Thyroid.blogspot.com continued

Thyroid.blogspot.com continued

Wednesday, November 22, 2006

Holistic Therapy for Graves’ Disease: An 8 Year Therapy Plan that Failed, or How to Stroke Out or Die When There is Conventional Medical Therapy

49 Y/O male ex- chirpractor, first sought medical care 8 years ago. He had every major symptom of Graves’ Hyperthyroidism. He refused medical therapy for most of the next 8 years.6 years ago after 2 years of holistic medicine, he had Hyperthyroid induced rapid irregular heart beats called atrial fibrillation. He did nothing for 6 years! He was sent to a heart specialist this year. He was told the thyroid needed therapy and the heart problem would go away. The heart was enlarged, and he was at risk for blood clots to his brain and a stroke if the thyroid was not treated. He never took the blood thinner medicine to prevent stroke. He continued holistic therapy, even though he was told the thyroid could be easily cured by radioiodine, surgery, or antithyroid pills.

When I saw him in consultation, he had a large goiter with blood flow sounds, Atrial fib out of control, and thyroid eye disease and skin disease.

The bone density was low.
The left atrium was enlarged and at risk for an embolus to the brain.
There was decreased function of the heart.

Ultrasound showed a firestorm pattern of increased blood flow in the thyroid.
There was a very high iodine uptake, and diffuse scan consistent with Graves’
hyperthyroid 8 years after first diagnosed!

He swore to me he was finally ready to be treated by standard thyroid therapy methods.

Well, he failed to return, and was trying another holistic regimen in hopes of cure.

He is a fool, and puts himself at grave risk for no reason. Modern well known therapy
could have fixed him 8 years ago. There is no holistic therapy for Graves’ Hyperthyroidism. I hope he learns this in time, before his stroke.

I sadly sent him a withdrawal letter as I did not want to be the physician of record when he became paralized from a blood clot from his heart, or when he went into heart failure.

Before 1940, there was a high mortality for untreated Graves’ Disease, but that was because there was no therapy! With 3 proven therapies today, no one should stroke out or die, unless you try unproven methods in cure yourself.

Dr.G.

Wednesday, November 08, 2006

Distant Metastatic Disease 30 years after Partial Thyroidectomy for Thyroid Cancer

I was not expecting this when a nurse called me to see her 85 Y/O father. He had a mass under the skin of his abdomen which was removed, and was found to be metastatic papillary thyroid cancer.The story gets worse. Since his surgery in his home country 30 years ago, he never knew that he had had thyroid cancer. The family did not tell him. They thought he had been cured by the partial thyroid surgery. There was no cancer follow up. With the distant cancer spread 30 years later, the family asked me to see him. He was wearing a pacemaker, had heart disease, and was not a good surgical risk. He was taking a heart drug, amioaderone, which was very high in iodine content. He had nodular masses in the lung by CT, and had significant thyroid tissue
still in the neck by ultrasound. 24 Hr uptake was 18%, the scan showed bilateral thyroid gland with cold masses in the left lobe. The thyroid tests confirmed severe hypothyroidism with TSH of 70. He had never been treated with thyroid hormone for the cancer or hypothyroidism. The TSH stimulated cancer marker TG was > 2000.
He was ready for ablation therapy, but was incontinent! No hospital would take him.
What do you do with this case?
After much thought, because he was most effected by the hypothyroidism, I elected to treat his hypothyroidism first. He had wide spread cancer with very high cancer marker, and had no local symptoms due to the cancer. I will wait for local symptoms and then treat for symptom relief with external radiation. This is a very sad case, because if he knew he had cancer, the patient might have sought medical care when there was a chance it would have help.

Tuesday, October 17, 2006

Why you need to see a Clinical Thyroidologist before parathyroid surgery

42 Y/O female sees me for a second opinion for the need for parathyroid surgery. She has documented hyperparathyroidism by calcium and PTH testing.Prior Parathyroid scan
was negative. Ultrasound before seeing me was consistent with a parathyroid adenoma on the left, but a thyroid nodule was seen on the right. There was no change of plans when the thyroid nodule was found pre-op. That was what prompted her to get a second opinion.

