Thyroid.About.Com, the Source for Dangerous Thyroid Information has Done it Again. Now You Don't Need an Endocrinologist at All!

The about.thyroid.com website, for alternative medical information has reached a new low. Patients with thyroid disease should NOT see an endocrinologist or thyroidologist. The post claims that "thyroid friendly" alternative types will listen to the patient and give them therapy based on symptoms, rather than hard thyroid hormone blood studies. The patients with cancer or needing radiation for Graves' disease are the exception, and need to see a thyroidologist. This is a very way out idea. Here is why. First, hypothyroid patients need to see a specialist at the first sign of disease. The careful examination of the neck by an expert will be able to feel a firm nodular surface of an early Hashimoto's thyroiditis. That will trigger an ultrasound. The ultrasound done real time by the endocrinologist could reveal a cancer nodule, goiter,or nodular goiter years before it can be troublesome to the patient. Waiting until the patient has cancer,or nodules that can result in a surgery is a poor concept,and is the major reason not to consider anyone other than an endocrinologist. Every patient with subclinical hypothyroidism with TSH >3.0 and slowly climbing yearly needs to see an endocrinologist,or thyroidologist PERIOD. Hashimoto's thyroiditis with progressively increasing TSH from 2.5 to 10 over 10-20 years, or has positive antibodies needs a complete endocrine/thyroid evaluation. TSH is a risk factor for thyroid cancer in patients with Hashimoto's thyroiditis.
Also TSH causes nodules to grow that are not cancer but look bad on a thyroid biopsy, and can result is surgery.Early detection of Hashimoto's can save surgeries and find cancer when it is small and curable. Also, in 35 years of practice,I have seen goiters melt away, and the antibodies disappear on T4 therapy. The disease will destroy the thyroid if you prevent the regrowth due to TSH. Failure to visit an endocrinologist to get an early diagnosis of possible troubles is a major mistake that will happen to some of those who read the posts on thyroid.about.com. Finally, that leaves only the few percent of all thyroid patients who are still complaining about symptoms when their T4, and TSH are normal, to seek those physicians, that prey on the patients ignorance and give them Armour, T3, Combo T4/T3, and compounded products, to treat symptoms totally unrelated to the thyroid disease. The impossible dream is that just treating thyroid problems will correct all the symptoms the patient have. That is not only a dream, but a pipe dream. They may feel better for a while due to the effect of T3 on the brain, but will suffer in the long run.

I challenge the website managers to allow comments, without deleting those that have a contrary opinion to it's alternative views. My comments given here in my last few blogs were sent as comments to the website. They were clearly received, but disappeared by the next day. The only comments that were allowed to appear were the "yes, I agree" type. The alternative thyroid audience will not like what I have to say, but there will be a few among them that will rethink their position.
Good Luck,
Dr.G.

A German Story of a Failed Treatment Plan for a Radiation Exposured Patient With a Toxic Nodule, and the Negative Long Term Effect on HER.

A 45 Y/O female presented to my center with a thyroid nodule. The history was positive for radiation therapy for a skin problem as a child in Germany. At age 30 she had symptoms of hyperthyroidism, and was diagnosed with a single toxic nodule by thyroid uptake and scan. The endocrinologist in Berlin referred her to a surgeon, who did a lobectomy removing only the lobe with the toxic nodule. 15 years later is when she arrived at my doorstep after a CT scan, done for another unrelated problem revealed a mass in the thyroid. A large scar over the left side of her neck was secondary to the childhood irradiation. A palpable mass was noted in the right lobe. The scar from the surgery was located over the other lobe area that was removed in Berlin. Her thyroid blood tests were normal, but the high frequency ultrasound was abnormal. There was a large nodule in the right lobe, but there were 10 nodules in all ranging in size from 3-10 mm. The left lobe was also enlarged and had nodules as well. Did the surgeon do a nodule removal only or was this regrowth? The ultrasound guided FNA of all nodules > 5 mm were benign. The patients problems began when the Berlin endocrinologist and the surgeon failed to factor in the radiation history in the surgery plan for the toxic nodule. The radiation history should have been the reason to do a total thyroidectomy to remove at risk thyroid tissue along with the toxic nodule. This would have removed the risk of cancer in the future, and would have prevented the progression of her goiter to the point that now she will need careful ultrasound and blood monitoring for the rest of her life. Any one of the nodules that were not biopsied could be a cancer, and if they grow another round of biopsies will be needed. The endocrinologists should have known that patients in their area have a high incidence of iodine deficient goiters. That toxic nodules arise out of those glands. Also that needed to remember that radiation therapy for benign conditions of the head and neck causes goiters, nodules, benign and malignant tumors. Her life would have been simple if they did a total as recommended, and simple thyroid blood T4, and TSH, would have been the only followup needed. Instead she will need yearly ultrasounds to follow the massive number of nodules that are present,or go in for another surgery now.
I wish her luck in the future,

Dr.G.

