The Thyroid Doctor’s log after seeing his patients. I am a rare bird. I am one of the few physicians to practice clinical thyroidology only for 35 years. I am the sole physician at the Santa Monica Thyroid Center, and have the best thyroid blood lab with Dr.Carole Spencer, expert in thyroid hormone analysis, and thyroid cancer markers, as my lab director.The lab is also CLIA certified in thyroid cytology. Dr.Guttler is a thyroid ultrasonographer certified by AACE, and AIUM.
Molecular Classifier saves surgery on a suspicious nodule
Tuesday, February 22, 2011 11:54 AM
Here is the result of an Afirma molecular classifier test done on a male patient set to go to surgery for a suspicious follicular lesion. they wanted to do a lobectomy.The Afirma sample was taken during a repeat FNA and the needle washout was sent to Veracyte for Afirma. The report shown below was benign. He was not a candidate for surgery, and will be followed with yearly examinations and ultrasound.

HMO Offers Poor and Outdated Thyroid Cancer Diagnosis and Therapy To One of Their Own Employees.
Monday, February 07, 2011 8:57 PM
45 Y/O F had a isthmus nodule felt by her GI physician. An ultrasound done by a radiologist noted more nodules and one of them was biopsied. The results were suspicious, but she refused a lobectomy until an outside opinion that she had to pay for out of her own pocket.A second biopsy was even less helpful. After it they still wanted to operate. Finally, she heard about molecular classifiers that could tell if a suspicious biopsy was benign from my website. She was asymptomatic, had 2 firm nodules on my examination. My endocrine neck diagnostic ultrasound result was dramatic. She had 3 very suspicious nodules with microcalcifications, and the whole right side of her neck lateral to the biggest suspicious nodule was full of 5-10 mm abnormal lymph nodes with all the criteria for thyroid cancer spread to local regional lymph nodes. There was no mention of the nodes in the radiology report. Ultrasound techs are not taught endocrine neck changes, such as lymph nodes or parathyroid glands, and only report the thyroid. Many biopsies done by radiology departments are done by PAs, not by radiologists. The biopsy was inferior and only suggested suspicious, because they failed to do smears and only did thin prep. This is a poor substitute for smears, and caused the endocrinologist to recommend lobectomy instead of total thyroidectomy. She did not have a pre-op ultrasound lymph node evaluation before planning to send her for surgery. The second opinion changed everything. She needed a lymph node biopsy and needle washout test for cancer marker thyroglobulin. She will surely be positive for metastatic thyroid cancer in many nodes in her right neck. She now has a pre-op Thyroglobulin test which was not planned before the surgery. She will now have a total thyroidectomy, and central compartment node dissection, but will have a complete level 2-5 node dissection. This is called a Modified radical neck dissection MRND. She was on her way to have a second right neck surgery in one year, which they would have told her it was a recurrence, but it was there all the time BEFORE the first surgery, if she did not get her own second opinion. Please, do not go in for thyroid surgery without an outside second opinion. She would have had many surgeries, and multiple doses of radioiodine as a result of an initial evaluation and therapy plan which was flawed.
Save Unnecessary Thyroid Surgery with new Afirma Molecular Marker Test
Wednesday, January 05, 2011 3:28 PM
Well thyroid patients heading to elective surgery for suspicious but not positive diagnosis of thyroid cancer, there is now a test, Afirma that can save you and 35,000 others this year from that surgery. It is a marker test with 143 genes, that if present on a 2 pass ultrasound guided FNA will give you a 96% chance it is benign. This is good enough to allow your thyroidologist to follow you yearly without surgery. The first soft opening 3 months of the year Veracyte Corp will do the test for you without out of pocket expense to you. They will bill your medicare,medical, and private insurance, and if there is any money due from you they will send you a letter telling you that you do not owe anything.
How does it work?
First, thyroid surgery is elective and is not an emergency no matter what the doctors tell you. Thyroid cancer is only 5% of all nodules, and it is slow growing to allow definite time for second opinions by experts.
There is time for more opinions, even when it is already on the surgery plan tommorow!
If the nodule was not called benign,or for sure cancer, then Afirma could be just the test you need to prevent a surgery, complications, and 12 weeks of recovery.

