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Active Surveillance for Micro-Papillary thyroid cancer 101: Macrocalcifications and Young Age <50 associated with rapid tumor doubling time.
Dr.Guttler’s Comments
1. TVDT is a good indicator for presenting the growing velocity of PTCs during active surveillance.
2. If your ultrasound has macrocalcifications in the cancer and you are young you should consider other forms of treatment than active surveillance.
3. Ethanol ablation or radiofrequency can treat the micropapillary as alternative to AS or surgery.
Call me at 310-393-8860 or secure email at thyroid.manager@protonmail.com.
Dr.G
Published Online:13 May 2019https://doi.org/10.1089/thy.2018.0609

Background: Tumor volume (TV) of papillary thyroid carcinoma (PTC) increases exponentially during active surveillance, and the growth rate differs for each patient. TV doubling time (TVDT) is considered a strong dynamic marker for the prediction of the growth rate and progression of the tumor.

Methods: This cohort study analyzed 273 PTC patients who underwent active surveillance for more than one year rather than immediate thyroid surgery. TVDT was calculated in each patient, and patients were divided into two groups: rapid-growing (TVDT <5 years) and stable (TVDT ≥5 years). Clinical and initial ultrasonography (US) features between the two groups were compared.

Results: The median patient age was 51.1 years (interquartile range [IQR] 42.2–61.0 years), and 76% of the patients were women. The initial TV of PTC was 62.1 mm3 (IQR 28.1–122.8 mm3). During a median of 42 months (IQR 29–61 months) of active surveillance, 10.3% of the patients had a TVDT of less than two years, 5.1% had a TVDT between two and three years, 6.2% had a TVDT between three and four years, 6.6% had a TVDT between four and five years, and 71.8% had a TVDT of five years or more. Patients in the rapid-growing group (77 patients; 28.2%) were significantly younger (p = 0.004) than those in the stable group (196 patients; 71.8%). Being younger than 50 years of age was significantly associated with rapid tumor growth of PTC (odds ratio = 2.31 [confidence interval 1.30–4.31], p = 0.004) in multivariate analysis. In ultrasound findings, macrocalcification was independently associated with rapid tumor growing of PTCs (odds ratio = 4.98 [confidence interval 2.19–11.69], p < 0.001).

Conclusions: TVDT is a good indicator for presenting the growing velocity of PTCs during active surveillance. Younger age and macrocalcification in the initial US were associated with rapid-growing PTCs. Determination of TVDT during the early phase of active surveillance may be helpful for the prediction of rapidly progressing PTCs and deciding whether to adopt an early surgical approach.

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Toxic Nodular Goiters 101: Alternatives to Surgery and Radioiodine with Anti-thyrioid Drugs, Ethanol and Radiofrequency Ablation.

DR.Guttler’s comments:

  1. Toxic nodular goiter and autonomous functioning thyroid nodules AFTNs are commonly sent to surgery or treated with radiation.
  2. This study confirmed that long term Tapazole was safe and effective treatment compared to RAI/131.
  3. A small 6 mg dose was effective in 96% of the study cases.
  4. This adds Tapazole to the list of alternative tretments for TNG and AFTN.
  5. Ethanol and radioifrequency ablation are two other alternatives.
  6. For patients who do not want surgery or radiation in their body these are three ways to correct the hyperthyroidism and keep the thyroid gland intact.
  7. Call me for a consultation to see if you are a candidate for Ethanol or RFA.
  8. 310-393-8860 or email to secure server at thyroid.manager@protonmail.com.
  9. Dr.G
Treatment of Toxic Multinodular Goiter: Comparison of Radioiodine and Long-Term Methimazole Treatment

Background: This study aimed to compare the effectiveness and safety of long-term methimazole (MMI) and radioiodine (RAI) in the treatment of toxic multinodular goiter (TMNG).

Methods: In this randomized, parallel-group trial, 130 consecutive and untreated patients with TMNG, aged <60 years, were enrolled and randomized to either long-term MMI or RAI treatment. Both groups of patients were followed for 60–100 months, with median durations of 72 and 84 months in the MMI and RAI groups, respectively.