Mary Shomon, and the Medical Review Board of about.thyroid.com, on their Opinion on the Top Thyroid Websites: Pros and Cons

The last newsletter from Mary Shomon has her company's opinion on the top thyroid websites. I am honored to be listed alongside the Endocrine Society, and the American Thyroid Association. She has cleverly added a medical review board, since her last top websites list, probably paid by her corporation, which has 12 physicians, who are evaluating the top sites. It should be noted that not a single endocrinologists is on the panel. The way Mary Shomon and her bosses treat top level endocrinologists, as bag men and women for the drug companies, there is no wonder why she can not get a real qualified expert clinical endocrinologist to be on the panel. Headed by an internist, and without a single physician board certification in endocrinology among them, they are asked to judge the top thyroid websites. The last "top" site they reviewed was her own site, about.thyroid.com. That shows the panel's level of objectivity. The panel appears to be just a rubber stamp for all the slanted views presented on their website. What was the review panel doing allowing Mary to blow her own horn, calling it a a top site. Not only did she include about.thyroid.com on the list of top sites, but plugged her book, Living Well with Hypothyroidism, and even worse plugged another of her books on an unrelated subject. The panel mentioned the slanted, and biased qualities of the other top sites toward evidenced based conventional medicine, because of corporate money funding the sites, but failed to mention that Mary's site was extremely outside the range of objective thyroid medical opinion. There was no mention that this approach was considered by the vast majority of physicians and patients to be beyond any reasonable credible concepts of thyroid patient care. The problem with The American Thyroid Association website, was according to the panel that it was in the pocket of drug companies, that is why they only mentioned mainstream medicine, and did not cater to alternative medicine. Similar knocks on other top thyroid sites, such as the Endocrine Society, were made by the panel. Finally, let me look at the comments made about my site, Thyroid.com, which was founded by me personally in 1997. This was the first private thyroid website, and except for a short partnering deal with Amazon, we have never accepted ads. Most endocrinologists and clinical thyroidologists will not waste their breath to respond to things listed on her website as it is considered a "way out" site. Let me take a moment to respond to the inaccurate comments made about my site.
1. The concept of virtual second opinions on the web did not start with me. Her site stated that I charge excessive fees for those opinions. The Cleveland Clinic had one before me and charged more than I do. A fee of $400-500 to review all the records, actual thyroid scans, ultrasounds, pathology materials and give the patient valuable advice is not excessive. 2. The few complaints they said they received are out of thousands of thyroid patients I have treated in 35 years. The patients who are unhappy with me are the ones who are told they are properly treated and need to look elsewhere for the cause of their symptoms. I am not an internist, or even an endocrinologist, but a clinical thyroidologist. I refer them to others but many insist, after reading the slanted stories on about.thyroid.com, that it is the thyroid causing the symptoms and I, as a mainstream physician, am not treating the symptoms only the numbers. 3. My Blog, www.thyroid.blogspot.com, is my personal diary about my experiences in 35 years practicing in the thyroid field. I do not have a paid corporate spell checker or any Grey Flannel Suits with lawyers packed inside them to correct my grammar or tell me not to write things that could hurt the image of the corporation, decrease the ad revenue from the Grapefruit therapy for Graves' disease suppliers and other alternative types. I do not want anyone telling me how to inform by readers. 4. As for bedside manner, I have plenty of that. Name five other endocrine physicians in the country that see thyroid patients 5 days a week, giving me a following of 3-5,000 patients from around the world. 5. As a test, please look at thyroid.com and then look at about.thyroid.com. I think you will see who is full of corporate cash from ads on the site. Why should patients be worried about the educational grants that keep excellent thyroid websites, such as the Endocrine Society, working, but do not also question the funding of about.thyroid.com which takes all comers as long as they have ad dollars to spend. Every page is clean of ads, and no money changes hands to support my website. I have turned down all ad revenue, and refuse to be a paid hack fishing for ads to pay the bills and make a profit for myself. I have turned down 5 figure offers to buy thyroid.com by corporations eager to take it and ruin it. I have refused to sell out to drug companies.

