Vol. 2, Issue 1
Thyroid A W A R E N E S S Thyroid Nodule Disease:
“Don’t Sweat the Small Stuff” page 6
Thyroid Cancer and
Chemotherapy page 10
American Thyroid Association Revised Guidelines for the Management of Patients with Thyroid Nodules and Differentiated Thyroid Cancer: A Summary
Power of Prevention is a public health awareness initiative dedicated to giving patients the resources they need to live healthier lives. For more than five years, Power of Prevention has been educating patients about a variety of endocrine conditions, including diabetes, thyroid dysfunction and obesity.
Thyroid Awareness Month
Ta b l e o f C o n t e n t s Thyroid Nodule Disease:
American Thyroid Association
“Don’t Sweat the Small Stuff” . . . . . . . . . . . . . . . 6 A look at the real implications of a thyroid nodule, and how they are often little cause for concern.
Hypothyroidism In Women . . . . . .
Symptoms and treatment options for this most common type of thyroid disease.
Revised Guidelines for the Management of Patients with Thyroid Nodules and Differentiated Thyroid Cancer: A Summary . .
New clinical research from the last three years has prompted an updated set of guidelines for the management of thyroid nodules and thyroid cancer.
THYCA: Thyroid Cancer Survivors’ Association Marks 15 Years of Service . . . 16 Thyroid Awareness Month Handouts
Thyroid Cancer and
Chemotherapy . . . . . . . . . . 10 The past five years have seen promising breakthroughs in new treatments for advanced thyroid cancer.
A Dentist Appointment
I’ll Never Forget . . . . . . . . . 12 How a routine trip to the dentist shed light on a case of papillary thyroid cancer.
Hypothyroidism . . . . . . . . . . . . . . . Hyperthyroidism . . . . . . . . . . . . . . The Thyroid, Pregnancy and Infancy . Hashimoto’s Thyroiditis . . . . . . . . . Thyroid Cancer . . . . . . . . . . . . . . . Radioiodine Therapy . . . . . . . . . . . Thyroid Nodules . . . . . . . . . . . . . . .
17–18 19–20 21–22 23–24 25–26 27–28 29–30
Check . . . . . . . . 31
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Thyroid Awareness Month Dear Reader, Thank you for reading the second annual “Thyroid Awareness” issue of the Power of Prevention magazine. This magazine is being distributed throughout the nation in the offices of endocrinologists who belong to the American Association of Clinical Endocrinologists (AACE). AACE is a professional medical organization with more than 6,000 members in the United States and 91 other countries. Founded in 1991, AACE is dedicated to the optimal care of patients with endocrine problems. Clinical endocrinologists specialize in diagnosing and treating thyroid disease, diabetes and osteoporosis, which have reached epidemic proportions in the United States. AACE initiatives inform the public about endocrine disorders and the Association also conducts continuing education programs for clinical endocrinologists.
This issue of the magazine was published by the American College of Endocrinology (ACE), the scientific arm of AACE. It will focus squarely on the thyroid. The magazine is one component of our sixteen year old campaign, “Thyroid Awareness Month.” Through the years, we have worked diligently with a single charge: Educate the millions of Americans with diagnosed or yet to be diagnosed thyroid condition about the signs and symptoms of thyroid disease. As many as 27 million Americans may suffer from a thyroid condition. Of that number, approximately half still remain undiagnosed. If you don’t suffer from some type of thyroid disorder, there is a good chance that someone you know does (a close relative, your neighbor, or a friend). The 2010 edition of the Power of Prevention: “Thyroid Awareness Month” issue covers important topics such as hypothyroidism, hyperthyroidism, Hashimoto’s thyroiditis, thyroid nodules, thyroid cancer, radioiodine therapy, the importance of the thyroid in infancy & pregnancy as well as instructions for performing the Neck Check®. In addition to the magazine, we encourage you to begin following AACE and Power of Prevention via Facebook (www.facebook.com/theaace) and Twitter (@theaace, @pwrofprevention). This way you can get not only Thyroid Awareness-related news, but news on all endocrine-related topics throughout the year. On the Power of Prevention Web site, www.powerofprevention.com, you can read patient stories, learn how to take the thyroid “Neck Check” and review a list of the “Top 10 Things You Should Know About Your Thyroid.” For women considering pregnancy, the website even has a list of the “Things Every Mother Should Know.” Thanks again for checking out a copy of the Power of Prevention magazine. I hope that you will find it useful and informative and I encourage you to share the information in these pages with your family and friends. I would like to leave you with one sentiment that we’ve repeated every year since “Thyroid Awareness Month” started, sixteen years ago: If your thyroid isn’t working properly, neither are you!
Thank you, jeffrey r. garber, md, facp, face AACE President and Power of Prevention Magazine Guest Editor
Jeffrey R. Garber, MD, FACP, FACE, studied mathematics at Cornell University before becoming a member of the first medical school class of the State University of New York’s Health Sciences Center at Stony Brook. He was an intern, resident and resident supervisor at LA County USC Medical Center. He returned east to be an endocrine fellow working under Sidney Ingbar in the Harvard Thorndike Laboratory at Boston’s Beth Israel Hospital (BIH). After six years at BIH, he entered private practice while simultaneously establishing the Endocrine Division at Harvard Community Health Plan, now known as Harvard Vanguard Medical Associates. Dr. Garber is presently Chief of Endocrinology at Harvard Vanguard Medical Associates and a member of the Beth Israel Deaconess Medical Center and Brigham and Women’s Hospitals endocrine divisions. He is an Associate Professor of Medicine at Harvard Medical School, where he has played a substantive role in the clinical training of more than thirty-five endocrine fellows. Presently, Dr. Garber is President of the American Association of Clinical Endocrinologists (AACE) He served as an AACE liaison to the American Thyroid Association (ATA) while he simultaneously served on both organizations’ boards for four years. He has taken an active role in promoting and reviewing AACE’s publications and positions in a number of clinical areas, most notably those pertaining to thyroid disease, in various arenas such as FDA hearings. He is currently on the AACE/ATA clinical practice guideline committees on hyperthyroidism and hypothyroidism, which he co-chairs. His book, The Harvard Medical School Guide to Overcoming Thyroid Problems was written for members of the lay public interested in learning about thyroid disorders.
Thyroid Nodule Disease: “don’t sweat the small stuff” B y D r . d a n i e l s . d u i c k
he thyroid gl and is located in the lower half of the neck in the midline - in the front of the wind pipe, below the voice box (larynx) and above the breast bone (sternum). The butterfly shaped gland produces thyroid hormone to help regulate body metabolism and maintain all body tissues and systems. The thyroid can develop a number of structural abnormalities. The entire thyroid may enlarge, which is known as a goiter. A single lump or nodule may appear without the remainder of the thyroid becoming enlarged. Multiple nodules may be present in an enlarged gland known as a multinodular goiter. Another term for nodule is tumor. Either term raises a patient's immediate concern about cancer. Yet, the actual overall risk of a thyroid nodule being malignant is actually quite small - about 1 out of every 20 nodules or 5% of diagnosed nodules are eventually proven to be malignant or cancerous.
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Certain features of a patient's history, physical findings and ultrasound imaging findings may suggest an increased risk or greater than a 5% average chance of malignancy: History • • • •
Family members with thyroid cancer Prior neck radiation therapy Prior malignancy of another kind Hoarse voice
Physical findings • A "hard" nodule • A "fixed" nodule that does not move when a physician pushes it with his or her fingers U lt r a s o u n d F e a t u r e s • • •
Microcalcifications Increased blood flow within a nodule detected by Doppler flow imaging. Irregular margins
A Diagnostic Ultrasound exam is the key test to es"incidental,” “silent," and seldom progressive, 10 miltablish whether a nodule may or may not need a dilimeter or less thyroid cancer in their neck, which will agnostic Fine Needle Aspiration Biopsy (FNAB). most likely never progress and become a problem in FNAB as the name indicates uses a very thin needle their lifetime. It is estimated that the number of these to sample a nodule. It is a protumors that continue to enlarge is cedure that is generally very well only around 1-2 % while 98-99% tolerated by patients. Selection is remain silent and non-problemat“…At any given time in adultimportant. Women over 40 have ic throughout adulthood. hood, seventeen to twenty a 40-50% chance of having one million or more Americans or more nodules detectable on When a larger thyroid nodule are walking around with an ultrasound that are "small" or 10 is found and is greater than 20 “incidental,” “silent,” and millimeters or less in diameter, millimeters or 2 centimeters, the seldom progressive, 10 which is slightly smaller than a same proportion, about 1 in 20 dime (a dime is 13 millimeters are malignant, but the risk begins millimeter or less thyroid in diameter). Moreover, the great to climb. Although the ability to cancer in their neck, which majority of these nodules is becure such cancers is still high it is will most likely never prognign and can be monitored over lower than it is for smaller canress and become a probtime without the need for aspicers. Whenever fine needle aspilem in their lifetime.” ration biopsy. If the nodule enration biopsy material in smaller larges, FNAB may be indicated. (but growing) nodules or in larger nodules is diagnostic of cancer or raises the possibility that cancer is present, denoted A small thyroid nodule that could be cancerous does by the terms "indeterminate" or "suspicious," surgery not have the same implications as a similar size nodule is recommended for therapeutic or diagnostic reasons. found in the breast or prostate. In the latter instances there is generally a far greater chance of a rapidly proAdditional information related to thyroid nodules gressing and spreading malignancy. Even more astoundand thyroid cancer can be located at the AACE Power ing is the fact that the most common type of thyroid of Prevention website at www.powerofprevention. cancer, papillary thyroid cancer that comprises 80 to 90 com by simply clicking on the Quick Links section % of all newly diagnosed and treated cases annually may related to thyroid diseases. have already been present for 10 to 20 years or more. How do we know this and why do we say the risk is very small for thyroid nodules that are 10 millimeters or smaller? Interestingly, numerous autopsy series of adults dying at all ages from another cause (such as auto accidents) have demonstrated the prevalence of these small cancers (6-16 %) and no difference in rates in 20-30 year olds versus any later decade in life. Thus, at any given time in adulthood, seventeen to twenty million or more Americans are walking around with an
Daniel S. Duick, MD, FACP, FACE, is the Immediate Past President of the American Association of Clinical Endocrinologists. He is an Illinois native and graduated from Northwestern University Medical School. He completed his medical residency and endocrinology fellowship training at both USC – Los Angeles County Hospital and Walter Reed Army Medical Center before serving two years of active duty in the Army. He subsequently joined the staff of Mayo Clinic (Rochester, MN) before moving to Phoenix, Arizona, where he served as the Director of the Internal Medicine Residency Training Program for 12 years at St Joseph’s Hospital and Medical Center. Dr. Duick then joined Endocrinology Associates, PA, in private practice in Phoenix. Dr. Duick has been an active and influential member of AACE. As Immediate Past President, Dr. Duick serves on the Board of Directors, as well as various AACE committees. POWER OF PREVENTION • Vol. 2, Issue 1
in women b y d r . d a n i e l e i n h o r n
ould it be my thyroid? This is one of the most commonly asked questions by women, especially to a clinical endocrinologist like me. The “it” usually refers to weight gain, fatigue, mood disturbance, sleep disturbance, hot or cold intolerance, and any one of dozens of similar concerns. Since the answer has to include that “it might be,” many thyroid tests are done even when the likelihood of thyroid disease is small. Since puberty, pregnancy, and menopause may cause identical symptoms to thyroid disease, those are the most common times women present with these symptoms. When thyroid disease does turn out to be the diagnosis, everybody is happy because the treatment is very satisfying, safe, and inexpensive. Most thyroid disease is autoimmune in nature, so it is not surprising that women have it 8 to 12 times more commonly than men. Most common of all is under active, or hypothyroidism, which affects between 12-30 million Americans, depending on how you define it. Symptoms include all those listed above, plus physical signs such as dry skin, hair, and nails, puffiness of hands and face, and, often, diffuse enlargement of the thyroid gland. Diagnosis must be made by lab test, however, since there are no diagnostic clinical features.