Results: In the MMI and RAI groups, 12 and 11 patients, respectively, were excluded because of side effects, choosing other modes of treatment and not returning for follow-up; 53 and 54 patients, respectively, completed the study for 60–100 months. In the MMI group, two patients (3.8%) experienced subclinical hypothyroidism, and 51 (96.2%) remained euthyroid until the end of study. The dosage of MMI to maintain euthyroidism was 6.3 ± 2.0, 4.5 ± 0.9, and 4.1 ± 1.0 mg daily during the first, third, and fifth years of continuous MMI treatment. One patient had elevated liver enzymes, and three developed skin reactions during the first three months, but no adverse effects from MMI occurred from 4 to 100 months of therapy. In the RAI group, 22 (41%) became hypothyroid, 12 (22%) had persistence or recurrence of hyperthyroidism, and 20 (37%) became euthyroid after 16.7 ± 2.7 mCi 131I.

Conclusion: Long-term, low-dose MMI treatment for 60–100 months is a safe and effective method for treatment of TMNG, and is not inferior to RAI treatment.

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Thyroid 101: Avoid Iodine Containing Thyroid Supplements,Iodine Drops ,Kelp and Armour Thyroid extract from Pigs.

The freaky little hormone-producing gland just under your Adam’s apple can malfunction in any number of ways. When it’s overactive it can cause weight and hair loss, and when underactive weight gain and sluggishness – but there are a whole slew of other potential symptoms.

Less common is the not necessarily serious goiter and the very scary thyroid cancer.

Hashimoto’s disease is a common cause of hypothyroidism, but they are not synonymous. In Hashimoto’s, dedicated lymphocytes attack and destroy the thyroid. It’s all very complicated!

A number of alt health types feel that conventional thyroxine treatments are inadequate and that standard blood tests aren’t sensitive enough to diagnose a low-functioning thyroid.

Many also recommend you up your iodine with foods like kelp, while endocrinologists are adamant this is actually dangerous. Make sure you get the right advice.

What the expert says

“Canada and the U.S. are iodine-sufficient areas. We get at 200 to 300 micrograms, and you only need 150 micrograms a day. Iodine in the form of supplements, including seaweed and kelp, is contraindicated for people with thyroid problems, especially those with Hashimoto’s or chronic thyroiditis. Avoid excess iodine outside the normal diet. If you eat fish, pizza, bread, eggs, broccoli, spinach, you will get enough. The tests are very accurate. Taking desiccated or Armour thyroid can get people in trouble because it changes from batch to batch and has a lot of T3 that can cause symptoms in the heart and bones.’

RICHARD GUTTLER, clinical professor of medicine, U. of Southern California

“Nodules can be caused by radiation. A lot of people who were treated with radiation for acne and ear problems in the early 60s are coming back now with thyroid nodules, and a significant proportion are cancerous. Also, the explosion at Chernobyl has resulted in a lot of cancer cases, particularly in kids. Surgery can be used to treat overactive thyroid. Take out the thyroid and the problem is gone. Genetics can play a role in thyroid cancer, as can ethnicity. Hawaiians have the highest incidence and Filipinos the second-highest. The incidence of thyroid cancer has doubled in the last decade. It’s the fastest-growing cancer in the world.”

JEREMY FREEMAN, professor of otolaryngology, head and neck surgery, University of Toronto

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1990 Today Show Thyroid Week After The President Bush and Wife Developed Graves’ Disease.
                      TV medical doctor Art Ulene for NBC interviews Dr.Guttler.
 Transcript of the show.
 https://archives.nbclearn.com/portal/site/k-12/browse/?cuecard=32058TranscriptHyperactive Thyroid GlandART ULENE, M.D.