Thank you, and keep looking for excellent endocrinologists, with good records, to care for you.
Good Luck,
Dr.G.

The Brits are Half Right, and Mary Shomon is as Usual All Wrong

The national health service NHS, of the United Kingdom, has banned the use of Armour thyroid, compounded combination thyroid preparations, Cytomel, and other products with anything but LT4 in them for treatment of hypothyroidism for all patients treated by the NHS. This is a good step by the NHS to get rid of these second tier drugs that cause more harm than good. The recent story by Ms. Shomon on about.thyroid.com was off base as usual, and aimed again at the fringe patients who feel they are not "doing well" on T4 alone, even though all the proven tests of T4, and TSH are completely normal. They are not hypothyroid, but are truly not feeling well, but for other reasons, not thyroid. As an expert in thyroid disease for 35 years, I am glad that we are finally seeing the beginning of the end of these drugs. To all the thyroid patients in the NHS, and the USA, do not pay any attention to doomsayers like Ms. Shomon, as she is not a physician, and as a hired gun for a large corporation, has an interest in appealing to the patients who are unhappy with the results of their thyroid therapy, even though it is properly treated with thyroid hormone of the T4 type. However, there are problems with the other part of the NHS guidelines. Although a TSH less than 10 is rarely associated with symptoms, as they correctly state,therefore, therapy for pure hypothyroidism is rarely needed when a TSH is less than 10. However, the problem is more complicated than that. TSH values between 2.5-10 are abnormal,and are associated with other problems than symptomatic hypothyroidism. As the TSH rises there is a increased risk of cancer of the thyroid, nodules, and goiter formation. If the NHS mandates ultrasounds for all patients with elevations of TSH above 2.5 and there is no goiter, or nodules, then follow up without thyroid therapy is reasonable. Also if the patient does not have heart disease or lipid abnormalities, then the use of TSH > 10 is a reasonable choice for symptomatic hypothyroidism for therapy. Remember, by the time the TSH rises it may be already the cause of significant nodule formation,and increased risk of thyroid cancer.
DR.G.

Thyroid Cancer: A Lesson in What Can Go Wrong with Multiple Unnecessary Surgeries

39 Y/O female has a lump found below her right ear. First problem. A excision biopsy was done by an ENT without any ultrasound, or fine needle biopsy. It was papillary thyroid cancer in a level 2 node. The patient was referred to an endocrinologist. He saw the results of the node biopsy, and told her she needed her thyroid out. Problem #2 There was no detailed lymph node mapping done before the referral to the surgeon.Problem #3 The surgeon, even knowing that there was a proven cancer node high up in the neck removed by the ENT, did not include a modified radical neck on the side of the cancerous node removed. Problem #4 When the surgeon took out the thyroid cancer, he was confronted with 3 lateral neck nodes that were next to the thyroid. This was his second chance to do a modified neck on that side, but he decided to take the easy way out and only cherry picked the 3 abnormal nodes. Problem #5 while removing the thyroid with the cancer, he came across 2 very abnormal nodes in the thyroid bed. They were positive for cancer, and again he failed to do the right thing and do a complete central compartment
node removal. Problem #6 After 100 MCI Radioiodine, and a negative whole body scan, she returned with elevated cancer marker, and finally the endocrinologist did an ultrasound lymph node mapping. Surprise, there were more nodes on the side of the twice cherry picked ones. Problem #7 There was no mention of the central compartment, but we already know the surgeon did not do a good job the first time only taking 2 nodes. There was surely more nodes that were crying out to make the surgeon do a central compartment along with the lateral neck. Problem # 8 Our gun shy surgeon, takes out the lateral nodes, but again fails to address the central compartment. Problem #9 She returns to the thyroid challenged endocrinologist, and recommends another dose of RAI/131, even though the last one was negative when she had all that cancer in her neck even before the first surgery. Wow, after 165 MCI I/131, and an increased risk of other cancers in the future, her Whole body scan was negative! Well, finally she had enough, and came to me for a second opinion. Even before I touched her neck, I knew she was still full on cancer nodes, especially in the central compartment, because of incomplete first thyroid surgery. There was a large scar all the way to her ear.
Ultrasound lymph node mapping revealed several abnormal nodes in the thyroid bed.
USGFNA of the biggest one was positive for cancer. Last major problem. After a lymph node excision, a total thyroidectomy with node picking, a lateral neck node surgery, she now needs a 4th surgery to clean out the central thyroid bed. These are the most dangerous, and can only be removed surgically, not with radiation.