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Elevation of thyroid stimulating hormone (TSH) is the diagnostic hallmark of hypothyroidism. Controversy exists over what level of TSH should be considered high. Traditionally, the range of normal has been .350 to 5.500. However, some endocrinologists believe that any TSH above 3, in the presence of suggestive symptoms and signs or evidence of autoimmunity, should be considered possibly hypothyroid. Levels above 10 should be treated even in the absence of symptoms or signs because hypothyroidism can adversely impact blood pressure, cholesterol, and other cardiovascular risk factors. The elderly have higher TSHs and pregnant women have lower TSHs, often below 1 in the first trimester and below 2.5 throughout the pregnancy. There is some value to knowing whether you have the most common form of hypothyroidism, Hashimoto’s Disease, since that is highly inheritable, especially among the females in the family. Named after Dr. Hakaru Hashimoto, it is diagnosed by the presence of antibodies to components of the thyroid, anti-TPO and anti-microsomal antibodies. Often these make the gland hard rubbery and enlarged, sometimes with nodularity that can be mistaken for malignancy. This, like virtually all forms of hypothyroidism, is permanent. An exception is post-partum hypothyroidism, which can be temporary. As with postmenopausal hormone replacement therapy, there is a lot of art, as well as science, to thyroid replacement therapy. Generally L-thyroxine or T4 (brand names Synthroid Levoxyl or Levothroid) is recommended at the lowest dose where the woman feels optimal and has a normal TSH, generally in the 1-2 range. Generics are
“Most thyroid disease is autoimmune in nature, so it is not surprising that women have it 8 to 12 times more commonly than men. Most common of all is under active, or hypothyroidism, which affects between 12-30 million Americans, depending on how you define it.” very inexpensive and are fine for the majority of women. The brand may be worthwhile in especially sensitive women for whom variability in the bioavailability of generics is an issue. Always important is remembering to take the L-thyroxine first thing in the morning on an empty stomach and to wait at least a half hour before putting anything else in the stomach, including vitamins, iron, calcium, food, etc., since so many things can interfere with the absorption of thyroid.
used because the fetus cannot use T3 and is dependent on T4 to T3 conversion for normal growth and development during the first critical 12-14 weeks of pregnancy. During pregnancy, thyroid requirements may go up dramatically, and so thyroid levels should be followed closely in each trimester. In some patient populations such as the elderly and those with heart or bone problems, high-normal TSH levels in the mid to upper range of normal may be advisable.
Not recommended are forms of thyroid replacement that contain T3, such as dessicated thyroid (e.g., Armour) or are pure T3 (Cytomel). This bypasses the body’s highly regulated T4 to T3 conversion, wherein just so much of T4 is converted depending on the body’s needs at the time. Complications of over-replacement are more likely with T3, including cardiac dysrhythmias, anxiety, bone loss, etc. As with most everything in medicine, there are exceptions, and some women have unequivocal benefit from T3.
Thyroid levels should be rechecked and the history and exam be reviewed at least annually since everyone changes over time. More frequent evaluations are reasonable during times of more rapid change, such as in menopause.
Titrating the dose of thyroid is an art. There is a difference between being somewhere on the normal range and being at the optimal point on that range. I often give women at least a few different doses to try for several weeks each to see if they can tell which feels “right.” It is remarkable how much difference a small adjustment of thyroid hormone can make. Three special circumstances are worth noting. In prepregnant and pregnant women, only T4 should be
In the end, it should be clear for each woman that she is at her optimal level for thyroid hormone replacement. If related symptoms exist, they can be addressed by other, non-thyroid, means, and the thyroid part of the equation can be put to rest.
Daniel Einhorn, MD, FACP, FACE, is President Elect of the American Association of Clinical Endocrinologists (AACE). He was the 2005 recipient of the Yank D. Coble, Jr., MD, Distinguished Service Award from the American College of Endocrinology (ACE). In 2006, he was elected Secretary of AACE. Dr. Einhorn was Co-Chair of the ACE Task Force and the Consensus Conference on the Insulin Resistance Syndrome. He is past Chair of the Clinical Research Committee, Membership Committee, and the AACE 3000 Campaign and has served six years on the Board of Directors of AACE. He is on the Board and Executive Committee of the California Chapter of AACE and has participated in regional AACE programs. He has presented at national AACE meetings for the past 10 years on subjects ranging from the evolving role of the clinical endocrinologist to clinical strategies, devices, and novel compounds. He has chaired and served on many AACE committees, including Strategic Planning, Nominating, and International. He received his BA from Yale (Summa Cum Laude) and his MD from Tufts (Alpha Omega Alpha) before going on to training at the Beth Israel Hospital, Harvard Medical School. He did a residency in internal medicine, a year of psychiatry, and his Fellowship in endocrinology before going on to be an Instructor of Medicine at Harvard.
POWER OF PREVENTION • Vol. 2, Issue 1
Thyroid Cancer and chemoTherapy B y d r . s t e v e n i . s h e r m a n
n 2009, at least 36,000 persons in the United respond to prior therapy saw significant tumor shrinkStates were diagnosed with one of the various age when treated with one or both of these chemoforms of thyroid cancer, a number that has been therapies, and cure was rare. Side effects were considincreasing at a surprisingly rapid rate (See Dr. erable, including reduced blood counts, increased risk Cooper’s piece on pages 8-9 and our handout on for infections, hair loss, nausea, and vomiting. As a pages 19-20). Fortunately, most of these persons will result, traditional chemotherapies have only been recdo very well, and live long enough to die from someommended for patients with very advanced disease as thing other than their thyroid cancer. Surgery to rea “last ditch” effort. move the cancerous thyroid gland, often including As disappointing as these poor neck lymph nodes as well, is the results from chemotherapy primary treatment used. For the were, even more frustrating was most common thyroid cancers “As drug companies have the lack of success in develop(papillary or follicular cancer), recently created many ing more effective or safer treatmany patients are also treated new drugs that attack ments. Between 1975 and 2000, with radioactive iodine and angiogenesis or the abfew clinical trials testing new high doses of thyroid hormone. normal cancer proteins, therapies for thyroid cancer were Some individuals may experinew opportunities have started, and they usually failed ence cancer reoccurrence, and emerged for testing novel to attract enough participants to often additional surgery and/or test adequately new treatments. treatments for advanced radioactive iodine therapies are Further, pharmaceutical comcapable of adequately treating thyroid cancer.” panies were reluctant to devote these patients. sufficient resources to support Some patients with thyroid cancer, however, develop new drug development for the disease, given the small serious problems, including cancer that metastasizes numbers of patients who needed help and the failure (or spreads) outside the neck to the lungs, bones, or of earlier studies. other organs. More than 1,500 persons die each year because of complications of thyroid cancer. For these The past five years have seen a remarkable turnaround patients, traditional therapies are often ineffective. in these trends. First, scientists have discovered many Surgery, radioactive iodine, and radiation treatments key steps involved in the development of thyroid cancan occasionally reduce symptoms or treat problems cers that provide potential “targets” for therapy. For that emerge because of progressing cancer. But, these example, many cancers require the creation of new treatments rarely cure metastatic thyroid cancer. Like blood vessels (called “angiogenesis”) for them to grow other malignancies, chemotherapies have been tried. larger than a few millimeters or to invade and spread Drugs that are used for other forms of cancer, like to other parts of the body. Angiogenesis appears to doxorubicin (Adriamycin®) or cisplatinum (Cisplabe as critical for thyroid cancers as for more common tin®), were studied in the 1970s and 1980s, with litmalignancies like colon or lung cancer. Additionally, tle evidence of benefit. Only about one out of five genetic mutations in thyroid DNA that cause most patients with metastatic thyroid cancer that did not thyroid cancers have been discovered. These abnormal
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genes lead to production of abnormal proteins in the tumor cell that promote the growth of the cancer, but these abnormal proteins can also be targeted by drugs as a way to treat the disease. As drug companies have recently created many new drugs that attack angiogenesis or the abnormal cancer proteins, new opportunities have emerged for testing novel treatments for advanced thyroid cancer. Second, patients and their physicians have become more aware of the availability of clinical trials testing new therapies. Thyroid cancer patients are now being referred by their physicians to participate in all phases of trials of promising drugs, with considerable success. An example of this new approach was the early testing of the drug motesanib, an inhibitor of angiogenesis. Nearly one in ten of the cancer patients in the earliest trials testing this drug were patients with advanced thyroid cancer, and several of them had good responses to the treatment. An international clinical trial was then performed to test the drug specifically in patients with growing papillary or follicular thyroid cancers that would not respond to more conventional treatments like radioactive iodine. Unlike previous attempts at clinical trials, this one succeeded, filling up with more patients than were actually needed months ahead of schedule. More importantly, nearly three-quarters of patients with previously growing metastatic thyroid cancers either experienced significant tumor shrinkage or at least saw their tumors stop growing, often for many months. Other drugs have also been tested this way in the past several years as well. Evidence is mounting that the drug sorafenib (Nexavar®) might similarly stop the growth of metastatic thyroid cancer by blocking angiogenesis as well as by affecting one of the mutated proteins found in papillary thyroid cancer (called BRAF). Much research is now ongoing to try to find better treatments for advanced thyroid cancers. At The University of Texas M. D. Anderson Cancer Center (www. mdanderson.org), where I work, we are studying several different approaches and new drugs. Our thyroid cancer research team involves endocrinologists, surgeons, and medical oncologists including those who specialize in the very earliest of drug studies (called
“phase I trials”). Patients can find information about our studies as well as those being done elsewhere through the web site www.clinicaltrials.gov. Side effects from these treatments definitely occur, and patients need to be aware that problems like high blood pressure, diarrhea, fatigue, and bad skin rashes frequently occur with these new drugs. In some cases, skin cancers are appearing while patients are treated with certain drugs. Therefore, patients need to be carefully selected who truly need these treatments, and they and their physicians must be on the lookout for development of side effects that themselves could require treatment. But, for many of our patients, as long as the benefits of the new chemotherapies outweigh the side effects, we carefully push forward with their treatments. With these advances, organizations such as the American Thyroid Association and the National Comprehensive Cancer Network now recommend that patients with progressing or symptomatic metastatic thyroid cancer, not responding to more traditional therapies like surgery or radioiodine, should be referred to participate in clinical trials of new or experimental drug treatments. Such research is absolutely necessary if we are to develop improved therapies that can cure metastatic thyroid cancer. However, for those patients who cannot or choose not to enter a clinical trial, treatment with angiogenesis inhibitors like sorafenib which are available for the treatment of other cancers can now be considered as a potential helpful option. Steven I. Sherman, MD,
is the Naguib Samaan Distinguished Professor in Endocrinology, the Chair of the Department of Endocrine Neoplasia and Hormonal Disorders, and Medical Director of the Endocrine Multidisciplinary Center at The University of Texas M. D. Anderson Cancer Center in Houston, Texas. After graduating from Harvard College magna cum laude in Biochemistry and Molecular Biology, Dr. Sherman earned his medical degree from the Johns Hopkins School of Medicine in Baltimore, Maryland. He stayed at Johns Hopkins for his internship and residency in internal medicine, and clinical fellowship in endocrinology and metabolism. He joined the faculty at Johns Hopkins upon completion of his training, and in 1993 was recruited to the M.D. Anderson Cancer Center. Specializing in the management of patients with advanced endocrine malignancies, Dr. Sherman is Director of the National Thyroid Cancer Treatment Cooperative Study Group and serves as Treasurer of the International Thyroid Oncology Group. He has led numerous phase II clinical trials evaluating novel therapies for metastatic thyroid cancer. He is author or co-author of more than 80 peer-reviewed journal articles, including New England Journal of Medicine, Annals of Internal Medicine, Lancet, Journal of Clinical Endocrinology and Metabolism, and Journal of Clinical Oncology.
