Doctor Thyroid

Antonio Bianco, MD, is the Charles Arthur Weaver Professor of Cancer Research in the Department of Internal Medicine. He is the president of Rush University Medical Group and vice dean for clinical affairs in Rush Medical College. Bianco came to Rush from the University of Miami Health System, where he served as professor of medicine and chief of the Division of Endocrinology, Diabetes and Metabolism. He has more than 30 years of experience in the thyroid field. He has been recognized with a number of national and international awards and membership in prestigious medical societies. A well-rounded investigator in the field of thyroid disease, Bianco led two American Thyroid Association task forces: one charged with drafting guidelines for thyroid research (as chair) and another responsible for developing guidelines for the treatment of hypothyroidism (co-chair). Bianco’s research interests include the cellular and molecular physiology of the enzymes that control thyroid hormone action (the iodothyronine deiodinases). He has contributed approximately 250 papers, book chapters and review articles in this field, and has lectured extensively both nationally and internationally. Recently, he has focused on aspects of the deiodination pathway that interfere with treatment of hypothyroid patients, a disease that affects more than 10 million Americans. He directs an NIH-funded research laboratory where he has mentored almost 40 graduate students and postdoctoral fellows. This episode includes the following topics: Thyroid produces thyroxin of T4.  T4 is not the biologically active, rather it is T3 T3 is biologically active Transformation of T4 to T3 happens throughs the body Levothyroxine has become the standard of care for treating hypothyroid patients T3 is the biologically active hormone, it could be by giving T4 only we are falling short Evidence based medicine wants to only treat with proven and documented therapy; T3 combination therapy is still not scientifically proven If patient takes T3 in the morning, it peaks about three hours later We have not developed a delivery system to maintain stable T3 levels The most important that we can challenge the pharmacy community is to deliver T3 in a way that it mimics the way it behaves in the human body Surveyed 12,000 patients and the ones on desiccated thyroid have higher QoL compared to those on Levothyroxine I was okay, I had a job, and then I had TT, and from that day forward my life is not the same.  Brain fog, and lack motivation We do not yet have evidence proving that combination therapy works, but some patients report improvement to QoL Mood disorders, depression, brain fog, memory loss, and lack of motivation are reported by TT patients T3 combination therapy does not Many symptoms of hypothyroidism is similar to menopause Depression like symptoms, difficult for weight loss, low motivation, less desire for physical activity, brain fog, memory loss are all symptoms patients report post TT Cannot yet yet distinguish between positive effects of T3 and placebo effects Side effects of T3 may include palpitation or sweating Improvement with combination T3 can be immediate, as reported by patients Patients on Levothyroxine most likely to be on statins, beta-blockers, and anti depressants Blood tests for TT patients, taking T3 and not Time of day to take blood tests Time blood sample depending on when patient takes lab work.  Ideally 3 or 4 hours after taking the T3 tablet Hypothyroid-like symptoms could be depression There is greater likelihood of depression symptoms for those taking Nearly 5% of the U.S. population takes T4 or Levothyroxine, as revealed by the NHANE survey.  This means 10 – 15 million Americans.  Levothyroxine is the most prescribed drug in the U.S. NOTES American Thyroid Association Bianco Lab A Controversy Continues: Combination Treatment for Hypothyroidism