I believe that real time high frequency Ultrasound done by the physician thyroidologist, is manditory in this case. Therefore, I repeated the US personally.
The 11 mm mass in the left extra-capsular area of the thyroid had a polar parathyroid like artery coming into the mass. The right lobe of the thyroid had a 6-8 mm mass with irregular border, cystic posterior enhanced views consistent with cystic fluid, and microcalcifications worrisome for papillary thyroid cancer. Also an abnormal shaped lymph node was seen on real time in level 4 lateral to the thyroid nodule in the right lobe.

You wonder if she is having surgery anyway, who cares if there is cancer, she will have her thyroid removed while doing the parathyroid.

Well, the reason is if the node is positive it can change the surgery. There will be a need to remove the lateral neck nodes as well as the total thyroid , and the parathyroid adenoma. This is called a three for one surgery. It would surely save her a relapse and surgery, and Radioiodine years later.

What happened?

The parathyroid was a single adenoma.
The right thyroid nodule was papillary thyroid cancer.
The node washing was positive for TG on FNA, and the surgeon did a right lateral neck node removal at the original surgery.

Now do you know why you need to see a clinical thyroidologist BEFORE you submit to surgery, even if it is recommended by a good endocrinologist, and surgeon. This evaluation may have saved her future surgery for cancer nodes. Pre-op physician
thyroidologist real time ultrasound and US guided FNA of nodes can change the
surgery planned for you 30-44% of the time.

Check www.thyroidologists.com or thyroid.com for details.

I will visit with you with the next great thyroid case soon,

Dr.G.

Thursday, October 05, 2006

Alternative Therapy for Graves’ Hyperthyroidism for 10 years: A Serious Failure

46 Y/O male sees me for the first time 10 years after he was first diagnosed with hyperthyroidism. He was trying alternative therapy and refused the main stream medical therapy for his disease. Each new therapy was giving him some relief for a short time. The goiter even shrunk for a while. Herbs, therapy in Mexico, accupuncture, and other treatments only gave partial relief. He continued to try other methods without much success. He developed a dangerous irregular heart beat called atrial fibrillation,AF, 7 years ago but still refused to follow the cardiologists advice to get the thyroid treated. He was doing poorly, and finally consented to be treated, when he learned that a stroke, and even death could occur if he continued to be untreated with western medications.

He had a visible goiter from across the room. The pulse was 130, and irregular,irregular. Slight exercise caused a rapid rise to 170-180.
He had muscle wasting, elevated nail beds called Plummer’s nails, Pre-tibial Graves’ Dermopathy, and mild Graves’ exopthalomas. I sent him to a sports store to but a sports heart rate monitor. I started him on beta blockers and ask him to monitor the dose until he was controled with mild exercise to 110-120.

The left atrium of the heart enlarges due to AF, and clots can be sent from the heart to the brain causing a stroke. I added 10 gr ASA to help stop clotting, and sent him for detailed cardiology`evaluation. I started anti-thyroid drugs to control hyperthyroidism for 6 weeks, before I give him radioiodine.

This is a rare example of the false hope given by alternative care givers to patients with clearly treatable disease. This false hope could have made him a drooling stroke victim for the rest of his life, or killed him by means of thyrocardiac disease, or liver failure.

In 32 years of private thyroid only practice, This is the worse example of the wrong headed approach to thyroid treatment, I have ever seen.

Your alternative approach works for some symptoms, but stay away from thyroid patients that have curable disease, which you put in danger when you offer half baked treatments that delay the onset of life saving western care.

Shame on all the fools that tried to treat him, with their treatment plans that have no validity, and their disrespect for the highly successful mainstream medical treatment, that has saved lives for 60 years!

Saturday, September 09, 2006

Doctor, My TSH is Low, but you tell me my Thyroid dose is correct. Then Why do I feel So BAD?

Patients need to be able to read the results of their tests, and know why they are taking thyroid hormone in the first place. The normal range for TSH is lower than before. It is 0.3-3.0.

There are three different dose levels depending on your disease

1. Hypothyroidism only without nodules, or goiter. The TSH should be between 0.5-2.0.

2. Suppression for nodules, or goiter in younger patients < 50 Y/O. The TSH should be between 0.1-0.5.

3. Active thyroid cancer needing maximum suppression to act as a hormonal chemotherapy.
The TSH needs to be lower than for hypothyroidism at < 0.1, and even <0.01 in active diease.