Apr. 1990. NBC Learn. Web. 19 August 2017APAUlene, A. (Reporter). 1990, April 16. Hyperactive Thyroid Gland. [Television series episode]. NBC TodayShow. Retrieved from  Thyroid Gland

ART ULENE, M.D. reporting:The thyroid gland is a small gland located in your neck right, right here, right in front of your windpipe.The gland produces a hormone that helps to regulate the body’s metabolism and the rate at which you burn up calories. If the thyroid gland is underactive, the metabolism slows down. If it’s overactive—or hyperactive, as we say in medicine–many body functions will seem to speed up.LOUISE WAN: hot, and I can’t sleep. I’m really hyper. I don’t know why. Just jump around, and even though I sit at the seat, maybe a couple of minutes I ha–I need to switch.ULENE: Five years ago, Louise Wan began to develop the classic symptoms of a hyperactive thyroid gland: nervousness, shakiness, excessive warmth, weight loss, and heart palpitations. Louise went to Dr.Richard Guttler, an endocrinologist, who found that her thyroid gland was slightly enlarged. He examined her for signs of hyperthyroidism, and ordered a blood test to check her thyroid hormone levels. They were high.Dr. Guttler also did a radioactive scan to measure how quickly her thyroid was processing iodine, which is an essential ingredient in thyroid hormone. The test uses minute amounts of radioactive iodine, note enough to damage any tissues in the body. The iodine is concentrated by the body in the thyroid gland. If the gland is hyperactive, it will take in greater amounts than normal of the iodine and will appear dark like this scan. Dr. Guttler diagnosed Louise’s problem as Grave’s disease, a condition in which the immune system manufactures abnormal antibodies which cause a speedup in the activity of the thyroid gland.RICHARD GUTTLER, MD (Endocrinologist): She had every classic symptom of Grave’s disease. She was shaking, she was nervous, she was losing weight.ULENE: Louise was then treated with radioactive iodine. She was given a much larger dose, large enough to literally destroy the overactive gland. Today she takes thyroid hormone pills in just the right amount to make up for what her gland can no longer produce.

 GUTTLER: How about till, tell me when.LANGFORD: Now.GUTTLER: Now.ULENE: Some patients with Grave’s disease, like Mary Ann Langford, also have problems with their eyes. This protrusion caused by swelling in the muscles behind the eyes.LANGFORD: It felt like someone holding my eyes open, and blowing, and going outside in bright sunlight. My eyes would water so badly that I couldn’t see.ULENE: Recently, Mary Ann underwent surgery to extend the length of one of her eyelids. Now she can close that eye, and is much more comfortable. The hyperthyroidism also caused changes in her skin,which required treatment with cortisone cream. Her problems continue today, even though her thyroid gland was removed twenty-five years ago.GUTTLER: She’s a classic example of how you have Grave’s disease for your whole life. You don’t just have Grave’s disease when your thyroid’s overactive. You can have trouble with your eyes and your skin your whole life, and that’s exactly what happened to her.ULENE: Lily O’Neary is at the opposite end of the spectrum.
LILY O’NEARY: My thyroid is hypro–it doesn’t work. So, I tired, I’m gaining weight, I had a headache.ULENE: Lily had the classic symptoms of an underactive or hypoactive thyroid. She was always tired, gaining weight, her face and hands were puffy, her reflexes were slow, and her hair and skin were dry. Dr.Guttler noticed that her thyroid gland was enlarged, a condition called goiter. A blood test confirmed that she had an underactive or hypothyroid condition, and she’s begun taking synthetic thyroid hormone to normalize her body’s metabolism.GUTTLER: Luckily, we have available the exact human thyroid, synthetically made in a factory, which is exactly what your thyroid makes, so we can just get you your thyroid function back in a pill. And the use of thyroid medication is what turned her around.ULENE: When your thyroid gland is overactive or underactive symptoms will appear, although they may occur so gradually it takes a long time to notice them.
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Thyroid Cancer 101: Most Q of L Issues Come from Surgery Complications and Radioiodine Therapy
Dr.Guttler’s comments:
1. There are many reasons to get second opinions before your thyroid surgery of radioiodine therapy for thyroid cancer.
2. This paper show the drop off in quality of life  for thyroid cancer patients from postoperative hypocalcemia
, dysphonia, dysphagia, scar appearance
, and complications from radioactive iodine.
3. More aggressive treatments ( total thyroidectomies, and radioiodine) and greater treatment-related adverse effects are associated with worse HRQOL scores in thyroid cancer survivors.
4.Thyroid cancer survivors (n = 1,743) reported a high incidence of complications related to surgery and radioactive iodine ablation.
5.Post surgery voice changes and trouble swallowing were associated with decreased Quality of Life.
Vocal cord paralysis
6.Short- or long-term complications of radioactive iodine, including gastrointestinal symptoms (51.9%), appetite changes (71.2%), sialadenitis (58.1%),
xerostomia (73.3%),
and xerophthalmia (45.1%)
were associated with worse quality of life.
7. A second opinion can find you dont have cancer even though the biopsy was positive. There is a benign tumor called papillary thyroid cancer the past that is now a benign thyroid tumor( NIFT-P ). A less aggressive surgery ( lobectomy) is only needed for diagnosis.
8. Some cancers are too small and show no signs of invasion and can be treated without surgery or radioiodine. This is called active surveillance.
9. Some of these small cancers if the patient does not want to have it in their neck for years can have alternative treatment with ethanol or radiofrequency.
10.Thyroid cancers have different mutations. Some mutations ( RAS ) suggest a type that can be treated with simple lobectomy.
11. Only the most aggressive thyroid cancers need total and radioiodine.
12. Save yourself from a lifetime of complications and poor quality of life by seeing a thyroid expert before the surgery.
13. Call 310-393-8860 or thyroid.manager@protonmail.com for my opinion.
Dr.G.
Surgery. 2019 Mar 18. pii: S0039-6060(19)30066-2. doi: 10.1016/j.surg.2019.01.034. [Epub ahead of print]
Clinical factors associated with worse quality-of-life scores in United States thyroid cancer survivors.
Abstract
INTRODUCTION:

