47 Y/O female has biochemical hyperparathyroidism. She saw me for evaluation of a thyroid nodule. While doing the ultrasound with high frequency probe, a 10 mm mass was seen in the area of the upper pole parathyroid, posterior and medial to the thyroid on the left. The thyroid
gland had positive antibodies and a USGFNA biopsy of the thyroid nodule confirmed Hashimoto's Thyroiditis. The suspicious parathyroid mass on the left with central polor artery
seen on power Doppler, was biopsied and had a thyroid follicular neoplasia pattern. Microfollicular without background colloid. The PTH washing from the mass is pending, However, the Calcium before the biopsy was 10.5, and one hour post biopsy was 7.9. It appears that the biopsy has necrosed the adenoma. There are reports of this happening after a biopsy. There have been attempts to do this in elderly patients who are not surgucal candidates. One 90 Y/O had Calcium of 12.5 , and the thyroidologist spent a few extra passes to try to infarct the adenoma. The calcium dropped to normal, and stayed normal until she died from other causes. We will check my patient to see if the Calcium stays normal. Ethanol injection, which is so successful for thyroid cysts has not been able to cure parathyroid nadenomas.
What does it mean?
In some patients a biopsy of a suspect parathyroid adenoma, may cure them, rather than just locate the specific abnormal gland for the surgeon.
Come to see me to locate the adenoma before you have surgery.
We may, even if unlikely, cure you!
Dr.G.
Sunday, May 28, 2006
Friday, May 12, 2006
Rare Central Hypothyroidism, But What is the Cause?
The male patient from an endemic goiter area of eastern Europe, sees me for a goiter.
The goiter is multinodular, but no Ultrasound suspicious nodules, and all below 10 mm.
No history of radiation exposure.
He is thin, and has muscle weakness. He complains of fatigue. His wife states he has had decreased libido since 1 1/2 years ago.
He has a multinodular goiter, and a BP 100/70. Normal pubic and axillary hair.
Normal male genitalia.
Prior testing 1, and 2 years ago by an internist had euthyroid FT4I and TSH, but lower
level Testosterone with low FSH/LH . a prolactin was also normal. He had a low normal repeat Testosterone one year ago.
FT4 0.6 TSH 2.9 Free T4 by dialysis 0.6.
Repeat FT4 0.3 TSH 0.69
The Head MR revealed a pituitary tumor. This non-cancerous tumor is replacing the normal pituitary gland. It is 3 cm in size. It is the cause of a rare cause of hypothyroidism.
Secondary hypothyroidism due to pituitary failure, caused by the tumor compressing the normal gland, and causing decreased TSH secretion. The patient is on the way to consultations to determine what the best therapy is for his tumor.
It is rare to see this , but the clues are low T4 with inapproprate normal TSH.
The free T4 by dialysis confirmed hypothyroidism, and the failure to see a rise in TSH as is usual with primary thyroid failure, was a major clue. The clincher was the wife's statement he had recent onset of decreased libido.
Also he had sexual problems and flabby muscle and weakness.
Beware of abnormal thyroid tests that do not match.
Get help from an expert.
www.thyroidologists.com
The goiter is multinodular, but no Ultrasound suspicious nodules, and all below 10 mm.
No history of radiation exposure.
He is thin, and has muscle weakness. He complains of fatigue. His wife states he has had decreased libido since 1 1/2 years ago.
He has a multinodular goiter, and a BP 100/70. Normal pubic and axillary hair.
Normal male genitalia.
Prior testing 1, and 2 years ago by an internist had euthyroid FT4I and TSH, but lower
level Testosterone with low FSH/LH . a prolactin was also normal. He had a low normal repeat Testosterone one year ago.
FT4 0.6 TSH 2.9 Free T4 by dialysis 0.6.
Repeat FT4 0.3 TSH 0.69
The Head MR revealed a pituitary tumor. This non-cancerous tumor is replacing the normal pituitary gland. It is 3 cm in size. It is the cause of a rare cause of hypothyroidism.
Secondary hypothyroidism due to pituitary failure, caused by the tumor compressing the normal gland, and causing decreased TSH secretion. The patient is on the way to consultations to determine what the best therapy is for his tumor.
It is rare to see this , but the clues are low T4 with inapproprate normal TSH.
The free T4 by dialysis confirmed hypothyroidism, and the failure to see a rise in TSH as is usual with primary thyroid failure, was a major clue. The clincher was the wife's statement he had recent onset of decreased libido.