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a d e nt i s t a p p o intm ent
i ’ll n e v e r f o rg e t b y k a r e n a . av i ta b i l e
My dentist saved my life. Yes, my dentist. During a routine six-month cleaning, my dentist checked my neck and under my tongue. This was not foreign to me. He explained years earlier cancers of the throat, tongue and jaw were on the rise, and it is his job to make sure everything is normal with each patient. While feeling my neck, he noticed a lump on the right side. “It may be a swollen gland, but if it doesn’t go away in a few weeks visit your medical doctor,” he said. Nearing age 40, I led a busy life. In addition to my full-time job as a travel editor with AAA, I had just returned to college to pursue a second degree and volunteered in my community. I exercised regularly and watched my diet. I never had a swollen gland, but I didn’t think it was something that was going to slow me down – I couldn’t see the lump, it didn’t bother me and I felt perfectly fine. A week later, I visited my gynecologist for my annual exam. I told him what the dentist said and asked him to check my neck for a swollen gland. “Swollen gland?” he said. “That’s your thyroid and you should see your regular doctor.” OK, maybe there was something wrong with my thyroid, I thought. So if I have to take medication, it wasn’t the end of the world. I went to my general practitioner the next day. He scheduled blood work and an ultrasound to “see what’s going on.”
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Results of the blood work didn’t show any problems with my thyroid but the ultrasound showed a threecentimeter lump leaning on the right side of my thyroid. I was referred to a surgeon to discuss options. “You’ve got this large lump which will never go away,” the surgeon said. “In fact, it will probably get bigger. We can biopsy it to ensure it is not cancer, or just keep an eye on it. It’s your call.” “Is a biopsy going to tell us 100 percent if I have cancer?” I asked. “Nope. Ninety-five percent,” he said. That 5 percent gray area was all I needed to hear to make my decision -- I wanted to have the lump removed. This also meant removing the right side of the thyroid. In my mind, there was no way around it. I wasn’t willing to take a chance with my life. Prior to the surgery, my father was diagnosed with Lou Gehrig’s Disease, a progressive neurodegenerative disease which causes patients to become paralyzed and leads to death. He was one in 50,000 people annually diagnosed with this debilitating disease. I remember thinking those were crazy odds and certainly didn’t think I would be one of the over 35,000 people diagnosed with thyroid cancer each year. Some family and friends thought I was crazy for going through with the surgery. “Why don’t you just get it biopsied each year? Why would you want to remove most of a vital organ if you don’t have to?” some asked. The answer was simple – because I refused to gamble my life away.
The morning of the surgery, the doctor explained that it would take about 90 minutes to remove the right lobe of my thyroid. He added that they would be testing the right lobe for cancer. He asked if he could remove the whole thyroid if that was the case. I granted my permission. The clock on the wall was the first thing I saw in the recovery room when I woke up. I quickly did the math. More than three hours had passed. I knew this was a bad sign. My fears were confirmed when my doctor entered the room. “You had cancer,” he said. “We had to remove your entire thyroid.”
Within two months, I underwent radioactive iodine treatment – to ensure any remaining thyroid cells in my body would be destroyed – and another ultrasound. All tests came back negative for additional cancer. Four years later, I remain cancer-free. I see my endocrinologist every three months, have an annual ultrasound examination and ingest a small amount of radioactive iodine each year as a precaution. My endocrinologist monitors my TSH (thyroid stimulating hormone) levels. If they are either too high or too low, he may choose to increase or decrease my dose of levothyroxine. He also organizes my ultrasounds and radioactive iodine treatments.
When I arrived in my hospital room, I tried to compose myself before facing my family. “In a few minutes,” I repeated to a nurse who kept coming in to tell me my family was waiting to see me.
Other than that, I’m back to living the life I’m used to. I graduated from college for the second time in May 2009, still volunteer in the community, exercise and continue to travel the globe as part of my work at AAA. Of course, my levothyroxine is the first thing I pack now.
Like me, my family knew something was wrong based on the length of time the surgery took. My doctor gave them the news before they came in to see me.
When you first hear the word “cancer,” the natural response is fear. As I have come to learn firsthand, however, thyroid cancer is very treatable and manageable.
No one, especially me, could believe this had happened to me. The next morning, the nurse came in to give me my first dose of levothyroxine – a thyroid replacement medication that I would have to take daily for the rest of my life. I was not looking forward to what lie ahead, who would? In addition to my daily medication, I would have to undergo radioactive iodine therapy, ultrasounds and ongoing monitoring. After a few days, the lab tests confirmed I had papillary thyroid cancer, one of the more common types, and I was expected to make a full recovery.
I may be one in 25,000 people to be diagnosed with thyroid cancer, but I still consider myself lucky in many regards. And I thank my dentist every time I see him.
editor’s note We were delighted to receive Ms. Avitabile’s unsolicited contribution to our magazine. Previously, endocrinologists belonging to AACE submitted all magazine pieces featuring patients. Ms. A’s decision to undergo surgery regardless of the result of a biopsy based on her wishes to eliminate uncertainty is a well-accepted basis for having surgery. Although a fine needle aspiration may be inconclusive, it is standard practice to do one before surgery. In some cases, in addition to establishing whether or not to remove both sides of the thyroid, it could lead to further preoperative evaluation in order to determine whether even more extensive surgery such as lymph node removal will be required (see sections on thyroid cancer). While her family and friends advised her to “get it biopsied each year”, yearly biopsies are not necessary when a nodule appears to be benign and is not growing. Lastly, although yearly ultrasounds are routinely done for several years after papillary thyroid cancer is diagnosed, most cases do not require yearly radioactive iodine imaging.
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A m e r i c a n T h y r o i d A s s o c i at i o n r e v i s e d g u i d e l i n e s f o r t h e
management of patients with thyroid nodules and differentiated thyroid cancer: A summary b y d r . d a v i d s . c o o p e r
Chair, American Thyroid Association Thyroid Nodule and Thyroid Cancer Guidelines Task Force
n november, the American Thyroid Association published a revision of its "Guidelines for the Management of Thyroid Nodules and Thyroid Cancer" in its journal, Thyroid. The guidelines are available free to the public at the American Thyroid Association web site (www.thyroid.org). The revised guidelines represent two years of work and modernize the original "thyroid nodule and thyroid cancer guidelines" that were published in 2006. The impetus for the revision was the large number of new clinical research findings that had been published on this topic over the last three years. Also, thyroid cancer is an important topic because of its increasing incidence in the United States and around the world. Furthermore, thyroid nodules, or “lumps on the thyroid,” continue to be diagnosed with great frequency, possibly because of the widespread use of various imaging procedures (CAT scans, MRIs, carotid ultrasound) that detect thyroid nodules "incidentally" or "by accident" with increasing frequency. The guidelines are "evidence-based" which means that the various research studies that were reviewed by the task force were rated according to whether the study provided "good" or "fair" evidence that a particular test or treatment would be effective. For those interventions where there is very little good research, the task force made recommendations based on “expert opinion.”
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Diagnosing Thyroi d Cancer For the management of thyroid nodules (See Dr. Duick’s piece and the thyroid nodules information), the guidelines focus on how physicians should evaluate patients with thyroid nodules using laboratory tests, thyroid ultrasound, and other imaging tools such as thyroid scans. It is recommended that all patients with one or more suspected thyroid nodules have thyroid ultrasound performed for three reasons: to precisely measure the nodule’s size; to see whether other nodules may be present within the thyroid that can't be felt; and, importantly, to look at the ultrasound appearance of the nodule or nodules, since it is now known that the ultrasound characteristics of a nodule is very helpful in establishing the likelihood it may be benign or malignant. The guidelines then make recommendations, based on the size of the nodule, the ultrasound appearance of the nodule, and other criteria, for which patients should have their nodule biopsied or aspirated, using a fine needle under ultrasound guidance. The guideline task force believes that the revised guidelines may lead to fewer biopsies being performed in the future, since the appearance of the nodule on ultrasound rather than its size should play a greater role in deciding whether a biopsy is performed.
Treating Thyroi d Cancer The extent of surgery that is necessary for patients with thyroid cancer is another major topic discussed in the revised guidelines. The guidelines review criteria to
help decide which patients require a total thyroidectomy versus a simple lobectomy removing only half of the thyroid, and which patients should have removal of potentially involved lymph nodes in the neck near the thyroid at the time of surgery. Following surgery, many patients will receive radioactive iodine to destroy the small amount of thyroid tissue that was left behind, known as remnant thyroid tissue. The new guidelines review which patients should receive this form of therapy, and which patients can be followed without additional treatment. Recent studies suggest that radioactive iodine therapy is not necessary in many low risk patients, and the guidelines task force believes that the new recommendations will lead to fewer patients receiving radioactive iodine in the future. The guidelines also discuss how patients with thyroid cancer should be treated with thyroid hormone following thyroidectomy. Many patients benefit from relatively high doses of thyroid hormone, which will lower their serum TSH levels. The purpose of this relates to the fact that TSH, a hormone that normally appears in the blood stream, can be a growth factor for thyroid cancer. On the other hand, too much thyroid hormone may have side effects, especially in elderly patients (e.g., osteoporosis in postmenopausal women, heart rhythm disturbances, symptoms of nervousness and anxiety). The guidelines discuss how to maximize the beneficial effects of thyroid hormone and to minimize the potential complications of thyroid hormone therapy.
Following Patient s wit h Thyroid Can cer The new guidelines review the use of serum thyroglobulin measurements in thyroid cancer patients. Thyroglobulin is a thyroid protein made by either normal thyroid tissue or thyroid cancer. Therefore, after all thyroid tissue is removed or destroyed by surgery and radioactive iodine therapy, serum thyroglobulin serves as an important tumor marker that is used to monitor patients to detect persistent or recurrent disease. The interpretation of thyroglobulin levels requires a certain degree of expertise on the part of the physician.
The revised guidelines also discuss the management of patients with advanced thyroid cancer, and recommend that radioactive iodine therapy be used in some patients, while other patients may be suitable candidates for newer therapies that are still not yet approved for thyroid cancer management by the U.S. Food and Drug Administration (For more information, please see section by Steven Sherman). On the other hand, even patients with widespread disease may do well without any treatment at all, since thyroid cancer often progresses very slowly and may have few symptoms.
Future Thyroid Cancer Research Finally, the guidelines present a number of areas for future research that the task force felt were especially important. These include more information on how to manage widespread metastatic disease using newer chemotherapy agents, better understanding of the long-term outcome of patients with very minimal disease that is detectable only because their serum thyroglobulin levels are slightly elevated, and better ways of measuring serum thyroglobulin in patients who have anti-thyroglobulin antibodies. This last issue is a particularly vexing one for approximately 20% of thyroid cancer patients, in whom serum thyroglobulin cannot be measured accurately. The revised "thyroid nodule and thyroid cancer guidelines" is a "living document", and will be revised again in another 2-3 years. The field is moving rapidly, and the American Thyroid Association is dedicated to providing clinicians with the best and most up to date evidence to help them manage their patients who have thyroid nodules and thyroid cancer.