Thyroid cancer survivors are a rapidly growing population in the United States. The factors that drive health-related quality of life (HRQOL) in this population have not been well characterized. We hypothesized that more aggressive treatments and greater treatment-related adverse effects would be associated with worse HRQOL scores in thyroid cancer survivors.

METHODS:

Thyroid cancer survivors (18-89 years of age) completed an online survey regarding their clinical history in addition to the Patient-Reported Outcomes Measurement Information System (PROMIS) 29 instrument. Univariable and multivariable modeling were performed to evaluate factors associated with worse HRQOL scores. We generated β-values and 95% confidence intervals to quantify the effect of each independent variable in the model.

RESULTS:

Thyroid cancer survivors (n = 1,743) reported a high incidence of complications related to surgery and radioactive iodine ablation. Postoperative dysphonia (ß 1.83-3.07) and dysphagia (ß 2.05-3.65) predicted worse HRQOL scores across multiple PROMIS domains. Younger patient age (age <45 years) and short- or long-term complications of radioactive iodine, including gastrointestinal symptoms (51.9%), appetite changes (71.2%), sialadenitis (58.1%), xerostomia (73.3%), and xerophthalmia (45.1%) were associated with worse HRQOL scores (P < .01).

CONCLUSION:

The factors associated with significantly worse HRQOL scores across multiple PROMIS domains for thyroid cancer survivors included patient age <45 years, postoperative hypocalcemia, dysphonia, dysphagia, scar appearance, and complications from radioactive iodine. Methods of evaluation, management, and prevention of these factors might positively impact HRQOL.

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Thyroid Cancer 101: What was in Ron Darling’s Chest?

Dr.Guttler’s Comments:

  1. It is rare to remove a lung metastatic mass, but not the lymph nodes that are in the upper chest area that can harbor lymph node metastasis. The prognosis is very different. Lymph nodes are just an extension of the local regional disease of the neck with good prognosis. However metastatic disease to the lungs is distant spread and has a worse prognosis.
  2. Thyroid cancer to the lungs is not usually a mass resected by surgery, but as diffuse disease treated by radioiodine as shown above.
  3. However a mass of upper chest metastatic thyroid cancer lymph nodes can be surgically removed.
  4. My last case with recurrent mass in the upper chest from papillary thyroid cancer had a second surgery to remove a CT guided biopsy proven metastatic lymph node metastasis mass in the upper chest. The lymph nodes came out as a  single “cluster of grapes”. The patient is alive and well 10 years after. This was not lung metastasis but regional local lymph node cancer which has a better prognosis.
  5. The diagram shows about 5 % of cancer lymph nodes are in level VII down in the upper chest area where my patient’s mass was a cluster of lymph nodes.
  6. Good luck to Mr.Darling either way.
Ron Darling diagnosed with thyroid cancer
Mets broadcaster and former pitcher Ron Darling announced on Monday he has thyroid cancer.

