10/27/04 Day three, since we discovered that Justice Rehnquist has thyroid cancer. The major news coverage has decreased, but the speculation, that he has a fatal cancer is growing. With one week to go, will it effect the vote? Check out a blog called Notes on ABCnews.com, for insider political scoop on this story.
Dr.G.

10/26/2004 Unraveling Thyroid cancer mystery, surrounding Chief Justice Rehnquist of the Supreme Court. Day 2 after the bombshell that he had thyroid cancer, it is now clear that he did not have a thyroidiectomy, but just a tracheostomy. This rules out surgical complications as the cause of the tracheostomy. The outlook now is very gloomy. Usually they open the neck and remove the cancerous thyroid gland. If they planned to only open the airpipe, without removing the thyroid, it usually means the thyroid was not intended to be removed. Usually it means a type of thyroid cancer that is not treated with surgery. There is only 2 cancers that may not be removed. One is a thyroid lymphoma, which is best treated by Radiation, and chemotherapy, and the other is the rare anaplastic thyroid cancer. This cancer grows so fast, that there is barely enough time to get ones personal effects in order. Death is rapid and usually is caused by local growth and choking to death. This may explain the early tracheostomy. The chance he will return to work is approaching zero. The ploy to act like everything will be alright, with return to work in 2 weeks, is to decrease the effect on the presidential election. The one year survival for this type of thyroid cancer is 0%. Compare that to the 20 year survival of 99% for regular papillary thyroid cancer. Dr.G.

10/25/2004 Update 9 PM In 30 years taking care of thyroid patients, including thyroid cancer, I have had only one case of mine needing a tracheostomy. This patient had an emergency bleed, which choked off his airpipe.After a few weeks, the tube was removed and he was normal. Post operative complications could be a leading cause. I was involved in a legal case as an expert witness for the defense of a surgeon, who caused a teenager to need a permanent tracheostomy, when a difficult surgery for thyroid cancer, injured both recurrent nerves. The tumor may

invade the nerves, and have to be sacrificed. Also this can occur due to malpractice. The other possibilitity is that it is a rare form of aggressive thyroid cancer. The worst case would be an Anaplastic Thyroid cancer.He is the right age, 80, as most patients with anaplastic are elderly. He was hoarse for some time recently.This could be a clue that the nerves to his voice box was being invaded by tumor. He also had radiation therapy for a previous tumor.That may have been the initial factor in his developing thyroid cancer. And lastly, he may have had a long standing undescovered thyroid condition, or tumor, that was the preliminary disease that was the site of the conversion to an anaplastic cancer.Also, long standing Hashimoto's Lymphocytic thyroiditis, in the elderly can be the site of lymphoma developing in the thyroid gland.I have seen 5 cases in 30 years of lymphoma in the elderly with Hashimoto's thyroiditis. All this is expert guess work on my part. I wish him well, and I hope I am wrong about the poor start to his therapy for thyroid cancer of unknown type.

The patients with anaplastic thyroid cancer, usually live only a few months after the diagnosis. In 30 years, I have seen 8 cases, and all had a rapid ,fatal outcome in 6-8 months of less. Dr.G. email comments to dr.guttler@thyroid.com

10/25/04 Chief Justice Rehnquist of the Supreme Court of the USA has Thyroid cancer. Expert thyroid Cancer doctor has opinions on his case. Also why he had to have a tracheotomy. Check out www.thyroid.com



Dr.G.

Daily diary of a thyroid doctor on his rounds in his



thyroid center, and on his virtual web consultations.







OCTOBER 2004 10/22/2004 Men usually are not good thyroid patients.I saw a 68 year old male with severe hypothyroidism secondary to radiation therapy for throat cancer 2 years ago. Also he had very high lipids, and high blood pressure. He was in denial about his heart. I refused to treat him until his heart was evaluated. 60% obstruction of the Left anterior descending corornary, was seen on angiogram. He has failed to return to the heart specialist, and continues to have hypothyroidism. When I tried to return him to euthyroidism with T4 he developed chest pain. He is very stuborn, and one year later is still hypothyroid on incomplete T4 therapy, and is just like an Emu with is head in the sand. Why men are usually the last to know they have severe thyroid disease, is unkown. I usually see them when they present with acute heart attack, and a thyroid screen shows they are also hypothyroid! They have no clue, that they have thyroid disease, and can rationalize away the most obvious thyroid symptom, as due to hard work or age. They tend to not listen to my medical advice, or follow up on their therapy. They also do not listen to their wife, when the wife suggests a visit to the doctor to look into some of their symptoms.