1. Call and make a consultation with me or a thyroidologist near you that offers Afirma.
2. Bring you FNA actual slides, or ask me to get them for you. If I decide the FNA is inadequate for diagnosis, which is a common occurence due to poor smearing and biopsy technique, i will repeat the biopsy and get the Afirma marker.
3. If the repeat FNA is benign or cancer I will discard the Afirma sample. However, if it is unclear as to the diagnosis,I will send the Afirma test to Veracyte. You get charged for my collection of the sample, and Veracyte will only bill your insurance if you have any. No out of pocket fees to you. If you have the 143 good genes the nodule is benign, and no surgery is needed. You can contact my office for more information on Afirma. 310-393-8860, fax 310-395-8147, or email [email protected]
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Lobectomy for a Large Benign Thyroid Nodule? Second Opinion Saved the Day
Tuesday, November 09, 2010 11:28 AM
50 Y/O female for second opinion on a referral for a lobectomy for a very large thyroid nodule. The FNA of the nodule was benign, but because of the size her endocrinologists referred her for surgery. The ultrasound described two small insignificant nodules 7 mm each in the opposite lobe. My evaluation revealed a major historical finding not known by the first opinion physician. Her sister had thyroid cancer. My ultrasound again saw the nodules but they has 4 + Doppler blood flow in the nodules, irregular borders. My FNA of the large nodule was also benign, but because of the ultrasound findings and the family hx of thyroid cancer I biopsied the two suspicious small nodules not evaluated by the first opinion physician. Both were positive for papillary thyroid cancer. What should you learn as a thyroid patient with a nodule?
1. Get an outside second opinion from a clinical thyroidologist before going under the knife.
2. The second opinion found out during the history that she was at risk due to the fact her sister had thyroid cancer.
3. Careful evaluation of the thyroid by ultrasound revealed not 2 insignificant small nodules, but suspicious nodules for FNA.
4. The second opinion consultant had now changed the whole case from a simple lobectomy to remove a large benign nodule, to a total thyroidectomy for cancer. The lobectomy would have left her with thyroid cancer in the other side that the surgeon would not have felt as they were too small to palpate.
4. The two tests needed before surgery for thyroid cancer would not have been done. They are thyroglobulin cancer marker and an ultrasound 6 level lymph node mapping. This procedure can result in a change in the extent of surgery 30% of the time to include one or more lateral neck lymph node compartments.