“After the removal of the mass on my chest along with further tests, I have been diagnosed with thyroid cancer,” Darling said in a statement.

“My doctors have said they are optimistic that the cancer is treatable and that I would be back on air talking baseball in the next month or so. I would also like to take this opportunity to thank everybody for their continued support.”

Mets land rooting for Ron Darling during tough times

Darling was a key member of the Mets’ 1986 World Series team and has been in the booth for the team since 2006, alongside Keith Hernandez and play-by-play man Gary Cohen.

“My heart goes out to Ron Darling. I know that Ron will beat this insidious disease,” Hernandez wrote on Twitter. “I’m heartened to hear that his doctors are very optimistic for a full recovery. I will stop at my church this day and light a candle for Ron and his entire family. I look forward to RJ’s return.”

Darling also works national games for TBS and MLB Network.

“Upon receiving today’s update on Ron’s prognosis,” said a statement from Fred and Jeff Wilpon and Saul Katz, “we are comforted to know that his condition is treatable and look forward to seeing him back on the air soon.”

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Case history:

52 Y/O female with enlarging nodule and symptoms of tightness and does not like the bulging of the nodule that seen by others.She was depressed about the looks of visible nodule.

Her depression increased when told she needed surgery.

No family history and all thyroid tests were normal. She did not take thyroid hormone. She was told by her primary, local endocrinologist and surgeon that surgery was the only answer. She did not want to have her thyroid even partially removed. She googled my website and set up a consultation.

PE; A large visible nodule on the left.

US TIRADS 2 15 ml cystic nodule on the left.

USGFNA was benign class II. DNA mutations and classifier were both negative.( Asurgen now Interpace ).

She returned for ethanol ablation therapy. 12 cc of cyst fluid removed and 7 cc 200 proof medical grade ethanol injected under US guidance in my outpatient office. After a few minutes the ethanol was removed. The killing effect of ethanol on the cyst lining cells is immediate. She had only slight pain on removal of the needle and needed no pain medication. After 30 minutes she left for her office. She returned for follow up in 2 months. She was very happy the nodule was not visible anymore. By 2015 the cyst was gone.

She was very happy with the results.

The image was before with the left cystic nodule.

Call me at 310-393-8860 or email to thyroid.manager@protonmail.com for treatemtn of benign thyroid nodules without surgery.

Dr.G.

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  •  Hashimoto/Graves’ Diseases Together: A patient in her own words.
  • K.B.

    “Dr. Guttler FIXED ME!. I went to 4 other doctors before I got to Dr. Guttler. NONE of them understood thyroid well enough to figure out my problem.  I found Dr. Guttler in 2008.  My daughter has acute Hashimoto’s Thyroiditis.  I have Hashimoto’s and Graves Disease (Hashi-toxicosis).  I went to a physician in Pasadena who told me that I needed to visit my OBGYN.  I had eyelid retraction, bulging eyeballs and double vision.for some reason, my internist did not find my eyelid retraction disturbing or concerning.  FOUR Ophthalmologists told me I had glaucoma.  I had Thyroid Eye Disease!!!!! Please understand that one can go blind using glaucoma drops when one does not have glaucoma but has thyroid eye disease.  I found out that thyroid is not taught in medical school.  To truly understand the thyroid, a doctor has to study and specialize in thyroid, not just endocrine.
    Dr. Guttler takes your blood himself in his office.  I LOVE IT.  He also does the ultrasound right in his office. I had developed nodules on my thyroid, my hair was falling out, I had bleeding fibroids, wasn’t sleeping well, thin nails and I was freezing all the time in addition to my pronounced eyelid retraction. NO ONE TOLD ME!  Luckily those nodules were benign.  I had gotten a physical from my internist every year.  The “normal” thyroid panel often does not reflect a problem. The correct blood tests can’t be ordered if the doctor doesn’t know how to order the proper blood tests.  Dr. Guttler is the ONLY Thyroid Endocrinologist that I have met that knows what he is doing. After three months on Synthroid my eyes went back in my head and my hair grew back at the temples. I immediately began sleeping more soundly.  I also lost the ten pounds that wouldn’t come off. It was amazing. ”

