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!


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.

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 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 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.


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 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.