10 Feb 202143min

Dr. Akira Miyauchi Professor Akira Miyauchi (Figure 1) is President and COO of Kuma Hospital, Center of Excellence in Thyroid Care, Kobe, Japan. He is a Japanese endocrine surgeon, and a pioneer in active surveillance, and visionary in regard to treatment of thyroid cancer.  World renowned researcher, and lecturer. As the associate professor of the Department of Surgery, Kagawa Medical University, he proposed and initiated a clinical trial of active surveillance for low-risk papillary micro cancer in collaboration with Kuma Hospital in 1993. In 2001, he was appointed the President of Kuma Hospital. Since then, he has been keen on the study of evaluating treatments for papillary micro cancer, observation versus surgery. During this episode, the following topics are discussed: Financial burden of surgery versus total cost of active surveillance over ten years. Stretching Exercises for Neck Setting patient expectations prior to FNA to manage anxiety When the laryngeal nerve is severed during thyroid surgery, it can and should be repaired, with proper surgeon skill and training. Rather than being stationery and immobile, patients should practice neck stretching exercise within 24 hours proceeding surgery.  There should be no fear about separating the incision. Total cost of surgery is 4.1x the cost compared to the cost of active surveillance.  In the U.S., the cost is higher. Incidence versus mortality Worldwide trends related to thyroid cancer Papillary Microcarcinoma of the Thyroid (PMCT) Unfavorable events following immediate surgery Results of research which began in 1993 The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society. By providing patient an active surveillance brochure prior to FNA, they are more open to not proceeding with surgery for small thyroid cancer management. Patient voice restores to near normal when repair of laryngeal nerve is done correctly.  All surgeons should be executing this to perfection. When doing next stretches one-day post surgery, patients report feeling much better and less pain, even one year after surgery. Protocol for delaying surgery depends on the patient’s age.  Older patients are less likely to require surgery.  75% of patients will not require surgery for their lifetime.   Listen to Doctor Thyroid here!  Akira Miyauchi, MD 35: Rethinking Thyroid Cancer ? When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles 21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies 50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering PAPERS and RESEARCH  Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid. Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery TSH-suppressive doses of levothyroxine are required to achieve preoperative native serum triiodothyronine levels in patients who have undergone total thyroidectomy. Stretching exercises to reduce symptoms of postoperative neck discomfort after thyroid surgery: prospective randomized study. Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Listen to Doctor Thyroid here!

9 Feb 202143min

Brittany Henderson, MD, ECNU is board-certified in internal medicine and endocrinology, with advanced training in thyroid disorders, including Hashimoto’s thyroiditis, Graves Disease, thyroid nodules, and thyroid cancer. Originally from Cleveland, Ohio, she graduated in the top 10% of at her class at Northeastern Ohio Medical University, where she received the honor of Alpha Omega Alpha (AOA). She completed her endocrinology fellowship training under a National Institutes of Health (NIH) research-training grant at Duke University Medical Center. She then served as Medical Director for the Thyroid and Endocrine Tumor Board at Duke University Medical Center and as Clinical Director for the Thyroid and Endocrine Neoplasia Clinic at Wake Forest University Baptist Medical Center. Topics discussed in this episode include: How to interpret my thyroid results? Why did I get this? Is it something I did? Thyroid controls nearly all body systems: heart, weight, brain, bowel. Testing and diagnosis: beyond blood-work TSH is the most common check TSH is like the reading of your electric meter: it tells you big picture for a month, not daily — it is not a fluid system, it changes by the hour TSH is not the cure all for reading thyroid health Full thyroid panel: Free T4 and Free T3 is important — highest in morning, lowest around 2p or 3p in the afternoon There is no one size fits all to Hashimoto’s — there are different types Blood tests: preparing for lab tests ‘Normal’ TSH but a patient does not feel normal Normal TSH range is controversial — .5 to 3 TSH is normal — if on thyroid replacement target 1.5 Suppressed TSH Dangers of suppressed TSH for thyroid cancer replacement or those on too much on thyroid replacement — heart failure, osteoporosis T3 symptoms of TSH is kept too low for too long The T4 — T3 relationship T4 is money in savings account — but you cant use it now — T3 is money in your pocket and available now Preferred thyroid replacement — but, issues with synthetic and desiccated The goal — T4 and T3 as stable as possible throughout the day — in light of absorption and interfering food Compounded medications A doctor must listen to the patient Generic levothyroxine and fillers — who is the manufacturer What is better, Nature or Armour? Why do some people do better on various thyroid replacement formulations? Gut biome The environment and thyroid disease Defining leaky gut Avoid foods that gut inflammation thereby worsening auto-immune disease Three food foes: processed foods, sugar, and iodine disruptors Is adrenal fatigue real? Supplements: vitamins and Hashimoto’s Nutrients needed to produce thyroid hormone, such as optimizing iron and selenium Anti-inflammatory vitamins and Vitamin A and Vitamin D Anti-oxidant vitamins — Vitamin B1, Vitamin C, and Glutathione What time of day to take to thyroid replacement medication What happens if you miss a day of thyroid replacement hormone? What does an endocrinologist feel about a patient seeing a Naturopath or an integrative medicine specialist? NOTES 57: The Gut⎥Antibiotics Danger, Fixing Inflammation, and Thyroid Health, with Dr. Lisa Sardinia 42: Flame Retardants Connected to Thyroid Cancer, with Dr. Julie Ann Sosa from Duke University Exposure to flame retardant chemicals and occurrence and severity of papillary thyroid cancer: A case-control study.  LGR5 is associated with tumor aggressiveness in papillary thyroid cancer. Hedgehog signaling in medullary thyroid cancer: a novel signaling pathway.  Dr. Brittany Henderson Facebook, Instagram, and Twitter: @DrHendersonMD, @charlestonthyroid, @hashimotosbook Websites: www.charlestonthyroid.com and www.drhendersonmd.com