David S. Cooper, MD, is a graduate of Johns Hopkins University. He received his medical degree from Tufts University School of Medicine where he was elected to Alpha Omega Alpha, and completed his Internal Medicine residency at Barnes Hospital/Washington University School of Medicine. He completed his Endocrinology Fellowship training at the Massachusetts General Hospital/Harvard Medical School. He is Professor of Medicine and International Health at the Johns Hopkins University School of Medicine and the Bloomberg Johns Hopkins School of Public Health, and Director of the Johns Hopkins Thyroid Clinic. He is a Contributing Editor of the Journal of the American Medical Association (JAMA), and is the Deputy Editor of the Journal of Clinical Endocrinology and Metabolism. He also serves as Editor-in-Chief for Endocrinology at Up-to-Date. He is the current Chair of the Subspecialty Board for Endocrinology, Diabetes, and Metabolism of the American Board of Internal Medicine. Dr. Cooper is the past Treasurer and the past President of the American Thyroid Association, and is also the recipient of the American Thyroid Associationâ€™s Distinguished Service Award. POWER OF PREVENTION â€˘ Vol. 2, Issue 1
ThyCa: Thyroid Cancer Survivors’ Association (www.thyca.org) Marks 15th Year Serving Patients, Families, Professionals, and Public Support Services, Education, Conferences, Outreach, and Thyroid Cancer Research Grants b y G a r y B l o o m , R o s e l l e K o v i t z , C h e r r y W u n d e r l i c h
hyroid cancer, which occurs in people of all ages from young children though seniors, is now diagnosed in about 37,000 people in the United States each year. While the majority of cases are treatable, with an excellent prognosis, some will not be so fortunate. For everyone, a diagnosis of thyroid cancer is life changing, regardless of its severity.
ThyCa: Thyroid Cancer Survivors’ Association provides a broad range of free support services, publications, and events to help thyroid cancer patients, their families, caregivers, and friends. ThyCa’s free services and resources include 11 e-mail support groups and a Facebook presence serving over 10,500 participants. The Person-to-Person Network matches people seeking support with a volunteer with the same diagnosis. The Toll-Free Number Team and E-Mail Team provide one-toone support. More than 80 local support groups in 35 U.S. states, as well as Canada, Costa Rica, and Philippines, help survivors and caregivers meet others in their communities. ThyCa’s Web site (www.thyca.org) provides more than 650 pages of comprehensive, medically reviewed thyroid cancer information, plus connections to ThyCa services, events, and other organizations, including AACE. ThyCa receives ongoing input from its 33-member Medical Advisory Council and over two dozen additional thyroid cancer specialists. Free downloadable publications on the Web site include the widely used ThyCa Low-Iodine Cookbook, available in English, French, and Spanish with guidelines from ThyCa medical advisors and researchers, and over 250 delicious recipes. It helps people with papillary and follicular thyroid cancer prepare for radioiodine scans or treatments. ThyCa mails out free patient information packets and free pediatric backpacks. The free online newsletter ThyCa News Notes goes to more than 15,000 people each month. ThyCa also sponsors Thyroid Cancer Awareness Month in September, and year-round awareness campaigns. Free bulk materials for physicians, hospitals, and community groups include the Thyroid Cancer Awareness Brochure featuring actress Catherine Bell, a thyroid cancer survivor; a fine needle aspiration booklet in English and Spanish, plastic wallet cards, and “Do you have thyroid cancer” brochures. Free regional workshops feature physician speakers and will take place on Saturday, April 17, 2010, in Kansas City, Mis-
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souri; on Saturday, May 22, in Towson, Maryland; and on Saturday, May 29, in St. John’s, Newfoundland, Canada. The annual 3-day Thyroid Cancer Survivors’ Conference grows each year, with more than 450 thyroid cancer survivors, caregivers, and health care professionals gathering last October in Boston, Massachusetts, from around the United States, Brazil, Canada, Puerto Rico, and United Kingdom. The 100-plus sessions included nearly 50 physician-led sessions with more than 25 physician speakers. The 13th International Thyroid Cancer Survivors’ Conference will take place on October 15-17, 2010, in Dallas, Texas. The conference has a nominal registration fee of $50, or $30 for registrants/ guests, with scholarships for the registration fee available on request. ThyCa raises funds for thyroid cancer research to find cures for all thyroid cancer, recognizing that many have lost their lives to thyroid cancer. ThyCa awarded the first patient-funded thyroid cancer research grant in 2003 and has awarded grants every year since. It will award two new research grants in 2010. One project will focus on papillary, follicular, and anaplastic, and the other on medullary thyroid cancer. ThyCa grants are available to researchers worldwide. Recipients have included researchers at Cochin Institut, Harvard Medical School, Johns Hopkins University School of Medicine, Ohio State University and Medical University of Gdansk, Memorial Sloan-Kettering Cancer Center, RushPresbyterian-St. Luke's Medical Center, University Hospital Basel, University Hospital Duesseldorf, University of California Los Angeles/Veterans Affairs West Los Angeles Health Care System, and University of Texas M.D. Anderson Cancer Center. We thank the American Association of Clinical Endocrinologists for the opportunity to introduce ThyCa’s services and resources. We invite all AACE members to tell your patients about ThyCa’s Web site, free services and resources. We greatly appreciate the fine work that endocrinologists do in support of patient care and well-being, and in research toward cures for all thyroid cancer. For information or to request free materials, e-mail firstname.lastname@example.org, call 1-877-588-7904, fax to 1-630-6046078, write ThyCa: Thyroid Cancer Survivors’ Association, Inc., PO Box 1545, New York, NY 10159-1545, or visit www.thyca.org.
Hypothyroidism What is hypothyroidism?
ypothyroidism (underactivity of the thyroid gland) occurs when the thyroid gland produces less than the normal amount of thyroid hormone. The result is the “slowing down” of many bodily functions. Although hypothyroidism may be temporary, it usually is a permanent condition. Of the nearly 25 million people suffering from a thyroid condition, most have hypothyroidism.
What are the features of hypothyroidism? In its earliest stage, hypothyroidism may cause few symptoms, since the body has the ability to partially compensate for a failing thyroid gland by increasing the stimulation to it, much like pressing down on the accelerator when climbing a hill to keep the car going the same speed. As thyroid hormone production decreases and the body’s metabolism slows, a variety of features may result. • • • • • • • • • • • • •
Pervasive fatigue Drowsiness Forgetfulness Difficulty with learning Dry, brittle hair and nails Dry, itchy skin Puffy face Constipation Sore muscles Weight gain and fluid retention Heavy and/or irregular menstrual flow Increased frequency of miscarriages Increased sensitivity to many medications
What are the major causes of hypothyroidism? AUTO IMMUNE THYROI D ITIS (Hashimoto’s thyroiditis—separate brochure available) The body’s immune system may produce a reaction in the thyroid gland that results in hypothyroidism and, often a goiter (enlargement of the thyroid). Other autoimmune diseases may be associated with this disorder, and additional family members may also be affected.
RA D IOACTIVE IO D INE TREATMENT Hypothyroidism frequently develops as a desired therapeutic goal after the use of radioactive iodine treatment for hyperthyroidism THYROI D OPERATION Hypothyroidism may be related to surgery on the thyroid gland, especially if most of the thyroid has been removed. ME D ICATIONS Lithium, high doses of iodine, and amiodarone (Cordarone, Pacerone) can cause hypothyroidism. SU B ACUTE THYROI D ITIS This condition may follow a viral infection and is characterized by painful thyroid gland enlargement and inflammation, which results in the release of large amounts of thyroid hormone into the blood. Fortunately, this condition usually resolves spontaneously. The thyroid usually heals itself over several months, but often not before a temporary period of hypothyroidism occurs. POST PARTUM THYROI D ITIS Five percent to ten percent of women develop mild to moderate hyperthyroidism within several months of giving birth. Hyperthyroidism in this condition usually lasts for approximately one to two months. It is often followed by several months of hypothyroidism, but most women will eventually recover normal thyroid function. In some cases, however, the thyroid gland does not heal, so the hypothyroidism becomes permanent and requires lifelong thyroid hormone replacement. This condition may occur again with subsequent pregnancies. SILENT THYROI D ITIS Transient (temporary) hyperthyroidism can be caused by silent thyroiditis, a condition which appears to be the same as postpartum thyroiditis but not related to pregnancy. It is not accompanied by a painful thyroid gland. CON G ENITAL HYPOTHYROI D ISM An infant may be born with an inadequate amount of thyroid tissue or an enzyme defect that does not allow normal thyroid hormone production. If this condition is not treated promptly, physical stunting and/or mental damage (cretinism) may develop.
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CENTRAL HYPOTHYROI D ISM TSH is produced by the pituitary gland, which is located behind the nose at the base of the brain. Any destructive disease of the pituitary gland may cause damage to the cells that secrete Thyroid-Stimulating Hormone (TSH), which stimulates the thyroid to produce normal amounts of thyroid hormone. This is a rare cause of hypothyroidism.
How is hypothyroidism diagnosed? Characteristic symptoms and physical signs, which can be detected by a physician, can signal hypothyroidism. However, the condition may develop so slowly that many patients do not realize that their body has changed, so it is critically important to perform diagnostic laboratory tests to confirm the diagnosis and to determine the cause of hypothyroidism. TSH ( THYROI D – STIMULATIN G HORMONE OR THYROTROPIN ) TEST An increased TSH level in the blood is the most accurate indicator of primary (not central) hypothyroidism. Production of this pituitary hormone is increased when the thyroid gland even slightly underproduces thyroid hormone. OTHER TESTS •
Estimates of free thyroxine: the active thyroid hormone in the blood. It is important to note that there is a range of free thyroxine levels in the blood of normal people, similar to the range for height, and that a value of normal free thyroxine values for the general populations vary a great deal. Thyroid autoantibodies: indicates the likelihood of auto-immune thyroiditis being the cause of hypothyroidism. A primary care physician may make the diagnosis of hypothyroidism, but assistance is sometimes needed from an endocrinologist, a physician who is a specialist in thyroid diseases.
How is hypothyroidism treated? Hypothyroidism is generally treated with a single daily dose of levothyroxine, given as a tablet. An experienced physician can prescribe the correct form and dosage to return the thyroid balance to normal. Older patients who may have underlying heart disease are usually started at a low dose and gradually increased while younger healthy patients can be started on full replacement doses at once.
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Thyroid hormone acts very slowly in some parts of the body, so it may take several months after treatment for some features to improve. Since most cases of hypothyroidism are permanent and often progressive, it is usually necessary to treat this condition throughout one’s lifetime. Periodic monitoring of TSH levels and clinical status are necessary to ensure that the proper dose is being given, since medication doses may have to be adjusted from time to time. Optimal adjustment of thyroid hormone dosage is critical, since the body is very sensitive to even small changes in thyroid hormone levels. Levothyroxine tablets come in 12 different strengths, and it is essential to take them in a consistent manner every day. A dose of thyroid hormone that is too low may fail to prevent enlargement of the thyroid gland, allow symptoms of hypothyroidism to persist, and be associated with increased serum cholesterol levels, which may increase the risk for atherosclerosis and heart disease. A dose that is too high can cause symptoms of hyperthyroidism, create excessive strain on the heart, and lead to an increased risk of developing osteoporosis. It is extremely important that women planning to become pregnant are kept well adjusted, since hypothyroidism can affect the development of the baby. During pregnancy, thyroid hormone replacement requirements often change, so more frequent monitoring is necessary. Various medications and supplements (particularly iron) may affect the absorption of thyroid hormone; therefore, the levels may need more frequent monitoring during illness or change in medication. Thyroid hormone is critical for normal brain development in babies. Infants requiring thyroid hormone therapy should NOT be treated with purchased liquid suspensions, since the active hormone may deteriorate once dissolved and the baby could receive less thyroid hormone than necessary. Instead, infants with hypothyroidism should receive their thyroid hormone by crushing a single tablet daily of the correct dose and suspending it in one teaspoon of liquid and administering it properly. Appropriate management of hypothyroidism requires continued care by a physician experienced in the treatment of this condition.