What went wrong?
Everything, but the most problematic was the failure to do mapping BEFORE the thyroidectomy. All the nodes would have been located, and in addition to a total thyroidectomy, and central compartment node removal, the lateral neck would have been done. The second problem was the failure to do an FNA on the first node. It would have stopped the first excision surgery, and triggered a extensive investigation of the neck nodes before the first thyroid surgery. Endocrinologists, and Surgeons need to become aware of the crucial role of ultrasound lymph node mapping. 3 surgeries, and a fourth one next week, and all this could have been saved by a careful pre-op evaluation before rushing off the OR. One surgery would have been enough. Finally, the excessive use of radioiodine in a low risk young women, when surgery was needed, put her at risk for other cancers in the future.

Please, get an expert outside opinion before the first surgery.
Remember, not all endocrinologists are experts in modern thyroid cancer therapy.
They are hard working internists and diabetic specialists, and have little time for modern thyroidology.
It can save you many months of morbitity, and unnecessary radiation, and surgeries.

Good Luck,

Dr.G.

Pregnant, But is Your Baby Getting Enough Iodine from Your Prenatals ?

The American Thyroid Association recommends prenatal vitamins with 150 mcg elemental iodine during pregnancy. The Institute of Medicine recommends 220 mcg iodine in pregnancy, and 290 mcg when breast feeding. There is no mandate for U.S. prenatal vitamins to have 150 mcgs of iodine. What does a pregnant women do to insure her baby is getting enough iodine?
The internet listed 127 nonprescription, and 96 prescription brands on the market in the U.S. Only 69% of non-RX brands had iodine listed. Even lower percentage of prescription brands listed iodine. 90% of them with iodine, listed > 150 mcg of iodine. 150 mcg of KI is only 114 of elemental iodine. Kelp based prenatal vitamins had >150 mcg iodine. This labeling is misleading. Researchers at Boston University measured 60 brands of prenatal vitamins for iodine content. The prenatal with KI had 119 mcgs as expected.
However, the kelp based prenatal had 33-610 mcgs of iodine. Over half had content that was different than listed on the label, including 10/25 with low iodine content. Kelp iodine content is variable, and one should stick to potassium iodide KI as the source of their prenatal iodine, not kelp.

Conclusions:
1. 69% of non RX prenatal, and 28% of prescription prenatal vitamins have iodine.
2. Kelp is a poor source of iodine due to variable amounts of iodine.
3. KI based prenatal is more consistent but only have 76% iodine content of the labeled 150 mcg, or 120 mcgs.
4. KI prenatals should be the drug of choice.
5. However future Prenatal vitamins should have 197 mcg KI to get to the recommended 150 mcgs elemental iodine supplement needed during pregnancy, and lactation.

What should the woman do now?

Get KI based Prenatal vitamins, and add a 100 mcg KI pill, to get the extra 80 mcgs you need.

Good Luck with the pregnancy,

Dr.G.

Reference:
Iodine Content of U.S. Prenatal Multivitamins
Leung, et al
American Thyroid Association national meeting abstract #106
Thyroid supplement page S-45
October 3 2008.