It is no emergency to go to surgery for a thyroid nodule. Stop, Think, and get proactive.
Second opinion from an expert thyroidologist can save you from the wrong surgery, as in this example.
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My Thyroid Ultrasound Referral Center is Certified by AIUM
Friday, November 05, 2010 6:54 PM
Endocrine Neck Ultrasound Lab of Southern California is the only referral center on the west coast that has both the certification of the physician sonographer by the American College of Endocrinology ACE, and the ultrasound lab certified by the American Institute of Ultrasound Medicine.100 endocrinologists have been certified by ACE, but only 5 have had their ultrasound equipment certified by AIUM. My referral ultrasound center is the only one double certified on the west coast. This allows us see referrals from general endocrinologists,and thyroid surgeons for specific studies. Diagnostic Endocrine neck ultrasound, lymph node mapping before and after cancer surgery, parathyroid localization, USGFNA of nodules,lymph nodes, and parathyroid adenomas. Interventional sonography for Ethanol injection treatment of benign recurrent cysts to replace surgery, and recurrent papillary, medullary cancer lymph nodes after prior neck dissection.
Media files
Clinical Thyroidologists: What we do for our patients.
Thursday, April 01, 2010 4:33 PM
In the last month in cooperation with filmmaker John Lynch, I have produced 5 2 minute videos to explain what a real clinical thyroidologist, who only see patients with thyroid disease or thyroid cancer does. The first one is an introduction to my center, and an example of the careful history and physical examination that still is the key to discovering the cause of the thyroid disease. The second is my clinical thyroid nuclear medicine section to evaluate toxic nodules, Graves disease, and cancer.The video is designed to explain why the thyroid expert is the best person to treat you, not the general nuclear medicine types who spend little time with thyroid patients. I can treat the cancer patients with radio-iodine as an outpatient. The hall mark of my center is the core thyroid lab, with excellent confirmed results for T4,T3,TSH,TPO Antibodies, Thyroglobulin, thyroglobulin antibodies,and Calcitonin. The Ultrasound section is top heavy with state of the art testing and treatment for nodules and cancer.We are one of the few centers to treat thyroid/parathyroid cysts,and cancer lymph nodes with ethanol. The thyroid cytology section is a leader in the field of alerting endocrinologist of the need to quality control the results of thyroid FNA,and surgical pathology results by general pathologists concerning their own private patients before subjecting them to surgery or radiation therapy. The videos are uploaded to my twitter site and blog.
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Iodine Induced Graves’ Disease Why Treat with Iodine?
Wednesday, June 24, 2009 6:14 PM
48 Y/O Female with hypothyroidism was treated with iodine pills and T3 cytomel. While on high dose T3 and iodine, she developed double vision and pop eye on the right. MR= swollen eye muscles=Graves Eye Disease.The patient was hyperthyoid on examination. The thyroid was enlarged, firm, and Ultrasound showed Graves’firestorm blood flow. The iodine was stopped, as was the T3. She was started on beta blocker and a I/123 uptake was planned. No ultrasound was ever done.A real time ultrasound was positive. Several nodules were suspicious for cancer.A Biopsy was done, and it was negative for cancer.The patient was cooled off with beta blocker, and was treated with RAI/131.The eye disease stabilized and then a muscle relocation procedure cured the double vision.
What did we learn?
Always see an endocrinologist or thyroidologist if you are told by your primary MD, you have thyroid disease.

Good luck,
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“My Physician found my TSH was high, and started me on thyroid hormone. Why am I worried about this ? Isn’t there more investigation needed?”
Thursday, April 30, 2009 11:09 AM
The answer to this Ask the Doctor email is yes. The finding of an elevated TSH or even a slowly increasing TSH over a few years is a clue to the onset of hypothyroidism. The abnormal TSH should be the starting point to investigate the cause of the failing thyroid and to evaluate the structure of the gland. TSH elevation even in the upper normal range has been found to be a risk factor for thyroid cancer. All newly diagnosed patients with TSH 2.5-10 are in the risk pool for cancer. The primary physician may not even feel the patient’s neck before starting therapy. The thyroid gland is almost always abnormal to physical examination by a clinical thyroidologist. Firm gland with cobble stone surface is usually missed by the primary physician. Before allowing the physician to treat you, you need a complete thyroid evaluation looking for nodules. The endocrine neck ultrasonographer thyroidologist will do a detailed study of the thyroid, lymph nodes and parathyroid areas. If a suspicious nodule or lymph node is found, an ultrasound guided FNA will be done. Modern thyroidology concepts include hands on ultrasound real time done by your thyroidologist or endocrinologist, not by a radiology tech, who prints out pictures for a radiologist to look at after the fact. The original evaluation when the abnormal TSH is found is the best time to see a clinical thyroidologist, notjust start thyroid hormone.
Surgery for Benign Thyroid Cystic Nodules? Not Anymore! There is a New Medical Treatment Using Injection of Alcohol call PEI
Thursday, April 30, 2009 11:55 AM
42 year old female with a large visible mass on the right thyroid lobe. She had local symptoms and did not like the looks of the mass, as it distorted her thin neck. Her thyroid tests were normal, but a complex cyst was seen in the right lobe on ultrasound.
An FNA and drainage of the cyst fluid was done. The free hand FNA done without ultrasound guidance, was negative for cancer, but the mass recurred in 4 weeks. The endocrinologist referred her to a surgeon to remove the mass. She was referred to me for a second opinion on the need for surgery. Of course she had searched the web for alternatives to surgery, and found my website.
She learned about my Ethanol Injection Method (PEI) for recurrent Cysts. The cyst was 11 ml in size and had a complex solid component. An ultrasound guided FNA aimed directly at the solid component to R/O cystic papillary thyroid cancer was negative. The injection of ethanol after draining the cyst was successful. She had slight burning sensation as the needle was removed, but othewise there was no other side effects. She returned in a month to see the effects of the ethanol on the cyst. When she walked int the examining room, she said, “The thing is gone”. The large visible mass was not seen on inspection, or was it felt on palpation. The mass was still there but was markedly reduced. From the original 11 ml to 0.6 ml. That was a >90%
reduction in size. The average reduction noted in the literature is 80%. She did not need surgery, because the reasons for surgery did not exist anymore.They are fear of cancer, obstruction,and removing an ugly mass for cosmetic reasons.