Hyperthyroidism What is hyperthyroidism?
TO X IC NO D ULE
A single nodule or lump in the thyroid can also produce more thyroid hormone than the body requires and lead to hyperthyroidism. This disorder is not familial.
yperthyroidism develops when the body is exposed to excessive amounts of thyroid hormone. This disorder occurs in almost one percent of all Americans and affects women five to ten times more often than men. In its mildest form, hyperthyroidism may not cause recognizable symptoms. More often, however, the symptoms are discomforting, disabling, or even life-threatening.
What are the features of hyperthyroidism? When hyperthyroidism develops, a goiter (enlargement of the thyroid) is usually present and may be associated with some or many of the following features: • • • • • • • • • • • • • • • •
Fast heart rate, often more than 100 beats per minute Becoming anxious, irritable, argumentative Trembling hands Weight loss, despite eating the same amount or even more than usual Intolerance of warm temperatures and increased likelihood to perspire Loss of scalp hair Tendency of fingernails to separate from the nail bed Muscle weakness, especially of the upper arms and thighs Loose and frequent bowel movements Smooth skin Change in menstrual pattern Increased likelihood for miscarriage Prominent “stare” of the eyes Protrusion of the eyes, with or without double vision (in patients with Graves’ disease) Irregular heart rhythm, especially in patients older than 60 years of age Accelerated loss of calcium from bones, which increases the risk of osteoporosis and fractures
What are the causes of hyperthyroidism? G RAVES ’ D ISEASE Graves’ disease (named after Irish physician Robert Graves) is an autoimmune disorder that frequently results in thyroid enlargement and hyperthyroidism. In some patients, swelling of the muscles and other tissues around the eyes may develop, causing eye prominence, discomfort or double vision. Like other autoimmune diseases, this condition tends to affect multiple family members. It is much more common in women than in men and tends to occur in younger patients.
SU B ACUTE THYROI D ITIS This condition may follow a viral infection and is characterized by painful thyroid gland enlargement and inflammation, which results in the release of large amounts of thyroid hormones into the blood. Fortunately, this condition usually resolves spontaneously. The thyroid usually heals itself over several months, but often not before a temporary period of low thyroid hormone production (hypothyroidism) occurs.
POSTPARTUM THYROI D ITIS Five to ten percent of women develop mild to moderate hyperthyroidism within several months of giving birth. Hyperthyroidism in this condition usually lasts for approximately one to two months. It is often followed by several months of hypothyroidism, but most women will eventually recover normal thyroid function. In some cases, however, the thyroid gland does not heal, so the hypothyroidism becomes permanent and requires lifelong thyroid hormone replacement. This condition may occur again with subsequent pregnancies.
SILENT THYROI D ITIS Transient (temporary) hyperthyroidism can be caused by silent thyroiditis, a condition which appears to be the same as postpartum thyroiditis but not related to pregnancy. It is not accompanied by a painful thyroid gland.
E X CESSIVE IO D INE IN G ESTION Various sources of high iodine concentrations, such as kelp tablets, some expectorants, amiodarone (Cordarone, Pacerone – a medication used to treat certain problems with heart rhythms) and x-ray dyes may occasionally cause hyperthyroidism in patients who are prone to it.
OVERME D ICATION W ITH THYROI D HORMONE Patients who receive excessive thyroxine replacement treatment can develop hyperthyroidism. They should have their thyroid hormone dosage evaluated by a physician at least once each year and should NEVER give themselves “extra” doses.
How is hyperthyroidism diagnosed? Characteristic symptoms and physical signs of hyperthyroidism can be detected by a physician. In addition, tests can be used to confirm the diagnosis and to determine the cause.
TO X IC MULTINO D ULAR G OITER
TSH ( THYROI D - STIMULATIN G HORMONE OR THYROTROPIN ) TEST
Multiple nodules in the thyroid can produce excessive thyroid hormone, causing hyperthyroidism. Typically diagnosed in patients over the age of 50, this disorder is more likely to affect heart rhythm. In many cases, the person has had the goiter for many years before it becomes overactive.
A low TSH level in the blood is the most accurate indicator of hyperthyroidism. The body shuts off production of this pituitary hormone when the thyroid gland even slightly overproduces thyroid hormone. If the TSH level is low, it is very important to also check thyroid hormone levels to confirm the diagnosis of hyperthyroidism.
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OTHER TESTS • Estimates of free thyroxine and free triiodothyronine: the active thyroid hormones in the blood. When hyperthyroidism develops, free thyroxine and free triiodothyronine levels rise above previous values in that specific patient (although they may still fall within the normal range for the generalpopulation), and are often considerably elevated. • TSI (thyroid-stimulating immunoglobulin): a substance often found in the blood when Graves’ disease is the cause of hyperthyroidism. This test is not routinely ordered since it does not usually affect treatment decisions or help in the diagnosis. • Radioactive iodine uptake (RAIU - a measurement of how much iodine the thyroid gland can collect) and thyroid scan (a thyroid scan shows how the iodine is distributed throughout the thyroid gland). This information can be useful in determining the cause of hyperthyroidism and ultimately its treatment. Sometimes a general physician can diagnose and treat the cause of hyperthyroidism, but assistance is often needed from an endocrinologist, a physician who specializes in managing thyroid disease.
How is hyperthyroidism treated? Before the development of current treatment options, the death rate from severe hyperthyroidism was as high as 50 percent. Now several effective treatments are available and, with proper management, death from hyperthyroidism is rare. Deciding which treatment is best depends on what caused the hyperthyroidism, its severity, and other conditions present. A physician who is experienced in the management of thyroid diseases can confidently diagnose the cause of hyperthyroidism and prescribe and manage the best treatment program for each patient.
ANTITHYROI D D RU G S In the United States, two drugs are available for treating hyperthyroidism: propylthiouracil (PTU) and methimazole (Tapazole). These medications control hyperthyroidism by slowing thyroid hormone production, and are frequently used for several months after the initial diagnosis of hyperthyroidism to normalize the thyroid hormone levels. Some patients with hyperthyroidism caused by Graves’ disease experience a spontaneous or natural remission of hyperthyroidism after a 12- to 18-month course of treatment with these drugs, and may sometimes avoid permanent underactivity of the thyroid (hypothyroidism), which often occurs as a result of using the other methods of treating hyperthyroidism. Unfortunately, the remission is frequently only temporary, with the hyperthyroidism recurring after several months or years off medication and requiring additional treatment, so relatively few patients are treated solely with antithyroid medication in the United States. Antithyroid drugs may cause an allergic reaction in about five percent of patients who use them. This usually occurs during the first six weeks of drug treatment. Such a reaction may include rash or hives; but after discontinuing use of the drug, the symptoms resolve within one to two weeks and there is no permanent damage. A more serious effect, but occurring in only about one in 250-500 patients during the first four to eight weeks of treatment, is a rapid decrease of white blood cells in the bloodstream. This could increase susceptibility to serious infection. Symptoms such as a sore throat, infection, or fever should be reported promptly to your physician, and a blood cell count should be done immediately. In nearly every case, when a person stops using the medication, the white blood cell count returns to normal. Very rarely, antithyroid drugs may cause severe liver problems, which can be detected by blood tests or joint problems characterized by joint pain
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and/or swelling. Your physician should be contacted if there is yellowing of the skin (“jaundice”), fever, loss of appetite, or abdominal pain.
RA D IOACTIVE IO D INE TREATMENT Iodine is an essential ingredient in the production of thyroid hormone. Each molecule of thyroid hormone contains either four (T4) or three (T3) molecules of iodine. Since most overactive thyroid glands are quite hungry for iodine, it was discovered in the 1940’s that the thyroid could be “tricked” into destroying itself by simply feeding it radioactive iodine. The radioactive iodine is given by mouth, usually in capsule form, and is quickly absorbed from the bowel. It then enters the thyroid cells from the bloodstream and gradually destroys them. Maximal benefit is usually noted within three to six months. It is not possible to eliminate “just the right amount” of the diseased thyroid gland, since radioiodine eventually damages all thyroid cells. Therefore, most endocrinologists usually strive to completely destroy the diseased thyroid gland with a single dose of radioiodine. This results in the intentional development of an underactive thyroid state (hypothyroidism), which is easily, predictably and inexpensively corrected by lifelong daily use of oral thyroid hormone replacement therapy. Although every effort is made to calculate the correct dose of radioiodine for each patient, not every treatment will successfully correct the hyperthyroidism, particularly if the goiter is quite large and a second dose of radioactive iodine is occasionally needed. Thousands of patients have received radioiodine treatment, including former President of the United States George Bush and his wife, Barbara. The treatment appears to be a very safe, simple, and reliably effective one. Because of this, it is considered by most thyroid specialists in the United States to be the treatment of choice for hyperthyroidism cases caused by overproduction of thyroid hormone.
Radioactive iodine treatment should never be given to a pregnant woman! Small amounts of radioactive iodine will also be excreted in breast milk. Since radioiodine could permanently damage the infant’s thyroid, breast-feeding is not allowed. If radioiodine is inadvertently administered to a woman who is subsequently discovered to be pregnant, the advisability of terminating the pregnancy should be discussed with the patient’s obstetrician and endocrinologist. Therefore, prior to administering diagnostic or therapeutic radioiodine treatment, pregnancy testing is mandatory whenever pregnancy is possible.
SUR G ICAL REMOVAL O F THE THYROI D Although seldom used now as the preferred treatment for hyperthyroidism, operating to remove most of the thyroid gland may occasionally be recommended in certain situations, such as a pregnant woman with severe uncontrolled disease in whom radioiodine would not be safe for the baby. Surgery usually leads to permanent hypothyroidism and lifelong thyroid hormone replacement therapy.
OTHER TREATMENTS A drug from the class of beta-adrenergic blocking agents (which decrease the effects of excess thyroid hormone) may be used temporarily to control hyperthyroid symptoms until other therapies take effect. In cases where hyperthyroidism is caused by thyroiditis or excessive ingestion of either iodine or thyroid hormone, this may be the only type of treatment required. Appropriate management of hyperthyroidism requires careful evaluation and ongoing care by a physician experienced in the treatment of this complex condition.
The Thyroid, Pregnancy and Infancy Why is it important to take care of the thyroid during pregnancy?
ven before conception, thyroid conditions that have lingered untreated can hinder a woman’s ability to become pregnant or can lead to miscarriage. Fortunately, most thyroid problems that affect pregnancy are easily treated. The difficulty lies in recognizing a thyroid problem during a time when some of the chief complaints — fatigue, constipation, and heat intolerance — can be either the normal side effects of pregnancy or signals that something is wrong with the thyroid. Although detecting a thyroid problem is important, it is equally necessary for those already diagnosed with a condition to have the thyroid checked if they are planning to become pregnant or are pregnant. Thyroid hormone is necessary for normal brain development. In early pregnancy, babies get thyroid hormone from their mothers. Later on as the baby’s thyroid develops it makes its own thyroid hormone. An adequate amount of iodine is needed to produce fetal and maternal thyroid hormone. The best way to ensure adequate amounts of iodine reach the unborn child is for the mother to take a prenatal vitamin with a sufficient amount of iodine. Not all prenatal vitamins contain iodine, so be sure to check labels properly.