Do not let a physician change your dose without knowing what your reason for taking thyroid hormone is. The suppressed TSH is not correct for hypothyroidism, but is needed for cancer and nodule and goiter suppression. The most suppression is for cancer patients that still have active disease.

Good Luck,
Dr.G.

Friday, September 08, 2006

Traumatic Damage, with painful bloody cyst formation, due to a child’s blunt blow to the mother’s neck

After an incident where the mother received a blow to the neck by her child, she began to experience pain and tenderness and marked swelling of her neck. She did not realize the trauma caused the swelling and was fearful of cancer, because it was rapid in onset and very large. She noted that the swelling deceased in size but was still painful. She had a large visible mass from across the examining room. The ultrasound confirmed a 5 cm cystic mass. The rest of the thyroid confirmed a diffuse goiter was present. Thyroid tests were normal. The ultrasound guided FNA produced 5.6 cc of bloody fluid. The attempt to biopsy the mass was unable to confirm an underlying cancer. She returned in 1 week. The mass was not visible and was decreased in size due to the decompression and fluid removal. The repeat US revealed a reduction of 60% in the size of the cyst. There was no pain or tenderness now. She was placed on thyroid hormone to suppress the goiter. If the cyst recurs, she will be a candidate for percutaneous ethanol injection, or PEI. This has replaced surgery as the primary therapy for non-cancerous recurrent cysts. There is an average 80% reduction in size with PEI.

If you have a recurrent cyst, please consider a visit to my center instead of a major surgical intervention for a minor cyst.

Wednesday, September 06, 2006

The Return of a Pituitary Tumor Patient

Today, I saw the man I diagnosed with pituitary hypothyroidism 6 months ago. He had secondary hypothyroidism. That means his hypothyroidism was due to the failure of the pituitary to send enough TSH to sustain normal thyroid function. An MR of the head revealed a large tumor that was interfering the normal gland function. He had low testosterone for several years. A 3-4 cm mass was seen on the MR. The surgery was long and difficult. However he returned to see me after the surgery, with normal pituitary function. The clue to his diagnosis was a low Free T4, and a normal TSH. This was not the usual numbers for primary thyroid failure and suggested a central cause for his failure. His testosterone normalized, and he was markedly improved. He does not need replacement or stress steroids!

Great case,
Good result.

Until next time,
Dr.G.

Tuesday, August 08, 2006

40 Heathy Years after So Called Papillary Thyroid Cancer Surgery: Serious Recurrence due to Undiagnosed Medullary Thyroid Cancer

60 Y/O female had a total thyroidectomy, lymph node removal from the neck, and superior mediastinum, and a mutilating radical removal of all neck structures on the right. Why?
The pathologic report, I tracked down from 1960’s called it a very, very agressive papillary thyroid cancer. She had mytosis in some areas, and spindle cell formation, but no signs of papillary structures, but many spindle cell groups. Her parents elected at age 18, not to tell her about the cancer, until age 24. They told her she was cured, but had to take thyroid hormone for life. She never saw an endocrinologist, and was fine until 37 years later, when she developed diarrhea. Specialist Gastroenterologist did not find a reason for the diarrhea, but had drawn a calcitonin, which was markedly elevated, at 4000, normal< 20. This was ignored, and never sent to the her primary physician. 38 years after the surgery, she developed dysphagia. An MR revealed a mass in the thyroid bed and in the mediastinum. It circled the carotid, esophagus, and some great vessels in the mediastinum. The calcitonin was still in the 4000 range and the CEA was 2 fold elevated. She saw experts on the east coast, and they were reluctant to intervene surgically. When I saw her, I was able to obtain the pathology report from 1960’s. She had exactly the same disease as in the 1960’s. The diagnosis of Medullary Cancer of the thyroid was not widely known, and usually called atypical aggressive papillary cancer then. Ultrasound guided FNA diagnosed Medullary adenocarcinoma in the masses in the thyroid bed.

Wow, I am impressed that something looking so aggressive in 1960, had not killed her in 40 years!

Armed with the knowledge that it was an extremely indolent cancer, I began to lobby for a debulking surgery to decrease tumor burden, and decrease diarrhea due to tumor bulk. I sent her to MD Anderson in Texas to see a extreme surgeon to operate.

I will update as this story unfolds.

Dr.G.