Thyroid Nodule Therapy in Patients with Insulin Resistance

Recent studies have shown that patients with high levels of insulin seen in obesity, diabetes, and in thin patients with insulin resistance have a larger thyroid gland by volume studies by ultrasound, and have a significant increased number of nodules.Thyroid vol.18(4),461-164 2008. Obese and non-obese patients with insulin resistance had increased thyroid volumes, compared to obese, and normal patients without elevated insulin levels. Also the number of nodules was increased over controls without excess insulin. Well if increased insulin is a thyroid growth factor as seen in animals studies, and suggested by these data, maybe we need to consider another medical approach to nodule therapy. Well the thyroid group from Argentina has treated patients with the drug metformin to reduce the insulin levels in patients with thyroid nodules. Metformin alone, with T4, T4 alone, and control with no therapy for 6 months. TSH was kept at 0.1-0.9 range,in the treated groups. The metformin dose was 1 gram. The patients were all from an iodine deficient country. The dramatic results were a marked reduction in the nodules with metformin alone, 73%, but this was even better with the addition on T4, 95%. The control without therapy was 26% reduction, and the T4 only was 35%. T4 only just prevented increased growth, but did not decrease nodule volume compared to controls. Insulin and TSH are growth factors for thyroid nodules. The dramatic results in Argentina is partially due to iodine deficiency, and the effects should be less in the USA. However,combination therapy may be worth a try in diabetic, obese patients, or thin patients with proven high insulin levels seen during a 75 gram glucose load test, who have benign thyroid nodules by Ultrasound Guided FNA.
Thanks,
Dr.G.

Reference:
6 th World Congress on Insulin Resistance Syndrome
September 25-27 2008
Los Angeles Ca
Abstract #20
Metformin Treatment of Benign Thyroid nodules in Euthyroid Patients with Insulin Resistance
H. Niepomniszcze et al.

Beware of Generic Substitution of Your Thyroid Hormone Therapy

160 adverse events happened in 2007 from switching sources of thyroid hormone, during an Endocrine Society and American Thyroid Association reported study. The FDA method of determining that different brands of thyroid hormone are equal is seriously flawed.
Thyroid hormone therapy requires fine tuning with TSH as an endpoint. If you get switched,the other thyroid pill may be different enough to cause you harm. The pill you were taking at the time your endocrinologist did the TSH testing should be the one you get from your drug store. If it is not, then you would need a new thyroid test in six weeks to see if this company thyroid hormone is still giving the correct amount by TSH re-testing. This is what needs to be done, and it should not be necessary if you received the same pill your were taking when you were first tested. However, the FDA in it's wisdom, has not allowed the black box warning to be added to the PDR listing of thyroid hormones. Elderly and thyroid cancer patients are most at risk for adverse results do the switching of brands. The elderly have heart problems if the dose is off.
Cancer patients can have regrowth of a dormant cancer if the thyroid hormone is inadequate, or heart problems if it is excessive.

Here is my advice:
1. Until FDA changes it's methods, the patient must be his own best advocate.
2. Demand to receive do not substitute scripts from your physician.
3. Insist on receiving the same company thyroid pill that you were tested on, from the drug store.
4. Look at the pill at the store to see if it is the same shape, color and that the store clearly informs you that it is the same as you were taking when you had the tests in your physicians office.
Good Luck,
Dr.G.

Reference: www.endo-society.org/publicpolicy/policy/upload/Joint_Statement_Levothyroxine-Thyroxine.pdf

What if My Primary Physician Tells Me I have a Single Thyroid Nodule?

First of all do not panic. 31% of the time the palpation is NOT accurate. 16% of the time there is no nodule at all! The referral to the radiologist for an USGFNA may result in a biopsy even if there is no nodule present, as they are only doing what the physician orders. Ask for a referral to an endocrinologist that does their own high frequency Ultrasound. Check www.thyroidologists.com for a clinical thyroidologist near you. Also, 15% of patients with a worrisome single nodule will actually have a multinodular goiter. The thyroidologist ultrasonographer will confirm if there is a nodule, detect additional nodules, that may need FNA biopsy, and identify the ultrasound characteristics of the nodules. The present guidelines tell us that not all nodules need biopsy, especially <10 mm nodules. If the nodule is <10 mm there must be abnormal lymph nodes found, or radiation history or family history of thyroid cancer.
>10 mm nodules there are solid, hypoechoic or have micro-calcifications, need FNA biopsy. >1.0-1.5cm cm nodules that are solid and either iso,or hypoechoic need FNA biopsy. If they want to biopsy all your nodules or the ones that are not listed here, ask for a second opinion BEFORE you let them do the biopsy. >1.5-2.0 cm complex nodule, with another suspicious feature, such as vascularity, irregular margins,,micro-calcifications need a biopsy.
>2 cm Predominantly cystic without suspicious US features should be biopsied.