Also he had sexual problems and flabby muscle and weakness.
Beware of abnormal thyroid tests that do not match.
Get help from an expert.
www.thyroidologists.com
Wednesday, May 10, 2006
Six Hour Surgery / No Problem??? / Wrong!
I was asked to do a second opinion on a prestige medical center in Chicago. The patient was sent to sugery because of suspicious biopsy result of a thyroid nodule. The patient was told she had normal thyroid tests and a normal gland except for the nodule. Her family sat out in the waiting room 6 hours! They thought the worst, when they were told the surgery only would take 90-120 minutes. An Endocrine surgeon did the surgery. When she woke up, they told her everything was O.K. She was shocked the surgery was 6 hours long, and they found no cancer, only thyroiditis. She was suspicious because they told there was no abnormality of her thyroid before the surgery. They sent her home on thyroid hormone. She continued to be upset that the surgery was so long, and no cancer was found. She was troubled enough to request I do a virtual second opinion, on thyroid.com. She sent me all the records and the slides from the surgery. After looking at the records, it was clear there was evidence she had Chronic Thyroiditis before the surgery that was missed, because her TSH's were all above 2.5, and she had mildly positive anti-TG antibody. I was just about to tell her the long surgery was due to the severe inflammation that occurs around the thyroid in Hashimoto's thyroidtitis, and not to worry, and all was well, when I looked at the surgical pathology. The pathology department
failed to note a follicular variant of Papillary thyroid cancer. I called the pathologist, and told him what I found. They did recuts, and agreed with my diagnosis. The cancer was nothing to worry about the surgeon told her. Obviously, she had lost all trust in her university physicians, and requested they send me all the recuts. She has an appointment to see me in Los Angeles to go over her opinions now that she knows she has cancer.
It is never to late to have a thyroidologist do a second opinion, even after the surgery! Check www.thyroidologists.com for one of us near you.
Be Proactive.
It is your Thyroid Gland.
Remember, Endocrinologists may be too busy with diabetes to be up to date with all the modern advances in clinical thyroidology. Go to the fountainhead of knowledge
in clinical thyroidology, your local expert clinical thyroidologist.
Be cautious and always get expert help before surgery, or as in this case after the result was smelling very fishy.
Dr.G.
failed to note a follicular variant of Papillary thyroid cancer. I called the pathologist, and told him what I found. They did recuts, and agreed with my diagnosis. The cancer was nothing to worry about the surgeon told her. Obviously, she had lost all trust in her university physicians, and requested they send me all the recuts. She has an appointment to see me in Los Angeles to go over her opinions now that she knows she has cancer.
It is never to late to have a thyroidologist do a second opinion, even after the surgery! Check www.thyroidologists.com for one of us near you.
Be Proactive.
It is your Thyroid Gland.
Remember, Endocrinologists may be too busy with diabetes to be up to date with all the modern advances in clinical thyroidology. Go to the fountainhead of knowledge
in clinical thyroidology, your local expert clinical thyroidologist.
Be cautious and always get expert help before surgery, or as in this case after the result was smelling very fishy.
Dr.G.
Monday, May 08, 2006
Thyroid Nodules: Why the Radiologist's Criteria is Wrong
Terry Davies, editor of the Thyroid Journal, had a word to say about the recent
Radiology consensus conference result on ultrasound for thyroid nodules. He states that consensus means no one agrees.
First, he makes a definitive statement on who should do thyroid ultrasound. "all thyroid ultrasonography should be done in real time by a thyroidologists, where the clinical history, examination, and be combined into a sensible plan."
The second big time comment by Dr Davies was " One thing to be sure of is the days of planting ones expert fingers on the neck and pronouncing the lack of thyroid nodules to the patient is gone".
Third is the fact that he states the disturbing fact that cancer is just as common in multinodular goiter as single nodule or worse. Also the biggest dominant nodule is not always the cancer.
The radiologist when all was said and done fell back on the size as the criteria for FNA. This goes against all logic as cancer starts small.
Dr. Jack Baskin and Dan Duick, clinical thyroidologists, founding members of the Academy of Clinical Thyroidologists, had an editorial which clearly showed the obvious defects of using size as a major criteria. They went as far to say size was irrelevant. The Ultrasound operator has to be experienced in USG/FNA of small nodules.
Finally, for all that are interested go to www.thyroidologists.com for the Academy of Clinical Thyroidologists position paper on US criteria for FNA of thyroid nodules and
suspicious cancer neck lymph nodes. You will find a different answer than the size only by the radiologists.