3 Feb 202155min

Dr. Jorge Calvo Lugar de estudio: U. de Panamà, Hospital de la Caja de Seguro Social, Fundaciòn Santa Fe (Colombia) U. Del Norte (Argentina), Sistema Integrado de Salud (Veraguas) Otros estudios: Laparoscopía, Curso de postgrado de Cirugía Gastrointestinal, Curso de postgrado de Cirugía de Cabeza y Cuello   En este episodio, se tratan los siguientes temas: ¿Cómo será la vida después de la cirugía? Embarazo después del cáncer de tiroides Parálisis de las cuerdas vocales Las complicaciones incluyen voz e hipo-calcio Sangrado durante la cirugía Tratamiento para hypo-calcium Vitamina D Embarazo y radiación TSH elevada después de la cirugía Problemas de TSH suprimido Número uno de miedo del paciente cuando se le diagnostica cáncer de tiroides y antes de la cirugía 32 años como cirujano tiroideo - cáncer papilar de tiroides Vigilancia activa Tasas de mortalidad del cáncer papilar de tiroides Recurrencia La mejor hora del día para tomar un reemplazo de tiroides Más información: www.doctiroides.com

3 Feb 202128min

Allen S. Ho MD is Associate Professor of Surgery, Director of the Head and Neck Cancer Program, and Co-Director of the Thyroid Cancer Program at Cedars-Sinai Medical Center. As a fellowship-trained head and neck surgeon. His practice focuses on the treatment of head and neck tumors, including HPV(+) throat cancers and thyroid malignancies. He leads the multidisciplinary Cedars-Sinai Head and Neck Tumor Board, which provides consensus management options for complex, advanced cases. Dr. Ho’s research interests are highly integrated into his clinical practice. His current efforts lie in cancer proteomics, HPV(+) oropharyngeal cancer pathogenesis, and thyroid cancer molecular assays. Dr. Ho has published as lead author in journals that include Nature Genetics, JCO, JAMA Oncology, and Thyroid, and is Editor of the textbook Multidisciplinary Care of the Head and Neck Cancer Patient (Springer 2018). Dr. Ho serves on national committees within the AHNS and ATA, and leads a national trial on thyroid cancer active surveillance (ClinicalTrials.gov ID: NCT02609685). He maintains expertise in transoral robotic surgery (TORS), minimally invasive thyroidectomy approaches, and nerve preservation techniques. Dr. Ho’s overarching aim is to partner with patients to optimize treatment and provide compassionate, exceptional care. In this interview — a discussion about Dr. Ho’s research; Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review. Topics include: prostate and thyroid cancer parallels prostate cancer and practical acceptance of active surveillance randomized and followed patients through true active surveillance overall survival, comparing thyroid and prostrate cancer tolerance of risk Older versus younger patient priorities Younger patient  thought process Weighing quality of life and risk Hypothyroidism, parathyroidism, laryngeal nerve risk in thyroidectomy… asymptomatic patients being made symptomatic due to treatment Physicians have embraced active surveillance for prostate cancer more than thyroid The patient leans on physician for guidance The Finland study: 17M in U.S. have thyroid cancer Extrapolation — Patients who die of other conditions, in autopsies very small thyroid cancers found in 36% of patients A lot of small cancers that need not be diagnosed The physicians perspective and influencing the active surveillance decision Shared decision making process Terminology… some people choose active surveillance even when nodule is greater than 2cm Jury is still out on what is considered safe size Size and lymph node spread is still being defined Moving away from Gleason system Some cancers are aggressive Some cancers are slow and not lethal Incidental cancers The word cancer or the c word… and shifting away from fear Radiology guidelines The Cedars Sinai active surveillance program 50% of patients who are offered surveillance accept it… which mirrors Japan Alienation of active surveillance patients Anxious, calm, and risk and prioritize risks of surgery  Thyroid cancer tends to strike younger patients.  Prostrate cancer tends to be older. Prostrate cancer may not improve survival Surgery in thyroid versus prostate is safer Radiation ad toxicity NOTES Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review 50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering 89: Your Patient ‘Type’ May Determine Your Thyroid Cancer Treatment → Dr. Michael Tuttle from Sloan Kettering 77: Broadway Performer Says No to Thyroid Cancer Surgery → Surveillance Instead 87: Is There a Stigma to Choosing Active Surveillance? → Dr. Louise Davies from The Dartmouth Institute Vigilancia activa en el tratamiento del microcarcinoma de tiroides. Dr. Allen Ho