Who should be tested? Despite the impact thyroid diseases can have on a mother and baby, whether to test every pregnant woman for them remains controversial. As it stands, doctors recommend that all women at high risk for thyroid disease or women who are experiencing symptoms should have a TSH and an estimate of free thyroxine blood tests and other thyroid blood tests if warranted. A woman is at a high risk if she has a history of thyroid disease or thyroid autoimmunity, a family history of thyroid disease, type 1 diabetes mellitus, or any other autoimmune condition. Anyone with these risk factors should be sure to tell their obstetrician or family physician. Ideally, women should be tested prior to becoming pregnant at prenatal counseling and as soon as they know they are pregnant.
Hypothyroidism during pregnancy When a woman is pregnant, her body needs enough thyroid hormone to support a developing fetus and her own expanded metabolic needs. Healthy thyroid glands naturally meet increased thyroid hormone requirements. If someone
has Hashimoto’s thyroiditis or an already overtaxed thyroid gland, thyroid hormone levels may decline further. So, women with an undetected mild thyroid problem may suddenly find themselves with pronounced symptoms of hypothyroidism after becoming pregnant.
What are the risks of an underactive thyroid gland during pregnancy? In the United States, most women who develop hypothyroidism during pregnancy develop mild disease and may experience only mild symptoms or sometimes no symptoms. However, if you had a mild, undiagnosed condition before becoming pregnant, the condition may worsen. A range of signs and symptoms may be experienced, but one needs to be aware that these can be easily written off as normal features of pregnancy. Untreated hypothyroidism, even a mild version, may contribute to possible pregnancy complications. Treatment with sufficient amounts of thyroid hormone replacement significantly reduces the risk for developing any of the following pregnancy complications associated with hypothyroidism: • • • • • •
Abruptio placentae Premature birth Postpartum hemorrhage Pre-eclampsia Anemia Miscarriage
Treating hypothyroidism during pregnancy There is no difference between treating hypothyroidism when a woman is pregnant than when she isn’t. Levothyroxine sodium pills are completely safe for use during pregnancy. They will be prescribed in dosages that are aimed at replacing the thyroid hormone the thyroid isn’t making so that the TSH level is kept within normal ranges. Once a woman begins taking thyroid hormone pills, she will be monitored closely until her TSH level is within normal ranges. Once it is, the doctor should check TSH levels every six weeks or so. The physician may also counsel patients to take their thyroid hormone pills at least one-half hour to one hour before or at least three hours after they take iron-containing prenatal vitamins or calcium supplements, both of which can interfere with the absorption of thyroid hormone.
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Hyperthyroidism during pregnancy Graves’ disease tends to strike women during their reproductive years, so it should come as no surprise that it occasionally occurs in pregnant women. Reports on pregnancies lasting longer than twenty weeks suggest that Graves’ disease occurs in 2 per 1,000 pregnancies or 0.2 percent of all pregnancies. Pregnancy may worsen a preexisting case of Graves’ disease. Graves’ disease can also emerge for the first time, typically during the first trimester of pregnancy. The disease is usually at its worst during the first trimester. It tends to then improve in the second and third trimesters and flare up again after delivery.
What are the risks of an overactive thyroid during pregnancy? A woman with hyperthyroidism while pregnant puts her at an increased risk for experiencing any of the signs and symptoms of hyperthyroidism. And unless the condition is mild, if it is not treated promptly, a woman could miscarry during the first trimester; develop congestive heart failure, pre-eclampsia, or anemia; and, rarely, develop a severe form of hyperthyroidism called thyroid storm, which can be life threatening. Hyperthyroidism, if untreated, can lead to stillbirth, premature birth, or low birth weight for the baby. Sometimes it leads to fetal tachycardia, which is an abnormally fast pulse in the fetus. Women with Graves’ disease have antibodies that stimulate their thyroid gland. These antibodies can cross the placenta and stimulate a baby’s thyroid gland. If antibody levels are high enough, the baby could develop fetal hyperthyroidism, or neonatal hyperthyroidism.
How is hyperthyroidism diagnosed during pregnancy? As with hypothyroidism, diagnosing hyperthyroidism based on symptoms can be tricky because pregnancy and hyperthyroidism share a host of features. Still, one should be aware of the symptoms and bring them to the attention of a doctor if they are experiencing them. For instance, feeling a heart flutter or suddenly becoming short of breath, both symptoms of hyperthyroidism, can be normal in pregnancy, but a doctor still may want to investigate these symptoms. An individual with any risk factors for thyroid disease should make certain they are tested. While hyperthyroidism can easily be diagnosed through blood tests, finding out what’s causing it may require scanning tests that use minimal amounts of radioactive iodine. During pregnancy, however, scanning tests are not done because small amounts of radioactivity may cross the placenta and become concentrated in the baby’s thyroid gland. Antibody tests can be used to distinguish Graves’ disease from
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other causes (For more information, please see the TSI section in the Hyperthyroidism information). A physical exam can help diagnose or distinguish a toxic adenoma or toxic multinodular goiter.
Treating hyperthyroidism during pregnancy Very mild hyperthyroidism usually does not require treatment, only routine monitoring with blood tests to make sure the disease does not progress. More serious conditions require treatment. However, treatment options are limited for pregnant women. Radioactive iodine, which is typically used to treat Graves’ disease, cannot be used during pregnancy because it easily crosses the placenta, potentially damaging the baby’s thyroid gland and causing hypothyroidism in the baby. Due to its potential risks, the goal of treatment is to use the minimal amount of antithyroid drugs possible to maintain a patient’s T4 and T3 levels at or just above the upper level of normal, while keeping TSH levels suppressed. When hormones reach the desired levels, drug doses can be reduced. This approach controls hyperthyroidism while minimizing the chances of a baby developing hypothyroidism.
Thyroid diseases in children Thyroid problems are much less common in children than adults, but when they strike, they can be more worrisome because of their potential effect on children’s growth and developing brains. In adults, treatment usually reverses the effects of thyroid diseases, even when they go undetected for years. Yet in early childhood, hypothyroidism can lead to permanent mental deficiencies and short stature if it is not treated promptly. Hyperthyroidism can lead to accelerated growth in children, and when it affects infants, it can be fatal. Thanks to screening programs that test all newborns for hypothyroidism, the immutable effects of that disease are prevented in numerous children. Each year, in North America alone, more than five million newborns are screened annually, and hypothyroidism is detected and treated in fourteen hundred of these infants. A child may be born with a thyroid condition or may develop one sometime during childhood. Diagnosing thyroid diseases that aren’t detected through screening programs can be especially tricky, since it is up to the parent to recognize when something is wrong. This certainly isn’t easy when dealing with young children who aren’t talking yet or with older children who may not be able to describe what they feel—or even know what they are feeling isn’t normal. If you or someone in your family has a thyroid condition, your child may be at a higher risk for developing a thyroid disorder.
Hashimoto’s Thyroiditis What is Hashimoto’s thyroiditis?
ashimoto’s thyroiditis (also called autoimmune or chronic lymphocytic thyroiditis) is the most common thyroid disease in the United States. It is an inherited condition that affects approximately 14 million Americans and is about seven times more common in women than in men. Hashimoto’s thyroiditis is characterized by the production of immune cells and autoantibodies by the body’s immune system, which can damage thyroid cells and compromise their ability to make thyroid hormone. Hypothyroidism occurs if the amount of thyroid hormone, which can be produced, is not enough for the body’s needs. The thyroid gland may also enlarge, forming a goiter.
What are the features of Hashimoto’s thyroiditis? Hashimoto’s thyroiditis may not cause symptoms for many years and remain undiagnosed until an enlarged thyroid gland or abnormal blood tests are discovered as part of a routine examination. When symptoms do develop, they are either related to local pressure effects in the neck caused by the goiter itself, or to the low levels of thyroid hormone. The first sign of this disease may be painless swelling in the lower front of the neck. This enlargement may eventually become easily visible. It may be associated with an uncomfortable pressure sensation in the lower neck. This pressure on surrounding structures may cause additional symptoms, including difficulty swallowing. Although many of the features associated with thyroid hormone deficiency occur commonly in patients without thyroid disease, patients with Hashimoto’s thyroiditis who develop hypothyroidism are more likely to experience the following: • • • • • • •
Pervasive Fatigue Drowsiness Forgetfulness Difficulty with learning Dry, brittle hair and nails Dry, itchy skin Puffy face
• • • • • •
Constipation Sore muscles Weight gain Heavy menstrual flow Increased frequency of miscarriages Increased sensitivity to many medications
The thyroid enlargement and/or hypothyroidism caused by Hashimoto’s thyroiditis progresses in many patients, causing a slow worsening of symptoms. Therefore, patients with either of these findings should be recognized and adequately treated with thyroid hormone. Optimal treatment with thyroid hormone will eliminate any symptoms due to thyroid hormone deficiency, usually prevent further thyroid enlargement, and may sometimes cause shrinkage of an enlarged thyroid gland.
What is the cause of Hashimoto’s thyroiditis? Hashimoto’s thyroiditis results from a malfunction in the immune system. When working properly, the immune system is designed to protect the body against invaders, such as bacteria, viruses, and other foreign substances. The immune system of someone with Hashimoto’s thyroiditis mistakenly recognizes normal thyroid cells as foreign tissue, and it produces antibodies that may destroy these cells. Although various environmental factors have been studied, none have been positively proven to be the cause of Hashimoto’s thyroiditis.
How is Hashimoto’s thyroiditis diagnosed? A physician experienced in the diagnosis and treatment of thyroid disease can detect a goiter due to Hashimoto’s thyroiditis by performing a physical examination and can recognize hypothyroidism by identifying characteristic symptoms, finding typical physical signs, and doing appropriate laboratory tests. ANTITHYROI D ANTI B O D IES Increased antithyroid antibodies provide the most specific laboratory evidence of Hashimoto’s thyroiditis, but they are not present in all cases.
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TSH ( THYROI D – STIMULATIN G HORMONE OR THYROTROPIN ) TEST Increased TSH level in the blood is the most accurate indicator of hypothyroidism. TSH is produced by another gland, the pituitary, which is located behind the nose at the base of the brain. The level of TSH rises dramatically when the thyroid gland even slightly underproduces thyroid hormone, so in patients with normal pituitary function, a normal level of TSH reliably excludes hypothyroidism. OTHER TESTS •
An estimate of free thyroxine: the active thyroid hormone in the blood. A low level of free thyroxine is consistent with thyroid hormone deficiency. However, free thyroxine values in the “normal range” may actually represent mild thyroid hormone deficiency in a particular patient, and not drop below the “normal range” unless it becomes more severe. Fine-needle aspiration of the thyroid: usually not necessary for most patients with Hashimoto’s thyroiditis, but a good way to diagnose difficult cases and a necessary procedure if a thyroid nodule is also present.
How is Hashimoto’s thyroiditis treated? For patients with thyroid enlargement (goiter) and hypothyroidism, thyroid hormone therapy is clearly needed, since proper dosage corrects any symptoms due to thyroid hormone deficiency and may decrease the goiter’s size. Treatment generally consists of taking a single daily tablet of levothyroxine. Older patients who may have underlying heart disease are usually started on a low dose and gradually increased, while younger, healthy patients can be started on full replacement doses at once. Thyroid hormone acts very slowly in the body, so it may take several months after treatment is started to notice improvement in symptoms or goiter shrinkage. Because of the generally permanent and often progressive nature of Hashimoto’s thyroiditis, it is usually necessary to treat it throughout one’s lifetime and to realize that medicine dose requirements may have to be adjusted from time to time. The body is very sensitive to even very small changes in thyroid hormone levels.