Dr.G.
Radiology consensus conference result on ultrasound for thyroid nodules. He states that consensus means no one agrees.
First, he makes a definitive statement on who should do thyroid ultrasound. "all thyroid ultrasonography should be done in real time by a thyroidologists, where the clinical history, examination, and be combined into a sensible plan."
The second big time comment by Dr Davies was " One thing to be sure of is the days of planting ones expert fingers on the neck and pronouncing the lack of thyroid nodules to the patient is gone".
Third is the fact that he states the disturbing fact that cancer is just as common in multinodular goiter as single nodule or worse. Also the biggest dominant nodule is not always the cancer.
The radiologist when all was said and done fell back on the size as the criteria for FNA. This goes against all logic as cancer starts small.
Dr. Jack Baskin and Dan Duick, clinical thyroidologists, founding members of the Academy of Clinical Thyroidologists, had an editorial which clearly showed the obvious defects of using size as a major criteria. They went as far to say size was irrelevant. The Ultrasound operator has to be experienced in USG/FNA of small nodules.
Finally, for all that are interested go to www.thyroidologists.com for the Academy of Clinical Thyroidologists position paper on US criteria for FNA of thyroid nodules and
suspicious cancer neck lymph nodes. You will find a different answer than the size only by the radiologists.
Dr.G.
Friday, April 21, 2006
Thursday, April 13, 2006
Who Should Take Care of Your Thyroid Nodule or Cancer?
There has been a big shift in the way thyroid cancer should be treated, and nodules evaluated. Before your primary care physician, referred you for studies, and only when it was obvious it was a nodule or cancer, did they refer you to others. In the past it was felt the obvious referral was to an endocrinologist, even though many PMD's sent you directly to a surgeon. The endocrinologist sent you for an ultrasound at the hospital radiologist's office. He sent you for a scan at the nuclear medicine department, and did a biopsy without ultrasound guidance in the office. The Endocrinologist sent the slides to the hospital for review. Then if the diagnosis was suspicious, atypical, or indeterminate, or frank cancer, he sent you to his local general surgeon. After the surgery, the endocrinologist deferred to the nuclear medicine physician, or the radiologist about the need and extent of radiation therapy. The NM physician almost always recommended Therapy.
The physicians treating you would return you to your primary care, who would monitor your thyroid hormone therapy.
What is wrong with this?
There is defects in the care of the thyroid nodule or cancer patient at each and every phase of this protocol.
1. The PMD should seek expert help ASAP, and not waste time with testing that is not needed or a waste. Feel a lump = refer! The best expert is a clinical thyroidologist, or endocrinologist with certified training in the personal use of ultrasound and nuclear medicine.
2. The PMD, or the patient needs to learn who is available with training in
interventional thyroidology, and refer direct to that physician. The main clue, is the endocrinologist trained in US, and USG biopsy by American College of Endocrinology? Radiologist, and nuclear medicine physicians, with their technicians are not the ones to be doing studies on your patients. The personal hands on clinical thyroidologist, or endocrinologist that is certified by ACE is the right person for your patient.
3. Before sending the patient to surgery, request a second opinion on the pathologist. There is a very wide variation in their ability to read thyroid biopsies. The overuse of a suspicious report, has resulted in too many needless surgeries.Even pathologists will tell you that thyroid is one of the hardest slides to read for them. Beware, and get another opinion.
4. Before surgery, you need to have several things done. First, a pre-op Cancer marker. That is a thyroglobulin TG. Make sure it was drawn BEFORE or 30 after the FNA, as it can be elevated by the trauma of the FNA biopsy.
5. Then, if the biopsy is positive, or very stronly suggestive of cancer, be sure to have a pre-op Lymph node evaluation by ultra-sensitive ultrasound, done by your trusty clinical thyroidologist, or US certified endocrinologist. The finding of abnormal cancer nodes, proven by cytology, and or washings for thyroglobulin will change the extent of the surgery needed 40% of the time.
4. If you are satified that your patient has a high likelyhood of cancer, then research to find the closest thyroid surgeon. A thyroid surgeon is one who dose 50-150 thyroidectomies a year, and certifies that a central compartment node removal will be standard in all his cancer cases. It will be worth a drive or flight to the nearest real expert. Failure to remove the central compartment nodes will result in an increased recurrence rate for years afterward. Finding lateral neck nodes on the pre-op node US will result in a lateral neck node removal at the time of the initial surgery.