1 Feb 202138min

Victor J. Bernet, MD, is Chair of the Endocrinology Division at the Mayo Clinic in Jacksonville, Florida and is an Associate Professor in the Mayo Clinic College of Medicine. Dr. Bernet served 21+ years in the Army Medical Corps retiring as a Colonel. He served as Consultant in Endocrinology to the Army Surgeon General, Program Director for the National Capitol Consortium Endocrinology Fellowship and as an Associate Professor of Medicine at the Uniformed Services University of Health Sciences. Dr. Bernet has received numerous military awards, was awarded the “A” Proficiency Designator for professional excellence by the Army Surgeon General and the Peter Forsham Award for Academic Excellence by the Tri-Service Endocrine Society. Dr. Bernet graduated from the Virginia Military Institute and the University of Virginia School of Medicine. Dr. Bernet completed residency at Tripler Army Medical Center and his endocrinology fellowship at Walter Reed Army Medical Center. Dr. Bernet’s research interests include: improved diagnostics for thyroid cancer, thyroidectomy related hypocalcemia, thyroid hormone content within supplements as well as management of patient’s with thyroid cancer. He is the current Secretary and CEO of the American Thyroid Association. In this episode Dr. Bernet describes that Hashimoto’s thyroiditis is an autoimmune condition that usually progresses slowly and often leads to low thyroid hormone levels — a condition called hypothyroidism. The best therapy for Hashimoto’s thyroiditis is to normalize thyroid hormone levels with medication. A balanced diet and other healthy lifestyle choices may help when you have Hashimoto’s, but a specific diet alone is unlikely to reverse the changes caused by the disease. Hashimoto’s thyroiditis develops when your body’s immune system mistakenly attacks your thyroid. It’s not clear why this happens. Some research seems to indicate that a virus or bacterium might trigger the immune response. It’s possible that a genetic predisposition also may be involved in the development of this autoimmune disorder. A chronic condition that develops over time, Hashimoto’s thyroiditis damages the thyroid and eventually can cause hypothyroidism. That means your thyroid no longer produces enough of the hormones it usually makes. If that happens, it can lead to symptoms such as fatigue, sluggishness, constipation, unexplained weight gain, increased sensitivity to cold, joint pain or stiffness, and muscle weakness. If you have symptoms of hypothyroidism, the most effective way to control them is to take a hormone replacement. That typically involves daily use of a synthetic thyroid hormone called levothyroxine that you take as an oral medication. It is identical to thyroxine, the natural version of a hormone made by your thyroid gland. The medication restores your hormone levels to normal and eliminates hypothyroidism symptoms. You may hear about products that contain a form of thyroid hormones derived from animals. They often are marketed as being natural. Because they are from animals, however, they aren’t natural to the human body, and they potentially can cause health problems. The American Thyroid Association’s hypothyroidism guidelines recommend against using these products as a first-line treatment for hypothyroidism. Although hormone replacement therapy is effective at controlling symptoms of Hashimoto’s thyroiditis, it is not a cure. You need to keep taking the medication to keep symptoms at bay. Treatment is usually lifelong. To make sure you get the right amount of hormone replacement for your body, you must have your hormone levels checked with a blood test once or twice a year. If symptoms linger despite hormone replacement therapy, you may need to have the dose of medication you take each day adjusted. If symptoms persist despite evidence of adequate hormone replacement therapy, it’s possible those symptoms could be a result of something other than Hashimoto’s thyroiditis. Talk to your health care provider about any bothersome symptoms you have while taking hormone replacement therapy. NOTES and REFERENCES Request an Appointment Victor Bernet, M.D.