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Optimal adjustment of thyroid hormone dosage should be guided by laboratory tests rather than symptoms alone. Levothyroxine tablets come in 12 different strengths, and it is essential to take them in a consistent manner every day. If the dose is not adequate, the thyroid gland may continue to enlarge and symptoms of hypothyroidism will persist. This may be associated with increased serum cholesterol levels, possibly increasing the risk for atherosclerosis and heart disease. If the dose is too strong, it can cause symptoms of hyperthyroidism, creating excessive strain on the heart and an increased risk of developing osteoporosis.
Other associated disorders As noted above, Hashimoto’s thyroiditis is a common disorder of the immune system, which affects the thyroid gland. However, much less often, the immune system can also mistakenly target virtually any other part of the body, causing it to malfunction, and this tendency runs in families. Although the majority of patients with Hashimoto’s thyroiditis and their genetic family members will never experience any other autoimmune condition, they do have a statistically increased risk of developing the following disorders: • • • •
Type 1 diabetes mellitus (insulin-requiring) Graves’ disease (goiter and hyperthyroidism or overactive thyroid) Rheumatoid arthritis Pernicious anemia (inability to absorb vitamin B12, potentially causing anemia and neurologic problems) • Addison’s disease (adrenal failure; the adrenal gland provides cortisol to handle stress and illness) • Premature ovarian failure (early menopause) • Vitiligo (patchy loss of skin pigmentation) • Thrombocytopenic purpura (bleeding disorder due to an inadequate number of platelets in the blood) • Lupus erythematosus (autoimmune disease that involves skin, heart, lungs, kidneys and joints) Appropriate management of Hashimoto’s thyroiditis requires continued care by a physician who is experienced in the treatment of this disease.
Thyroid Cancer What is thyroid cancer?
he thyroid gland is located in the lower front of the neck, above the collarbones, and below the voice box (larynx). Thyroid cancer (carcinoma) usually appears as a painless lump in this area. In most cases, the lump is only on one side, and the results of thyroid function tests (blood tests) are usually normal. There are four main types of thyroid cancer (papillary, follicular, medullary and anaplastic). Since the vast majority are either papillary or follicular, and these are the only two types treatable with radioiodine, we will focus on these two types.
What are the features of thyroid cancer? Many patients with thyroid cancer have no symptoms whatsoever, and are found by chance to have a lump in the thyroid gland on a routine physical exam or an imaging study of the neck done for unrelated reasons (CT or MRI scan of spine or chest, carotid ultrasound, etc.). Some patients with thyroid cancer become aware of a gradually enlarging lump in the front portion of the neck, which usually moves with swallowing. Occasionally, the lump may cause a feeling of pressure. Obviously, finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.
What are the causes of thyroid cancer? As with many types of cancer, the specific reason for developing thyroid cancer remains a mystery in the vast majority of patients. Some major risk factors are: • •
A history of radiation to the head or neck, especially during childhood Genetic predisposition (the influence of heredity), particularly for the medullary type of thyroid cancer
How is thyroid cancer diagnosed? (NOTE: See Thyroid Nodule handout) First, your physician takes a detailed history and performs a careful physical examination, especially of the
thyroid gland. The best diagnostic approach for a specific patient will be determined by your physician after careful consideration of all the facts. The tests available to your physician for evaluation of the thyroid lump include, but are not limited to, the following: •
Fine-needle aspiration biopsy: this is usually done first and, if positive, significantly reduces the need for more elaborate and expensive testing Ultrasonography: this may be required for guidance of the fine needle biopsy if the nodule is difficult to feel Thyroid scan: this can be done to see if the mass is capable of concentrating radioiodine, particularly in those patients with low TSH levels Blood studies
How is thyroid cancer treated? Fortunately, most types of thyroid cancer can be diagnosed early and cured completely, but a thoughtful and comprehensive investigation is necessary. If thyroid cancer is suspected after review of all the information, referral to an experienced thyroid surgeon is recommended. If the diagnosis of thyroid cancer is certain or highly likely, the usual approach is to remove both sides of the thyroid gland. If the diagnosis of thyroid cancer is much less certain or cannot be made during surgery, only the side of the thyroid containing the lump may be removed. If cancer is subsequently confirmed, further consultation with the endocrinologist is appropriate. Additional surgery may be required to remove the remaining tissue in order to reduce the risk of recurrence of cancer. In cases when the risk of recurrence is significant, radioactive iodine treatment may be recommended in order to destroy any remaining malignant thyroid cells. Radioactive iodine treatment should never be given to a pregnant or nursing woman! Small amounts of radioactive iodine will also be excreted in breast milk. Since radioiodine could permanently damage the infant’s thyroid, breast-feeding is not allowed. If radioiodine is inadvertently administered to a woman who is subsequently discovered to be pregnant, the advisability of terminating the pregnancy should be discussed with the patient’s obstetrician and endocrinologist. Therefore,
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prior to administering diagnostic or therapeutic radioiodine treatment, pregnancy testing is mandatory whenever pregnancy is possible. After radioiodine therapy, thyroid medication (levothyroxine) should be started and dosed to replace the function of the thyroid and to decrease the likelihood of cancer recurrence. Periodic monitoring is supervised by the endocrinologist, and may include ultrasound examinations, radioiodine body scans, and periodic testing of a blood protein called thyroglobulin, which
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is found in normal thyroid cells but can also be produced by thyroid cancer cells. The optimal frequency of further monitoring studies to be certain that the cancer has not recurred will be determined by your physician. Fortunately, most types of thyroid cancer have a very good prognosis when diagnosed early and treated by a physician who is familiar with its management.
Radioiodine Therapy What is radioiodine therapy?
f you have an overactive thyroid gland or have been diagnosed with thyroid cancer, your endocrinologist may prescribe radioactive iodine (radioiodine) as part of your overall treatment. You, your family, and your coworkers may have some questions about this therapy.
Background The thyroid gland produces hormones that regulate the body’s metabolism. In order to produce these hormones, the thyroid gland requires large amounts of iodine, which is found in seafood, table salt, bread, and various other foods. Iodine is an essential ingredient in the creation of thyroid hormone. Each molecule of thyroid hormone contains either three (T3) or four (T4) molecules of iodine. Most overactive thyroid glands are quite hungry for iodine. This led to the discovery in the 1940s that an overactive thyroid gland could be “tricked” into destroying itself by simply feeding it radioactive iodine. Your endocrinologist can also use radioiodine to treat some types of thyroid cancer. Radioiodine has been used for more than 60 years in the treatment of thyroid diseases with remarkably few undesirable effects. However, problems may rarely occur when very large doses are given, including decrease in taste sensation and irritation of the salivary glands, or the gastrointestinal tract. No significant increase has been seen in the number of birth defects in children born later to women who have received this type of treatment. A very small number of patients may develop a second cancer years after treatment with a high dose of radioiodine.
Hyperthyroidism (overactive thyroid) Before the development of current treatment options, the death rate from severe hyperthyroidism was as high as 50 percent. Now several effective treatments (antithyroid drugs, surgery, and radioiodine) are available, and death from hyperthyroidism is rare. Deciding which treatment is best depends on what caused the hyperthyroidism, its severity, and other conditions present. Endocrinologists are experienced in the management of thyroid diseases and can confidently diagnose the cause of hyperthyroidism and prescribe and manage the best treatment program for each patient.
It is not possible to eliminate “just the right amount” of the diseased thyroid gland, since radioiodine eventually damages all thyroid cells. Therefore, most endocrinologists usually strive to completely destroy the diseased thyroid gland with a single dose of radioiodine. This results in the intentional development of an underactive thyroid state (hypothyroidism), which is easily, predictably and inexpensively corrected by lifelong daily use of oral thyroid hormone replacement therapy. Although every effort is made to calculate the correct dose of radioiodine for each patient, not every treatment will successfully correct the hyperthyroidism, particularly if the goiter is quite large, in which case a second dose of radioactive iodine will be needed.
Thyroid cancer The two most common types of thyroid cancer (papillary and follicular) can usually be treated with radioiodine because the cells are able to take up some iodine. Radioiodine is usually administered either: A F TER REMOVAL O F THE THYROI D An experienced thyroid surgeon can remove most of the thyroid with a very low risk of surgical complications. In many cases, surgery followed by thyroid hormone therapy is sufficient to treat thyroid cancer. When it may not be sufficient, radioiodine can be used to destroy the remainder of the gland, which might harbor additional microscopic clusters of thyroid cancer. In that case, you may be advised not to use thyroid hormone replacement for several weeks after the operation, in order to allow the thyroid levels to drop below normal. This will lead to maximal stimulation of the remaining thyroid cells to concentrate iodine and be destroyed when you receive a dose of radioiodine. This treatment significantly reduces the possibility of recurrent cancer and also improves the ability to detect and treat any future cancer recurrences that might develop. D URIN G F OLLO W - UP
Thousands of patients have received radioiodine treatment, including former President of the United States George Bush and his wife, Barbara. The treatment appears to be a very safe, simple, and reliably effective one. Because of this, it is considered by most thyroid specialists in the United States to be the treatment of choice for hyperthyroidism cases caused by overproduction of thyroid hormones.
Patients with residual thyroid cancer or cancer that has spread to regions outside of the neck can undergo a scan with a test amount of radioiodine. Scanning with radioiodine helps to determine the extent of “persistent” or “recurrent” thyroid cancer, whether it may respond to additional doses of radioactive iodine, and how much radioactive iodine to use for treatment. If any iodine is concentrated in the areas of the thyroid cancer, another dose of radioiodine can be given to try to destroy the tumor. This treatment is safe, well tolerated, and has successfully treated many cases of thyroid cancer even after the tumor has spread.
Radioactive iodine is given by mouth, usually in capsule form, and is quickly absorbed from the bowel. It then enters the thyroid cells from the bloodstream and gradually destroys them. Although the radioactivity from this treatment remains in the thyroid for some time, it is largely eliminated from the rest of the body within a few days. Its effect on the thyroid gland usually takes between one and three months to develop, and maximal benefit is usually noted within three to six months.
All patients with thyroid cancer should have regular follow-up examinations by an endocrinologist. Additional doses of radioactive iodine may be recommended if thyroid cancer remains (which is called “persistent”) or reappears later (which is called “recurrent”). Your thyroid hormone replacement therapy will need to be stopped long enough to allow you to become hypothyroid, so that maximum response to the treatment will occur.
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What happens to the radioiodine after a treatment? Since surgery removes the vast majority of thyroid tissue, much of the radioiodine will not be absorbed and will leave the body primarily through the urine. Small amounts will also be excreted in saliva, sweat, tears, vaginal secretions, and feces. Nearly all the radioactive iodine will leave the body during the first two days after the dose has been given.
What about pregnancy? If radioiodine is inadvertently administered to a woman who is subsequently discovered to be pregnant, the advisability of terminating the pregnancy should be discussed with the patient’s obstetrician and endocrinologist. Therefore, prior to administering diagnostic or therapeutic radioiodine treatment, pregnancy testing is mandatory whenever pregnancy is possible.
What about breast-feeding? Small amounts of radioactive iodine are excreted in breast milk. Since radioiodine could permanently damage the infant’s thyroid, breast-feeding is not allowed.