5. Post surgery care is not the place to rely on the oncologist, surgeon,radiologist, or nuclear medicine physician. Oncologist treat other cancers, not thyroid cancer, which is a hormonal cancer, best treated by thyroid experts. NM types are still passing out high doses of radiation, and making people sick with thyroid hormone withdrawal for useless total body scans in low risk cases. Radiation is no cure, and can cause solid tumors and blood tumors years later, when it is unnecessary in low risk cases. Yearly bouts of severe symptoms of thyroid withdrawal, to get a total body scan, when they are clearly not needed, in most cancer cases is cruel and unnecessary today. Cancer markers,and Ultrasensitive US done by real thyroid cancer experts is the best way to follow thyroid cancer today.
Careful staging by the thyroidologist will be the first step to decide the extent of the further therapy.
6. The therapy with radiation, and the use of thyroid hormone as "chemotherapy, not just replacement, is and should always be under supervision of the clinical thyroidologist, until there is clear indication that the disease is under control.
That is when the TG is non-detectable on TSH suppression, and in in some expert's hands, stays that way after Thyrogen stimulation ( rh TSH ). TSH must be suppressed until it is clear the patient is safe. It is not O.K. to have a TSH in the normal range, if there is clear evidence of disease, by elevated TG.
7. No one cares more about the status of the cancer, and nodule patients under their care, than a hands on clinical thyroidologist, or a ACE certified US endocrinologist.
8. Failure to seek the new age clinical endocrinologist or thyroidologist may result in future problems for your patients.
Good Luck,
Richard B. Guttler, MD,FACE
President,
Academy of Clinical Thyroidologists
www.thyroidologists.com
Clinical Professor of Medicine
Keck School of Medicine
University of Southern California
Director,
Sanatr Monica Thyroid Center
www.thyroid.com
The physicians treating you would return you to your primary care, who would monitor your thyroid hormone therapy.
What is wrong with this?
There is defects in the care of the thyroid nodule or cancer patient at each and every phase of this protocol.
1. The PMD should seek expert help ASAP, and not waste time with testing that is not needed or a waste. Feel a lump = refer! The best expert is a clinical thyroidologist, or endocrinologist with certified training in the personal use of ultrasound and nuclear medicine.
2. The PMD, or the patient needs to learn who is available with training in
interventional thyroidology, and refer direct to that physician. The main clue, is the endocrinologist trained in US, and USG biopsy by American College of Endocrinology? Radiologist, and nuclear medicine physicians, with their technicians are not the ones to be doing studies on your patients. The personal hands on clinical thyroidologist, or endocrinologist that is certified by ACE is the right person for your patient.
3. Before sending the patient to surgery, request a second opinion on the pathologist. There is a very wide variation in their ability to read thyroid biopsies. The overuse of a suspicious report, has resulted in too many needless surgeries.Even pathologists will tell you that thyroid is one of the hardest slides to read for them. Beware, and get another opinion.
4. Before surgery, you need to have several things done. First, a pre-op Cancer marker. That is a thyroglobulin TG. Make sure it was drawn BEFORE or 30 after the FNA, as it can be elevated by the trauma of the FNA biopsy.
5. Then, if the biopsy is positive, or very stronly suggestive of cancer, be sure to have a pre-op Lymph node evaluation by ultra-sensitive ultrasound, done by your trusty clinical thyroidologist, or US certified endocrinologist. The finding of abnormal cancer nodes, proven by cytology, and or washings for thyroglobulin will change the extent of the surgery needed 40% of the time.
4. If you are satified that your patient has a high likelyhood of cancer, then research to find the closest thyroid surgeon. A thyroid surgeon is one who dose 50-150 thyroidectomies a year, and certifies that a central compartment node removal will be standard in all his cancer cases. It will be worth a drive or flight to the nearest real expert. Failure to remove the central compartment nodes will result in an increased recurrence rate for years afterward. Finding lateral neck nodes on the pre-op node US will result in a lateral neck node removal at the time of the initial surgery.