1 Feb 202135min

M. Regina Castro, MD is a consultant in the Division of Endocrinology at the Mayo Clinic in  Rochester, MN.  She is an Associate Professor of Medicine. She is the Associate Program Director for the Endocrinology Fellowship program,  and Director of Endocrinology rotation for the  Internal Medicine Residency.  She is also a member of the Thyroid Core Group at Mayo Clinic. She served from 2009 to 2015 as Thyroid Section Editor for AACE Self-Assessment Program and has authored several chapters on Hyperthyroidism, Thyroid Nodules and thyroid cancer. She has served on various committees of the ATA, including Patient Education and Advocacy committee, the  editorial board of Clinical Thyroidology  for Patients (CTFP),  Trainees and Career Advancement committee  and  is at present  the  Chair of the Patient Affairs and Education Committee. She currently serves on the ATA Board of Directors. Her professional/academic Interests:  Clinical research related to thyroid nodules and thyroid cancer,  clinical care of patients with various thyroid diseases, and medical education. During this interview, the following topics are addressed: What is a thyroid nodule?  A lump that could be benign or cancerous The prevalence depends on how you search for them 60% of people in the U.S. will have nodules 90% are benign Sometimes done during routine physical exam Sometimes the patient discovers it Usually is discovered when imaging is done for other reasons — during CT scan Medical history of radiation to head or neck as a child, family history of thyroid cancer, size of nodule, abnormal lymph nodes in the neck Usually patients with a nodule are asymptomatic Best test to look at the nodule is an ultrasound of the nodule Features in the ultra sound determines how suspicious a nodule is A biopsy is ordered based on appearance, if nodules are clearly defined are more likely to suggest they are benign If nodule looks dark or borders are irregular, or increased blood flow within the nodule may cause concern Quality and resolution of thyroid ultra sound is high resolution and provides a clear look Coaching patients through the anxiety through a possible biopsy The majority of nodules can be observed ATA guidelines suggest observation based on the result of the biopsy Suspicious nodules that are less than 1cm are sometimes determined to best observe and not remove Cancer will be in only 5% of biopsies A smaller, low risk cancer should warrant a lesser surgery — and reduce the chance of surgical complications When to remove a nodule even if no cancer?  If other structures are being obstructed, such as breathing or swallowing, sometimes surgery relieves symptoms regardless if cancer or not Observation — and follow up recommendations 15% are labeled indeterminate If surgery, surgeon needs to be experienced — many surgeons conducting thyroid surgery are low in experience The Mayo Clinic thyroid cancer team Biopsy results in two hours versus two weeks NOTES The American Thyroid Association Dr. Regina Castro 64: Managing Indeterminate Thyroid Nodules, with Dr. Kimberly Vanderveen from Denver Center for Endocrine Surgery

28 Jan 202121min

Fabián Pitoia, MD, Ph D.   Jefe de la sección tiroides, División Endocrinología Hospital de Clinicas decla universidad de Buenos Aires Sub director de la carrera de medicos especialistas en Endocrinología- hospital de clinicas   Docente adscripto de medicina interna.   Temas de este entrevista incluye:   El tema de hoy es la gestión de la vigilancia activa microcarcinoma ¿qué es el microcarcinoma y qué es la vigilancia activa? Para aquellos que siguen el podcast de Doc Thyroid, es posible que conozcan mi historia, tuve una tiroidectomía y cáncer de tiroides. Cuando escuché la palabra cáncer de mi médico, creó miedo y ansiedad. Pero, ¿la palabra cáncer relacionada con el cáncer de tiroides es diferente? (papilar) ¿Puede decirnos cómo y por qué esto es cierto? Por ejemplo, en comparación con el cáncer de cerebro o el cáncer de páncreas ... ¿Cuántos pacientes con cáncer papilar de tiroides ves un año? ¿Cuántos pacientes con cáncer papilar de tiroides han muerto bajo su cuidado? (La intención de esta pregunta es reducir el miedo en la audiencia sobre la palabra cáncer) Cuéntanos más sobre la vigilancia activa ... es una nueva practica? ¿Y por qué estamos escuchando más sobre esto últimamente? ¿Cómo sabe un paciente si es adecuado para ellos? ¿Cuál es el tratamiento para los pacientes que eligen este tratamiento? ¿Todos los hospitales en América Latina ofrecen vigilancia activa? ¿Cómo puede un paciente encontrar doctores que lo ofrezcan? La Dra. Davies dice que algunos pacientes en su programa dicen sentirse "estúpidos" por dejar el cáncer en su cuerpo. ¿Hay apoyo emocional para aquellos que eligen Vigilancia Activa Microcarcinoma? Dr. Fabian Pitoia

25 Jan 202143min