What about multiple nodules?
DO NOT allow them to Biopsy all the nodules. Prioritize based of Ultrasound findings. If there are multiple similar, coalescent nodules without suspicious features, they can biopsy the largest one.

Thyroid Ultrasound In summary,
Palpable Nodule
1. Assess if it is the same nodule seen on ultrasound, and look for suspicious findings. Review the ultrasound for other non-palpable nodules and their suspicious findings and select for USGFNA biopsy if indicated.

Non-palpable nodules seen on ultrasound.
1. Assess for need for Biopsy by suspicious findings, or history of radiation or family history.

Multiple Nodules
1. Select the nodules for biopsy based on suspicious findings or size.

All Nodules
1.Assess the lymph nodes for clues to the presence of thyroid cancer.

Always ask to see the actual diagnostic ultrasound and the report before allowing a biopsy to be done.

Good Luck,

Dr.G.

Reference:
Frontiers in Thyroid Cancer
ATA Guidelines in Clinical Practice
July 11-12 2008
Boston Mass.

What do I Need to do Before my Thyroid Cancer Surgery?

If you are told you have a positive cancer FNA biopsy result on a thyroid nodule, or they say it is suspicious for cancer, what do you neeed to be done BEFORE the surgery?
First, if you are not seeing a thyroidologist, or an endcrinologist with an interest in thyroid cancer, request a referral.
The Pre-operative screening should include a cancer marker test, thyroglobulin.
A detailed thyroid ultrasound to determine if there is tumor on the other lobes.
The thyroidologist should do an ultrasound lymph node mapping of your neck. 20-80% of patients already have mets in the local nodes around the thyroid. If abnormal nodes are found, an USGFNA for cytology, and Thyroglobulin cancer marker washings should be done.
If positive the original surgery plan will be changed in at least 20-30% of the cases, to include the lateral neck area of the cancer nodes.
Now you can go to surgery, and have the definitive first surgery, and save yourself from the recurrence and need for a second surgery in 1-5 years.
Good Job,

Dr.G.

What is a Low Risk Thyroid Cancer, and Do I Need Radiation?

How do I know if I am very, low risk?
If you are <45 years old,
Get your pathology report from your surgery.
Look for these items:
Very Low Risk is a patient has a single < 1 cm cancer nodule.
No lymph node mets.
The cell type is not an aggressive type, such as Tall Cell.
There is no extension beyond the capsule of the thyroid gland.
Then there is no family history of thyroid cancer, and no radiation exposure.

What needs to be done to treat you?
You will only need lobectomy, as there is no benefit from total thyroidectomy.
Also there is no benefit from Radioiodine ablation therapy with any dose.
Death 0% Recurrence by 20 years 8%

How do I know if I am low risk?
If you are <45 years old.

Again get the pathology report.
Papillary Ca 1-4 cm without nodes or distant spread.
No local invasion outside of the thyroid gland.

Follicular CA <2 cm

Minimal capsule invasion, but no vascular invasion.
What needs to be done if I am low risk?
Total thyroidectomy is definitely needed.
Radioiodine therapy is controversial.
May be only on a select few rather than knee jerk use in everyone.
Careful discussion with a thyroidologist before you accept the radiation therapy.

<40 years old Death 0%
<40 years old <3 cm RAI Dubious

Remnant Ablation with RAI/131?
All high risk patients, but not all very low, or most of the young low risk patients.

Stage I Age <45 Size <2cm No LN NO Radiation Ablation Needed
Stage II Age >45 Size >2 cm + LN rhTSH Stimulated Remnant ablation


Good Luck,

Dr.G.

Why a General Endocrinologist Should Not be your Thyroid Doctor

10-15 years ago, a referral for thyroid second opinion from an internist, and from a general endocrinologist would show that the endocrinologist knew more about the thyroid condition than the internist. Sadly, it is not the case today. With diabetes and general medicine taking up the majority of the waking hours for the endocrinologist, there is now a loss of thyroid specific expertise by the endocrinologist. He is little better than a general internal medicine physician. He is still the king of diabetes, but not thyroid.