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 Thyroid No Surgery: Ethanol Ablation instead of Surgery. One Patient’s Review.
  • Mary B.
  • Valencia California
  • In her own words
8/9/2018

“I went to see Dr. Guttler with a large fluid filled cyst/nodule on my thyroid. All the doctors I had seen previously recommended surgery to take out the thyroid. They all claimed not to know about any other treatments which seemed really fishy to me. Anyway, I googled for alternatives and thankfully found Dr. Guttler in Santa Monica. He performs a treatment called PEI – percutaneous ethanol injection – that got rid of the cyst in just one office visit! No surgery and only minimal discomfort. I just got back from a follow up visit with ultrasound a year later and that thing is still gone! I still can’t believe that this problem was so easy to treat and without the pain, risk and recovery of surgery. No hospital, minimal pain and no scarring. If you have any sort of thyroid issues or you’re getting conflicting information, I highly recommend you see. Dr. Guttler!”

DR.Guttler’s Comments:

  1. This is a common theme about ethanol ablation. Many physicians recommend surgery and think PEI is dangerous and painful.
  2. Those comments are completely wrong. PEI is safe and only mild pain occurs.
  3. It is the treatment of choice but why do so many fail to take advantage of this outpatient procedure?
  4. Patients have to find physicians doing PEI on the internet as their physicians failed to inform them it was an alternative first line therapy.
  5. Call me at 310-393-8860 or email to thyroid.manager@protonnail.com for details.
  6. Keep your intact thyroid after PEI. Save your thyroid from the surgeon’s knife and lifetime of possible complications and thyroid hormone therapy.
  7. DR.G

Image of a PEI treatment of a large thyroid cyst with the needle in the center about to draw out the cyst fluid and put in the ethanol.

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Thyroid No Surgery: Why You Need a Second Opinion Before You have Thyroid Surgery: You may not need it! Stephanie in New York came to see me before she was on the list for thyroid surgery.

DR.Guttler’s Comments:

  1. This patient’s story is universal. As soon as the primary send the patient to get an ultrasound and biopsy and the results are suspicious the knee jerk reaction is to send them to their local surgeon bypassing the local endocrinologist. The surgeon recommends surgery of course.
  2. The patient must be their own advocate and request outside second opinion as seen with this patient.
  3. My opinion after a complete re-evaluation and adding DNA mutation studies was the nodule was not suspicious and was benign.
  4. The second opinion saved her from thyroid surgery.
  5. The hospital stay, surgery, post op recovery, possible complications, and loss of work were not going to happen Stephanie.
  6. Call me at 310-393-8860 or email to thyroid.manager@protonmail.com for my opinion before you go to surgery.
  7. Thyroid surgery is elective and there is no rush to have the surgery.
  8. The is time to search for second opinions.

Stephanie from New York

12/14/2018

“I went to see Dr. Guttler after I was misdiagnosed going to a “top endocrine surgeon.” The endocrine surgeon’s biopsy technique was faulty and gave a false reading. Dr. Guttler did the thyroid tests CORRECTLY in his office.. the ultrasound, biopsy, and cancer markers & blood test. When the endocrine surgeon wanted to do surgery and do a lobectomy, Dr. Guttler found that it was completely unnecessary! He also found many other things that the endocrine surgeon did not! Not only did this doctor save my life, but he also has an impeccable bedside manner! Please go see him before you have thyroid surgery. It may just save your life too…

Also, his nurse Alicia is fantastic! She is so quick and helpful with everything!! Thank you Dr. Guttler and Alicia!!”

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