a sibling.
She as a history of ingesting a large amount of iodine containing supplements. She eats seaweed, kelp, and powdered seaweed at each meal. Bilateral nodular goiter is noted on neck examination. TFT's were borderline with TSH of 2.8 N 0.4-2.5,FT4 0.89 N 0.8-2.0 FT3 2.6 N 1.9-5.1 TG 154, TPO <10.1 TG AB <1,0. 24 hour urine free iodine was 3002 mcgs N 100-400.
The excessive use of iodine containing products such as seaweed will cause progressive thyroid enlargement as in this case.It can cause hypothyroidism in patients with autoimmune thyroid disorders, such as Hashimoto's thyroiditis. Non-toxic goiters can become toxic goiters. Even a normal thyroid that has 1/2 left after lobectomy may fail under the pressure of high dose iodine supplements.
Dr.G.
She as a history of ingesting a large amount of iodine containing supplements. She eats seaweed, kelp, and powdered seaweed at each meal. Bilateral nodular goiter is noted on neck examination. TFT's were borderline with TSH of 2.8 N 0.4-2.5,FT4 0.89 N 0.8-2.0 FT3 2.6 N 1.9-5.1 TG 154, TPO <10.1 TG AB <1,0. 24 hour urine free iodine was 3002 mcgs N 100-400.
The excessive use of iodine containing products such as seaweed will cause progressive thyroid enlargement as in this case.It can cause hypothyroidism in patients with autoimmune thyroid disorders, such as Hashimoto's thyroiditis. Non-toxic goiters can become toxic goiters. Even a normal thyroid that has 1/2 left after lobectomy may fail under the pressure of high dose iodine supplements.
Dr.G.
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