Get a second opinion before having thyroid surgery for a cyst.

Good Lck,Dr.G.
Media files
Thyroid.About.Com, the Source for Dangerous Thyroid Information has Done it Again. Now You Don’t Need an Endocrinologist at All!
Friday, March 20, 2009 11:14 AM
The 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 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,
Media files
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.
Saturday, March 14, 2009 1:33 PM
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,

Media files
Mary Shomon, and the Medical Review Board of, on their Opinion on the Top Thyroid Websites: Pros and Cons
Friday, February 27, 2009 8:41 PM
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, 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 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,, 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, 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,, 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 and then look at 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 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 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,
Media files
The Brits are Half Right, and Mary Shomon is as Usual All Wrong
Saturday, February 21, 2009 8:36 PM
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 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.
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Thyroid Cancer: A Lesson in What Can Go Wrong with Multiple Unnecessary Surgeries
Tuesday, November 04, 2008 4:15 PM
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,

Media files
Pregnant, But is Your Baby Getting Enough Iodine from Your Prenatals ?
Wednesday, October 15, 2008 2:40 PM
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.

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,


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.
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Thyroid Nodule Therapy in Patients with Insulin Resistance
Thursday, October 02, 2008 11:36 AM
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.

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.
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Beware of Generic Substitution of Your Thyroid Hormone Therapy
Tuesday, September 16, 2008 12:53 PM
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,

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What if My Primary Physician Tells Me I have a Single Thyroid Nodule?
Tuesday, July 29, 2008 1:06 PM
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 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,


Frontiers in Thyroid Cancer
ATA Guidelines in Clinical Practice
July 11-12 2008
Boston Mass.
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What do I Need to do Before my Thyroid Cancer Surgery?
Thursday, July 17, 2008 12:32 PM
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,

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What is a Low Risk Thyroid Cancer, and Do I Need Radiation?
Tuesday, July 22, 2008 9:56 AM
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,

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Why a General Endocrinologist Should Not be your Thyroid Doctor
Monday, June 30, 2008 6:20 PM
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

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Calcitonin Measurement in All New Thyroid Nodules
Monday, June 16, 2008 2:23 PM
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.


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Alarms Go Off in Restrooms When Radiated Thyroid Patients Urinate.
Monday, June 16, 2008 12:28 PM
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,


Tajiri et al
Radioiodine and Flame sensors

abstract Endocrine Society Annual meeting San Francisco Ca 6-15-2008.
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Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors
Friday, June 13, 2008 3:34 PM
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,
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Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors
Thursday, April 30, 2009 11:12 AM
I do not recommend the use of compounding pharmacy
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