5. Post surgery care is not the place to rely on the oncologist, surgeon,radiologist, or nuclear medicine physician. Oncologist treat other cancers, not thyroid cancer, which is a hormonal cancer, best treated by thyroid experts. NM types are still passing out high doses of radiation, and making people sick with thyroid hormone withdrawal for useless total body scans in low risk cases. Radiation is no cure, and can cause solid tumors and blood tumors years later, when it is unnecessary in low risk cases. Yearly bouts of severe symptoms of thyroid withdrawal, to get a total body scan, when they are clearly not needed, in most cancer cases is cruel and unnecessary today. Cancer markers,and Ultrasensitive US done by real thyroid cancer experts is the best way to follow thyroid cancer today.
Careful staging by the thyroidologist will be the first step to decide the extent of the further therapy.
6. The therapy with radiation, and the use of thyroid hormone as "chemotherapy, not just replacement, is and should always be under supervision of the clinical thyroidologist, until there is clear indication that the disease is under control.
That is when the TG is non-detectable on TSH suppression, and in in some expert's hands, stays that way after Thyrogen stimulation ( rh TSH ). TSH must be suppressed until it is clear the patient is safe. It is not O.K. to have a TSH in the normal range, if there is clear evidence of disease, by elevated TG.
7. No one cares more about the status of the cancer, and nodule patients under their care, than a hands on clinical thyroidologist, or a ACE certified US endocrinologist.
8. Failure to seek the new age clinical endocrinologist or thyroidologist may result in future problems for your patients.
Good Luck,
Richard B. Guttler, MD,FACE
President,
Academy of Clinical Thyroidologists
www.thyroidologists.com
Clinical Professor of Medicine
Keck School of Medicine
University of Southern California
Director,
Sanatr Monica Thyroid Center
www.thyroid.com
Saturday, April 01, 2006
The Return of TRH / Another Scam?
The TRH Stimulation test was the best way to look at accurate assessment of thyroid
function for 20 years. This was because the TSH was not accurate in the low range.
The TSH presently used by most labs,is able to read very low TSH values. I used TRH testing until the baseline TSH was able to replace the TRH Stimulation test. The TRH Stimulation Test is never used by experts anymore except for rare pituitary or hypothalmic disorders. There is no need for it now that it's value as a sensitive testing agent has been replaced by a newer, better baseline TSH.
The drug disappeared from sight. The Drug company that makes it does not even mention it on it's USA, or world website. The company is in the UK.
Mary Shomon of about.thyroid.com, in her article "The Return of TRH Stimulation Test", showcases a physician of unknown credentials, who states every physician needs to know how to do this test. Mary does not know that this test was found to be unnecessary in our modern world. TRH is similar to museum quality drugs such desicated thyroid. They have served their purpose well, but are outdated and not needed anymore.Please ask Mary, or the physician who wants to test you with TRH, why the drug company does not plaster ads all over the TV, with this exciting breakthrough! This is another example why smart patients will learn to live without reporting of this quality by MS.
Mary, as usual you are wrong again.
I will only comment on her site when she really tries to pull a fast one on thyroid patients.
Dr.G.
function for 20 years. This was because the TSH was not accurate in the low range.
The TSH presently used by most labs,is able to read very low TSH values. I used TRH testing until the baseline TSH was able to replace the TRH Stimulation test. The TRH Stimulation Test is never used by experts anymore except for rare pituitary or hypothalmic disorders. There is no need for it now that it's value as a sensitive testing agent has been replaced by a newer, better baseline TSH.
The drug disappeared from sight. The Drug company that makes it does not even mention it on it's USA, or world website. The company is in the UK.
Mary Shomon of about.thyroid.com, in her article "The Return of TRH Stimulation Test", showcases a physician of unknown credentials, who states every physician needs to know how to do this test. Mary does not know that this test was found to be unnecessary in our modern world. TRH is similar to museum quality drugs such desicated thyroid. They have served their purpose well, but are outdated and not needed anymore.Please ask Mary, or the physician who wants to test you with TRH, why the drug company does not plaster ads all over the TV, with this exciting breakthrough! This is another example why smart patients will learn to live without reporting of this quality by MS.
Mary, as usual you are wrong again.
I will only comment on her site when she really tries to pull a fast one on thyroid patients.
Dr.G.
Thursday, March 23, 2006
Why a Thyroid Scan can save you from Unnecessary surgery
A 65 Y/O F patient was referred for biopsy for a 2.5 cm nodule.
She came from Cleveland on the Great Lakes, a known goiter area in the past from iodine deficiency. The ultrasound was eu-echioc, with significant 2 vessel blood penetration. She was told that benign nodules can have significant blood flow. She was not excited to be biopsied unless absolutely necessary. Even though the ATA guidelines call for biopsy, I elected to scan her first. The thyroid experts feel that if the TSH is normal you won't find a hot nodule on scan. Well her TSH was normal at 0.89.