Are future pregnancies possible? As a precaution, males are advised to avoid fathering a child for several months. Females are advised to postpone pregnancy for six months or more in order to help stabilize their thyroid status for conception. Even though the amount of radioactivity retained may be small and there is no medical proof of an actual risk from radioiodine treatment, there is a theoretical risk to a developing fetus. Such precautions essentially eliminate direct fetal exposure to radioactivity, and markedly reduce the possibility of conception with sperm that might theoretically have been damaged by exposure to radioiodine. You may need to contact your physician for guidance about methods of contraception. Regulations regarding the use of radioiodine therapy are made by the U.S. Nuclear Regulatory Commission (NRC). Physicians and hospitals that administer this therapy must have a license to administer radioiodine, and must adhere to stringent regulations regarding its use. If you have any questions before or after receiving your treatment, please do not hesitate to contact your physician or your hospital radiation safety officer for clarification.
Is hospitalization necessary for treatment with radioiodine? Treatment for hyperthyroidism is almost always done on an outpatient basis, because the dose required is relatively small in comparison with the doses typically used for treatment of thyroid cancer. If you have to take a larger dose of radioiodine for treatment of thyroid cancer, you may need to be admitted to the hospital for several days depending on the amount of radioiodine administered, your living environment, state of residence, or local practice patterns. If you require hospitalization, your hospital room will have frequently handled items (such as the television control, table,
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phone, faucet handles, etc.), covered with protective material, and the floor will be partially covered. These precautions are designed to prevent the radioactive iodine from contaminating those items that will be reused by other patients after your dismissal from the hospital. To limit the contamination of your personal items, you should bring a minimal amount of belongings for your stay. Clothing should be limited to what you wear when you are admitted. You should use hospital gowns during your stay. You may want to bring disposable items like magazines and newspapers, but important or durable items like hardback books, work papers, and craft items should be left at home. All items will be monitored when you are discharged from the hospital. Check with your endocrinologist about any other issues. Recommendations for reduction of exposure to others for several days after treatment: • • • • • •
Use private toilet facilities, if possible; flush twice after each use. Bathe daily and wash hands frequently. Drink normal amount of fluids. Use disposable eating utensils or wash your utensils separately from others. Sleep alone and avoid prolonged intimate contact. Launder your linens, towels, and clothes daily at home, separately from others. No special cleaning of the washing machine is required between loads. This is because the radioiodine administered is water soluble. Do not prepare food for others that requires prolonged handling with bare hands (such as mixing a meat loaf or kneading bread).
Brief periods of close contact, such as handshaking and hugging, are permitted. Your endocrinologist or radiation safety officer may recommend continued precautions for up to several weeks after treatment, depending on the amount of radioactivity administered. Patients receiving radioactive iodine should also carry information about their treatment with them in order to fully inform authorities who are in charge of screening for radioactive materials in public areas such as airports and subways.
After treatment, should contact with other people be limited? The amount of radioactive exposure to other persons during your daily activities will depend on the duration of contact and the distance you are from them. As an example, a person two feet away receives only one fourth the exposure of someone one foot away. Therefore, the general principle is to avoid prolonged, close contact with other people for several days. If your work or daily activities involve prolonged contact with small children or pregnant women, you have to wait for several days after your treatment to resume these activities. Those patients with infants at home should arrange for care to be provided by another person for the first several days after treatment. It will not be necessary for you personally to stay elsewhere after your treatment, although you will need to sleep alone for several days.
Thyroid Nodules What is a thyroid nodule?
he thyroid gland is located in the lower front of the neck, above the collarbones, and below the voice box (larynx). A thyroid nodule is a lump in or on the thyroid gland (See Dr. Duick’s story on page 6). Thyroid nodules are common, but are usually not diagnosed. They are detected in about six percent of women and one to two percent of men. They are 10 times as common in older individuals than in younger ones. Sometimes several nodules will develop in the same person. Any time a lump is discovered in thyroid tissue, the possibility of malignancy (cancer) must be considered. Fortunately, the vast majority of thyroid nodules are benign (not cancerous). Most patients with thyroid nodules have no symptoms whatsoever. Many are found by chance to have a lump in the thyroid gland on a routine physical exam or an imaging study of the neck done for unrelated reasons (CT or MRI scan of spine or chest, carotid ultrasound, etc.). In addition, a substantial number are first noticed by patients or those they know who see a lump in the front portion of the neck, which may or may not cause symptoms, such as a vague pressure sensation or discomfort when swallowing. Obviously, finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.
afterward with no ill effects. This test provides specific information about a particular patient’s nodule; information that no other test can offer short of surgery. Although the test is not perfect, a thyroid needle biopsy will provide sufficient information on which to base a treatment decision more than 75 percent of the time, eliminating the need for additional diagnostic studies. Use of fine needle biopsy has drastically reduced the number of patients who have undergone unnecessary operations for benign nodules. However, about 10-20 percent of biopsy specimens are interpreted as inconclusive or inadequate; that is, the pathologist cannot be certain whether the nodule is cancerous or benign. This situation is particularly common with cystic (fluid-filled) nodules, which contain very few thyroid cells to examine, and with those nodules composed of clusters of thyroid or follicular cells that cannot be conclusively determined to be either benign or malignant. In such cases, a physician who is experienced with thyroid disease can use other criteria to make a decision about whether or not to operate. The fine needle biopsy can be repeated in those patients whose initial attempt failed to yield enough material to make a diagnosis. Many physicians use thyroid ultrasonography to guide the needle’s placement.
What is a thyroid scan?
What is a thyroid needle biopsy?
A thyroid scan is a picture of the thyroid gland taken after a small dose of a radioactive isotope normally concentrated by thyroid cells has been injected or swallowed. The scan tells whether the nodule is hyperfunctioning (a “hot” nodule), or taking up more radioactivity than normal thyroid tissue does, taking up the same amount as normal tissue (a “warm” nodule), or taking up less (a “cold” nodule). Because cancer is rarely found in hot nodules, a scan showing a hot nodule eliminates the need for fine needle biopsy. If a hot nodule causes hyperthyroidism, it can be treated with radioiodine or surgery.
A thyroid fine needle biopsy that employs a very thin needle, usually smaller than one used to draw blood, is a simple procedure that can be performed in the physician’s office. Many physicians numb the skin over the nodule prior to the biopsy, but it is not necessary to be put to sleep, and patients can usually return to work or home
Neither a thyroid scan nor radioiodine treatment should ever be given to a pregnant woman! Small amounts of radioactive iodine will also be excreted in breast milk. Since radioiodine could permanently damage the infant’s thyroid, breast-feeding is not allowed. If radioiodine is inadvertently administered to a
Nodules can be caused by a simple overgrowth of “normal” thyroid tissue, fluid-filled cysts, inflammation (thyroiditis), or a tumor (either benign or cancerous). Most nodules were surgically removed until the 1980s. In retrospect, this approach led to many unnecessary operations, since fewer than 10 percent of the removed nodules proved to be cancerous. Most removed nodules could have simply been observed or treated medically.
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woman who is subsequently discovered to be pregnant, the advisability of terminating the pregnancy should be discussed with the patientâ€™s obstetrician and endocrinologist. Therefore, prior to administering diagnostic or therapeutic radioiodine treatment, pregnancy testing is mandatory whenever pregnancy is possible. Fortunately, the vast majority (90 â€“ 95 percent) of thyroid nodules are benign. Unfortunately, thyroid scans show that most thyroid nodules, both benign and malignant, are cold or nonfunctioning. Therefore, although almost all thyroid cancers are nonfunctional on scan, the majority of nonfunctional nodules are benign. For this reason, thyroid scans are of relatively little value in most patients unless TSH levels are toward the lower end of the normal range or below the normal range. For more information on TSH levels, visit www.powerofprevention.com.
What is thyroid ultrasonography? Thyroid ultrasonography is a procedure for obtaining pictures of the thyroid gland by using high-frequency sound waves that pass through the skin and are reflected back to the machine to create detailed images of the thyroid. It can visualize nodules as small as two to three millimeters. Ultrasound distinguishes thyroid cysts (fluid-filled nodules) from solid nodules. Many nodules have both solid and cystic components, and very few purely cystic nodules occur. Recent advances in ultrasonography help physicians identify nodules that are more likely to be cancerous. Thyroid ultrasonography is also utilized for guidance of a fine needle for aspirating thyroid nodules. Ultrasound guidance enables physicians to biopsy the nodule to obtain an adequate amount of material for interpretation. Such guidance allows the biopsy sample to be obtained from the solid portion of those nodules that are both solid and cystic, and it avoids getting a specimen from the surrounding normal thyroid tissue if the nodule is small. Even when a thyroid biopsy sample is reported as benign, the size of the nodule should be monitored. A thyroid ultrasound examination provides an objective and precise method for detection of a change in the size of the nodule. A nodule with a benign biopsy that is stable or decreasing in size is unlikely to be malignant or require surgical treatment.
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How are thyroid nodules treated? Your endocrinologist will use the tests mentioned above to arrive at a recommendation for optimal management of your nodule. Most patients who appear to have benign nodules require no specific treatment, and can simply be followed. Some physicians prescribe levothyroxine with hopes of preventing nodule growth or reducing the size of cold nodules, while radioiodine may be used to treat hot nodules. If cancer is suspected, surgical treatment will be recommended. The primary goal of therapy is to remove all thyroid nodules that are cancerous; and, if malignancy is confirmed, remove the rest of the thyroid gland along with any abnormal lymph nodes. If surgery is not recommended, it is important to have regular follow-up of the nodule by a physician experienced in such an evaluation.
very time you look in the mirror, a key to your well-being is staring back at you: your thyroid gland. The thyroid gland is a small, butterfly-shaped gland located in the lower front of the neck, above the collarbones, and below the voice box (larynx). Your thyroid gland makes hormones that help control the function of many of your body’s organs, including your heart, brain, liver, kidneys, and skin. Making sure that your thyroid gland is healthy is important to your body’s overall well-being.
Some patients who have an enlarged thyroid gland may also produce too much or too little thyroid hormone. Because many symptoms of thyroid imbalance may be hard to recognize and may be mistaken for symptoms caused by other conditions, the best way to know for sure about your thyroid health is to ask your doctor for a TSH (thyroidstimulating hormone) test, a simple blood test that measures whether your thyroid gland is functioning normally. If you have a family member with thyroid disease, are over the age of 35, or have any symptoms or risk factors associated with thyroid disease, you should talk to your doctor about getting a TSH test. It’s not difficult to keep your thyroid in balance, but you need to know your numbers. If you are diagnosed with thyroid disease, be sure to take your thyroid medicine every day, as instructed by your doctor, and
refill your prescription on time so that you don’t miss any doses. Your doctor may want to periodically run a TSH test to monitor your thyroid levels to ensure that you receive the optimal dose of thyroid medicine. Use the tips below to monitor your levels and discuss them with your doctor. H o w t o t a k e t h e t h y r o i d “ N e c k C h e c k ”
All you will need is: A. Glass of water B. Handheld mirror 1.
Hold the mirror in your hand, focusing on the lower front area of your neck, above the collar bones, and below the voice box (larynx). Your thyroid gland is located in this area of your neck.
2. While focusing on this area in the mirror, tip your head back. 3. Take a drink of water and swallow. 4. As you swallow, look at your neck. Check for any bulges or protrusions in this area when you swallow.
Reminder: Don’t confuse the Adam’s apple with the thyroid gland. The thyroid gland is located further down on your neck, closer to the collarbone. You may want to repeat this process several times.
5. If you do see any bulges or protrusions in this area, see your physician. You may have an enlarged thyroid gland or a thyroid nodule that should be checked to determine whether further evaluation is needed.
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Thyroid Awareness Month 2010