Friday, August 04, 2006

Strip Searched at the White House, Airport, and Courthouse

If you receive radioiodine therapy for thyroid cancer, or hyperthyroidism, you may be strip searched at security check points because the therapy will cause detectors to go off months after the radiation is safe. It still will set off the scanners for up to 12 weeks. You need to get a form from your physician stating, you were treated and are not a risk. Please do not go to areas of secure detectors, such as airports without a formal letter from the treating physician. White House guards have strip searched a man, and 4 patients have been strip searched at Banks,and airports because they had no documentation of the therapy.

Dr.G.

Thursday, July 27, 2006

The Best Thyroid Patients in My Clinic Last Week

The first patient of the week was from Italy, and had pain and tenderness in her neck area by the left lobe. She was treated for iodine deficient nodular goiter from Italy. The Ultrasound confirmed a cystic nodule. she must have bled into her goiter. An US guided FNA confirmed no cancer in the cystic nodular goiter.

A 14 Y/O male from a family, where many members have autoimmune thyroid disease, had a goiter for several years, but because the TSH was normal, no therapy had been given by the child’s physician. By the time I saw him he had a larger goiter, positive TPO, and Tg antibodies, and a 1.8 cm nodule in the right lobe. He now will need a needle biopsy, because the physician did not get an endocrine consult 2 years earlier. Thyroid therapy,then, may have prevented the nodule formation.

An 85 Y/O with a long standing goiter that was never treated, developed apathetic toxic nodular goiter, which was noted on routine yearly physical,by low TSH. The only abnormal finding was lid lag. She had no symptoms to report.

77 Y/O female with Hurtle Cell Follicular Carcinoma treated 7 years ago by lobectomy only, and no radiation I/131 ablation, presents with a new nodule in the other lobe not removed at the first surgery.

A patient from Chicago was told after a six hour thyroid surgery for a nodule, that all was well. She sent me all the material including the orginal surgery slides. On the slides I noted a cancer which was not reported on the original report. She was very upset and came out to LA to see me. She had papillary thyroid cancer, but had no abnormal cancer nodes on my neck node ultrasound.She will follow up yearly with me.

Have a good week,

Dr.G.

Sunday, July 16, 2006

The Best Thyroid Patients in My Clinic Last Week

The week was full of unusual cases.

1. 30 Y/O singer with a lingual thyroid. The patient had a sore throat and went to an ENT.
When they looked down the throat they saw a whitish mass at the back of the tongue. MR confirmed a 2.5 cm mass. The TSH was elevated to 5.6. The possibility of a rare congenital undecended thyroid at the base of the tongue was confirmed by thyroid imaging with 123/Iodine.There was no uptake in the neck where the thyroid usually is located, but was very hot in the posterior pharynx. The image showed uniform uptake without cold areas. The ultrasound showed coarse calcifications in the gland but no nodules. He was treated with thyroid hormone to keep the lingual thyroid from enlarging.

2. 6 month retired special forces policeman, developed Graves’ Disease after a severe stress related to a murder of a rapist who was holding hostages at a clinic where the people worked.His eyes were swollen and reddened from thyroid eye disease.

3. A 2 Y/O infant developed Graves’ disease and even on proper therapy had global retardation in growth, speach and motor co-ordination. The infant had a goiter, and was tall for it’s age.
The infant “flew around the room” with the mother chasing after. This is the youngest patient I ever saw in 30+ years as a consultant with Graves’.

4. A thyroid cancer patient who refused surgery for an ultrasound FNA proven recurrence in a lymph node. The node had 400+ ng/ml Thyroglobulin Tg cancer marker in the node washings. She allowed me to inject Ethanol by ultrasound guidance directly into the cancerous node. She returned in 4 weeks, and the node was now 50% smaller, but the doppler blood flow was gone! The blood TG went from 2.0 to 0.9 after the Ethanol therapy. She allowed me to repeat the procedure called Percutaneous Ethanol Injection, PEI again.

Well it was a big week at my thyroid center, and we will see what is in store for me next week.

Dr.G.

Sunday, May 28, 2006

Parathyroid Adenoma Cured by FNA, not Surgery

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.

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

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.

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.

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

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.

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.

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.

Thursday, January 05, 2006

Surgeons Don’t Need to be Cowboys

this is an audio post - click to play

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

Add Your Comment

Contact Info
1328 16th Street, Santa Monica, CA 90404
Monday – Friday
9:00 AM to 5:00 PM
(310) 393-8860