She had increased uptake in the nodule with decrease in the rest of the gland. There were no nodules in the opposite lobe. I told her she had a hot nodule.It was not toxic yet, but was going in that direction. We talked about surgery, Radioiodine, or observation therapy. I told her it was not cancer, and she did not need a biopsy.Hot nodules are never cancer. She elected to be treated with radioiodine in the next few weeks.
We are too needle happy in the pursuit of cancer, when only 5 % of all nodules are cancer.
The longer I practice thyroidology, the less needle happy I have become.
We need to look at the whole patient and try to stop excessive surgery.
Dr.G.
She came from Cleveland on the Great Lakes, a known goiter area in the past from iodine deficiency. The ultrasound was eu-echioc, with significant 2 vessel blood penetration. She was told that benign nodules can have significant blood flow. She was not excited to be biopsied unless absolutely necessary. Even though the ATA guidelines call for biopsy, I elected to scan her first. The thyroid experts feel that if the TSH is normal you won't find a hot nodule on scan. Well her TSH was normal at 0.89.
She had increased uptake in the nodule with decrease in the rest of the gland. There were no nodules in the opposite lobe. I told her she had a hot nodule.It was not toxic yet, but was going in that direction. We talked about surgery, Radioiodine, or observation therapy. I told her it was not cancer, and she did not need a biopsy.Hot nodules are never cancer. She elected to be treated with radioiodine in the next few weeks.
We are too needle happy in the pursuit of cancer, when only 5 % of all nodules are cancer.
The longer I practice thyroidology, the less needle happy I have become.
We need to look at the whole patient and try to stop excessive surgery.
Dr.G.
Monday, February 13, 2006
The Thyroid Biopsy Report. Why it is a Big Problem for Those with a Nodule, or The Pathologists are either The Good, the Bad or the Ugly
When your doctor tells you the report from the thyroid biopsy was atypical, suspicious, and recommends a surgery, what do you do next? Well, the answer will not be, see a surgeon. Why not? Because the reading of your biopsy is a very difficult thing to do
well for pathologists. It is the hardest thing a pathologist has to do.
If it is hard, then why should you take the result as a fact. Maybe, the pathologist is not sure what you have, and covering his own a.. . Well, there are real thyroid cancer experts out there to help you out of this fix.
Do not consider the surgery recommendation by your doctor, until you get the slides
reviewed by an expert. The best way to assure yourself that the surgery is really needed, is to see a thyroidologist. He will review your slides and help you decide if surgery is needed. Check our website for one. www.thyroidologists.com
Remember, pathologists come in 3 distinct groups.
The Good, the Bad and the Ugly. you want the good ones only!
Your only chance to avoid unnecessary surgery, and complications, is to demand another opinion, before you put your neck on the line at surgery.
Make sure your nodule biopsy is reviewed by the first group, not the last two.
The best approach is to be a Doubting Thomas when they recommend surgery based on a report from pathologists that are trying to read slides from the thyroid gland, when they admit it is their toughest gland to get right.
Remember, 95% of nodules are not cancer, but the bad, and ugly pathologists will send many more for unnecessary surgery, because they do not understand thyroid cytology.
Dr.G.
well for pathologists. It is the hardest thing a pathologist has to do.
If it is hard, then why should you take the result as a fact. Maybe, the pathologist is not sure what you have, and covering his own a.. . Well, there are real thyroid cancer experts out there to help you out of this fix.
Do not consider the surgery recommendation by your doctor, until you get the slides
reviewed by an expert. The best way to assure yourself that the surgery is really needed, is to see a thyroidologist. He will review your slides and help you decide if surgery is needed. Check our website for one. www.thyroidologists.com
Remember, pathologists come in 3 distinct groups.
The Good, the Bad and the Ugly. you want the good ones only!
Your only chance to avoid unnecessary surgery, and complications, is to demand another opinion, before you put your neck on the line at surgery.
Make sure your nodule biopsy is reviewed by the first group, not the last two.
The best approach is to be a Doubting Thomas when they recommend surgery based on a report from pathologists that are trying to read slides from the thyroid gland, when they admit it is their toughest gland to get right.
Remember, 95% of nodules are not cancer, but the bad, and ugly pathologists will send many more for unnecessary surgery, because they do not understand thyroid cytology.
Dr.G.
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.
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