Case History

51 Y/O female seeks my opinion on the thyroid condition she is not sure she has, or the therapy that is needed.2 years ago the endocrinologist, while treating her type one diabetes, noted an upper normal TSH, 5.61 and commented on her enlarged thyroid on his physical. He did nothing to evaluate the goiter, and told her to return in a year.
He did not offer therapy. She had a family with autoimmune disease of the thyroid.
Aunts with Graves' disease, and papillary thyroid cancer. No antibodies were drawn or was an ultrasound done to evaluate the goiter.Next year the TSH was 6.32 and he offered her thyroid hormone, but no work up. This resulted in her getting a second opinion with me. The thyroid was visible from across the room.There was a large 2 cm nodule on the right. The ultrasound found 6 nodules of which two were > 1.5 cm.
One was 3 cm.It had an irregular border, and 3 deep penetrating blood vessels on power Doppler. There was a papillary thyroid cancer in the larger nodule by USGFNA, and she was studied for abnormal nodes,which was negative. She had surgery, and is disease free with undetectable Cancer marker 6 weeks post surgery. She is lucky to have sought another opinion on her very excellent endocrinologist taking care of her type one diabetes, but learned that his knowledge was less that needed to care for her thyroid diease.

Good Luck

Dr.G.

Calcitonin Measurement in All New Thyroid Nodules

Is Calcitonin screening of all thyroid nodules cost Effective? A recent study by Cheung and associates in the JCEM 93:2173-2180,2008, suggests it is worth the expense. They found it was comparable to screening with TSH,colonoscopy,and mammography. Two groups were studied. One following the guidelines for nodule evaluation by the American thyroid Association ATA, and the other the same ATA except a calcitonin was added to the work up.The results of the added calcitonin to the ATA guidelines were:
The main outcome measures C/E, or dollars per life years saved LYS. $11,793 per LYS for the a calcitonin group. US screening with calcitonin would yield an additional 113,000 life years saved. at a cost increase above current ATA guidelines of 5.3 %. The calcitonin screening is most cost effective in young males with larger nodules, but is still cost effective in screening of the whole thyroid nodule population. The lack of studies on the cost effective nature of screening was the reason the ATA guidelines did not include calcitonin. Now this recent study would suggest it should be added to the nodule work up.

Calcitonin is a marker for Medullary thyroid cancer. It is a rare thyroid cancer that can occur in families. Family screening is done with DNA studies, not calcitonin.

Thanks,

Dr.G.

Alarms Go Off in Restrooms When Radiated Thyroid Patients Urinate.

A 30 Y/O female with Graves' hyperthyroidism was treated with 15 Millicuries of radioiodine. The next day she entered the restroom at her workplace, and an alarm of a flame sensor sounded. This happened everyday for 6 days, whenever she went to the restroom to urinate,the sensor went off and stopped when the toilet was flushed, and the radiation in the toilet was washed away. The sensor was 10 feet away from the toilet in the ceiling. The flame sensors are usually installed in restrooms in department stores, airports, shopping centers and movie theaters. Another Graves' patient activated the flame sensor in a department store restroom 2 days after treatment with 30 Millicuries of I/131. A flame sensor was studied. A patient was with Graves' set off the alarm 3 days after treatment when she passed urine. Also the flame sensor could sense I/131 gamma rays, even when a I/131 capsule was covered by a UV light interception seal. Airport radiation detectors are known to go off when a patient is treated with RAI/131. The fact that alarms can go off in restrooms all over the world when a thyroid patient urinates gamma rays into the toilet water has not been reported before. Any physician using Radioiodine to treat thyroid patients should inform them about this malfunction of restroom sensors after they are treated.

Wow, one more thing to tell my patients after radioiodine therapy. The best thing to do is flush the toilet, and the alarm will stop! Don't panic and run out without flushing.

Good Luck,

Dr.G.

Tajiri et al
Radioiodine and Flame sensors

P2-190
abstract Endocrine Society Annual meeting San Francisco Ca 6-15-2008.
abstract

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not use compounding pharmacy thyroid hormone for my patients. There are pure thyroid hormones made by companies such as Abbott, that makes Synthroid. Errors have been found with other medications from these pharmacies. Recently, errors have occurred when they have compounded thyroid hormone.
Case History:

46 Y/O male admitted the hospital with 22 pound weight loss,palpitations, but he did not have thyroid enlargement on physical exmination. He had a history of hypothyroidism, and had been taking thyroid hormone replacement therapy with Synthroid for 10 years. However, recently he changed physicians and the new PMD, switched him to compounded T4/T3 combination. Prior to the switch he had complained of fatique, but the first physician told him the thyroid tests were normal on his Synthroid. TSH was 1.5 N0.3-3.0. He sought a second opinion and that is when the new physician told him that he needed T3 along with the T4. 6 weeks later he was admitted. The thyroid tests were off the chart, T4 75 N 4-12, T3 1541 N 70-170. The pills were made in error, and had 11 times the dose per pill. The patient was treated in the hospital until the pulse rate was normal and discharged on beta blockers. He was clinically improved , had gained weight, and felt better by 3 weeks. Off thyroid he became hypothyroid. He was switched back on his old dose of Synthroid and the TSH was returned to normal. The pharmacy denied using that dose on any other patient. Well, why use them at all, when, safe commercially available pure thyroid hormones are available by Rx from your physician. Stay away from physicians that tout compounded hormones for treating your thyroid conditions.

Good Luck,
Dr.G.

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not recommend the use of compounding pharmacy

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

There are not many therapy alternatives to surgery if you have a goiter. The large goiter may be causing obstructive symptoms, or harbor a cancer.
The obstructive component can be evaluated by MR, and pulmonary function testing, including flow loop to see if there is any upper airway obstruction. Any suspicious nodules found on ultrasound need to be biopsied. If no obstruction or cancer is found, then alternatives are available. The most widely used is low dose Radio-iodine therapy.
In Europe and special centers, Laser has been used to shrink goiters. However, experience with this method is limited at present, although it seems promising.
Thyroid hormone is effective if the goiter responds to suppression.However, it usually dose not work on very large goiters. Ethanol Injections, PEI, are not for treatment of a whole gland, but for single cystic nodules. The best method now is Radio-iodine therapy.

Case Presentation:

69 Y/O female with coronary artery disease, bypass surgery, and mild heart failure was noted to have a large goiter causing tracheal deviation, and symptoms of obstruction. The MR showed mild tracheal narrowing, and the breathing test showed an abnormal flow loop consistent with upper airway obstruction due to the enlarged goiter. The treatment of choice is surgery, but because of her heart condition, alternatives were sought. Thyroid hormone was considered dangerous with heart disease. She was referred to me for consideration for ethanol, laser, or Radio-iodine. As listed above RAI was the best alternative for her. The goiter was visible from across the room.The trachea was deviated, and the ultrasound found two suspicious nodules in the goiter.They were biopsied and were benign colloid nodules. Thyroid blood testing was normal for TSH, T4, and Antibodies. The thyroid uptake was not elevated, but was to the lower normal range of 11% at 24 hours. Normal 8-32. After informed consent, including all about off label use of Thyrogen, rhTSH stimulation to boost the low uptake, she was put on a low iodine diet for two weeks. The single injection of rhTSH was given, and the TSH rose to 32. A repeat Thyrogen Stimulated thyroid uptake was positive for a significant increase in uptake to 56%. The image showed diffuse increased uptake throughout the goiter. The radiation safety instructions were reviewed with the patient and her urinary continence was assessed. There were no children in her house and she was told to stay away from her grandchildren. The arrival of the iodine dose was followed by confirming the correct dose was sent, checking for leaks, and preparing a paper for her to keep with her when she traveled by air to see her brother in 3 weeks. This will explain to the security at the airport that see has been treated with radiation, and is not a terrorist! The 30 Millicuries was given in my office as an outpatient and she was sent home. She was told to suck on lemon drops, and drink water, and avoid close contact with people for 5 days. She could go for her morning walks as usual. She could watch TV with her husband if she sat 3-5 feet away from him. She returned in one week and her thyroid goiter was firmer, but not tender.Thyroid blood tests revealed slight decrease in TSH, but no change in T4, or T3. By 12 weeks there was an obvious decrease in goiter size. Thyroid tests returned to normal, and the goiter had continued to decrease at 6 months. Repeat MR confirmed shrinkage, and the Flow loop study improved. The trachea was not narrowed, and the mild obstructive pattern on the flow loop was also better. She has noted improvement in her symptoms as well. She is followed twice yearly, and is doing well without ever having thyroid surgery.

When Surgery is offered as a treat option for your goiter, consider looking into alternative therapy with radio-iodine.

Good Luck,

Dr.G.

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

88 Year Old with Recurrent Papillary Thyroid Cancer: Do No Harm or Treat?

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.