10/21/2004 Neck Tatoo to ward off Goiter. The patient today is 86 years old. She developed a small goiter as a teen in Iran. In order to stop the goiter from growing,a tatoo was placed on her neck over the thyroid area. The real cause of her goiter was iodine deficiency which was endemic in Iran. She followed her children to the USA. The magic of the tatoo was
broken when she began to choke. She had a very large goiter. It grew down into her upper chest area.
It pushed the air pipe to one side of the midline. She was not a candidate for surgery, even though she had obstructive symptoms. Her heart was too weak. I elected to treat her with radioiodine. However, the iodine uptake was too low, 16% at 24 hours. After one dose of 0.1 mg Thyrogen IM, her uptake increased to 61%. I gave her 30 Millicuries I/131. She had no complications, and had reduced her goiter enough to relieve her choking symptoms. The tatoo did not ward off the goiter, but modern medical non-surgical therapy stopped the growth, and even decreased it by 46%.Dr.G.

10/20/2004 Progressive Graves' Opthalmopathy Treated by combined Total Thyroidectomy, followed by ablation radioiodine therapy.The male patient today is 35, and returns after combined therapy for Graves' Hyperthyroidism. When he first saw me he was toxic, FT4 4.6, TSH <0.01. He had been taking PTU medical therapy for one year. He had received a course of steroids for worsening Graves' eye involvement. He had progression of the eye disease on PTU. We discussed definitive therapy. I told him there was a 20% chance that the eye disease may continue to get worse after radioiodine. I told him about recent studies showing burn out of the eye disease by 2 years, after total thyroidectomy, followed by ablation of the remnant left after surgery with radioiodine. This appears to remove the source of the antigen that stimulates the eye disease. He elected to have the surgery. He returned post op, and when he was scanned there was two focal areas of remnant thyroid left. The 24 hour uptake was 8%. He received an ablation dose of I/131. He has not shown any progression since the onset of combined definitive therapy over the year ago. The eye symptoms are improved, but the proptosis is unchanged. The Mayo Clinic studies on a cohort of 119 in Olmstead County, revealed about 20% developed eye disease over the next 5 years after radioiodine therapy. That is twice as many as had the eye disease before therapy.Thyroid 14:9: September 2004 page 716.

10/19/2004 Radioiodine Therapy for Nontoxic Goiter.The patient was 60 years old with a large nodular goiter, osteoporsis, and a long history of taking Armour thyroid with no response. The pretreatment goiter was > 6 cm on the right and 5.5 cm on the left, with a 3.6 cm benign nodule that was biopsied multiple times and was a colloid nodule.

Because of her bone disease, and age, she was not

interested in either high dose T4 therapy or surgery.

She was informed about the use of Radioiodine to treat her goiter. However the radioiodine uptake was low, 5.5% at 6 hours. She elected to receive Thyrogen Stimulation to increase the 24 hour uptake to 55%, 72 hours after a single shot of 0.1 mg thyrogen I.M. She received 15 MCI I/131. She had no complications, from the therapy. 18 months later, her goiter had decreased by 50%. Her nodule decreased from 3.6 to 2.1 cm.

She only takes a replacement dose of T4.

Dr.G.

10/15/2004 Taking thyroid, but is it really needed? Today I faced a difficult problem, related to a female patient that was put on thyroid hormone by her primary care physician. The pretreatment TSH was normal. She had been on excess thyroid hormone off and on for several years. She still was gaining weight. Her neck exam was negative, and her thyroid ultrasound was normal. I convinced her to try to see if she may not need to take thyroid hormone. After 4 weeks on T3, she had enough T4 in her blood sample to make it likely that her thyroid was indeed normal. After 2 weeks off T3 she had almost normal TSH, and FT4. However, she felt "hypothyroid", and had weight gain and a puffy looking face. This was the hardest time. She was sure she was hypothyroid.I told her the withdrawal from T4 causes symptoms similar to hypo- thyroidism. By 6 weeks off thyroid she had normal FT4 and TSH. She still was slightly puffy, but felt better. She returned 10 weeks off therapy and was markedly improved. She was another example of over zealous use of thyroid hormone to treat symptoms that were not due to "real thyroid failure. Dr.G.