There are 36,000 new thyroid cancer
cases a year in the USA.

1. Only 1600 deaths.
2. The finding of a nodule by your physician is not an emergency.
3. You need to relax, and slowly position yourself to get the best care from the beginning.
4. 400,000 thyroid cancer patients are alive in the USA.
5. Few deaths, but most need long term follow up.
6. The painless nodule or enlarged thyroid is the only sign.
7. There are no symptoms.
8. Only 5% of all nodules are cancer. Do not panic, as the odds are in your favor it is not CANCER.
9. A Family history of thyroid cancer is a risk factor.
10. Radiation therapy is another.
11. High frequency thyroid ultrasound is the best screening test.
12. Complete thyroid evaluation by an endocrinologist BEFORE surgery.
13. This saves mistakes in the early phase of the diagnostic and therapy plan.
14. Ultrasound guided Fine needle biopsy, by an expert thyroid ultrasonographer is mandatory for accuracy. Free hand Needle biopsy should not be done, even on big palpable nodules. The best place to aim the needle can only be seen with ultrasound.
15. The proper production of the smears from the thyroid biopsy is a major problem.
16. The smearing technique of many FNA physicians, produce unreadable slides which are bloody, and air dried, and prone to be inadequate or produce doubtful results, that require to be repeated by an thyroid expert, and may be the cause of over reading a nodule as follicular neoplasm due to artifacts of the technique.
17. One clue to poor smearing technique is the use of thin prep, instead of smears. Thin Prep is not recommended for thyroid biopsies.
18. Get an expert thyroid cytopathologist to read the smears. The smears can be sent by FEDEX to an expert. Try Outpatient Pathology Associates, and ask for Dr. John Abele to do a second opinion. Check out his website at www.outpatientpathology.com.
19. Always request an outside expert second opinion. Thyroid biopsies are hard to read even by most well trained pathologists.
    
20. If it is cancer, request a pre-surgery ultrasound lymph node mapping. This will help in planning your original surgery. Remember, this is a new indication for the ultrasound, so you have to insist that it be done. It can save you another surgery in the future.
21. What if an abnormal node or nodes are found in the endocrine neck by ultrasound?
22. Request an USGFNA biopsy of the nodes, and a washing for cancer markers.
23. If positive for a cancer node, make sure the surgeon adds that neck area to the original surgery plan.
24. Request a pre-surgery cancer marker.
25. The cancer markers are thyroglobulin for papillary and follicular.
26. Calcitonin is the marker for Medullary thyroid cancer.
27. The surgery plan will be changed 20-30-% of the time by pre-surgery ultrasound lymph node mapping.
28. INSIST you have this Test before your surgery!
29. This will save a late recurrence by ridding the neck of cancer nodes with the first surgery.
30. Ask for a thyroid surgeon. He must operate at least 50-150 times on the thyroid a YEAR.
31. The complication rate is lower with a true thyroid surgeon.
32. Check www.endocrinesurgery.org
33. The choice of surgeons is the most important decision to make, after finding a clinical thyroidologist. (www.thyroidologists.com)
34. Don’t be rushed into surgery for fear of cancer. Thyroid cancer is slow growing, and there is time to plan for the best outcome.
35. This will save you a second surgery, complications and result in a clean bloodless surgery.
36. What are the names of the cancers of the thyroid?
37. Papillary is 80% of all cancer
38. Follicular is 10%
39. Medullary is 5 %
40. Anaplastic is rare, but occurs in elderly patients with pre-existing goiter.
41. Lymphoma is also rare, but occurs in elderly patients with Hashimoto’s thyroiditis.
42. Thyroid Cancer Treatment Maxim: Do no harm.
43. Get another opinion if nuclear medicine wants to give radiation in the form of radioiodine to low risk patients. A low risk patient has a MACIS Mayo Clinic prognostic score < 6.00.
    Even a 30 Millicuries low dose ablation is not necessary, when sensitive cancer marker thyroglobulin, and high frequency ultrasound lymph node mapping are done at 6-12 month intervals.
44. The old saw of giving radiation to every patient with a diagnosis of thyroid cancer must stop.
45. The routine use of radioiodine diagnostic whole body scans should be discouraged. They are not helpful in most low risk cancer patients.
46. Greater than 80 MCI can cause an increase incidence of solid tumors.
47. Cancers of the stomach, kidney, breast, female tract, prostrate and penis are increased after ”routine” 100 millicure radioiodine therapy.
48. Most nuclear medicine departments still routinely give 100 MCI to all patients.
49. Radioiodine is not an emergency therapy. Take your time to decide if it is really necessary.
50. After the surgery, leave the hospital on thyroid hormone, and see the thyroidologist in 4 weeks.
51. Get the slides from the surgery to the thyroidologist for his or her review. MACIS Mayo Clinic prognostic scoring from the original surgery slides will be done by your thyroidologist.
52. The score is based on your age, size of the tumor, complete removal of the tumor, and local invasion outside the thyroid gland into the neck muscles.
53. A MACIS score of < 6.00 is a 99% prognosis of 20+ years survival, and this means, that you will probably not die from this tumor.
54. However, recurrences can occur in the neck after many years.
55. That is the reason long-term follow-up with ultrasound and TG cancer marker by your thyroidologists, is needed yearly after the first year.
56. Low risk Thyroid cancer is like other chronic diseases, which persist but do not kill you.
57. Small numbers of cancer cells are seeded to the neck nodes even before the first surgery.
58. However, Neck Lymph node thyroid cancer is not a bad prognostic sign.
59. It is not included in the Mayo Clinic MACIS Scoring System.
60. Get a one-month post surgery blood cancer marker for thyroglobulin (TG), T4, and TSH.
61. The thyroidologist will discuss the therapy plan for your future thyroid cancer care.
62. This will usually include 6 and 12 month visits for cancer marker testing and yearly high frequency thyroid and neck ultrasound, preformed by your clinical thyroidologist.
63. He or she is an expert certified endocrine neck ultrasonographer.
64. What if an abnormal node is found at your visit?
65. USGFNA biopsy, and TG needle washing is performed by your thyroid ultrasonographer.
66. If positive, you have to have another surgery to remove all the nodes in the side of neck that had the positive node.
67. However, if that side was operated on in the past, it may be dangerous to go back in again.
68. You have two options. 1. A blue dye can be injected by US guidance on the surface of the cancer node one hour before surgery to help the surgeon find the node. This is done as an outpatient by the thyroidologist.
69. The second is the use of US guided injection of ethanol into the cancer node by a qualified thyroid ultrasonographer. Ethanol will kill the viable cancer cells in the node. The procedure is called PEI, percutaneous ethanol injection.
70. If you have a medium or high-risk cancer after MACIS scoring he or she may recommend radioiodine therapy. However 90% are low risk and DO NOT NEED RADIATION.
71. Nuclear medicine physicians often use the term “magic bullet”, because they say the radiation goes to the thyroid cancer cells, and does little damage or no damage to other tissues.
72. If it is needed, it is relatively safe, except when high doses are given to patients that do not need it.
73. In my experience, it will not cure you, and will not be effective in treating neck cancer nodes. Surgery is the best method.
74. The patient hopes for a cure, and is often mislead that radioiodine will “cure” them.
75. Radioiodine will only prolong the intervals between recurrences in moderate or high-risk cases. It will not cure you.
76. 150 MCI treatment doses can be given as an outpatient in many states. It is safe to do this, and makes hospitalization unnecessary in most thyroid cancer patients.
77. Find a thyroidologist to administer the radioiodine to you as an outpatient.
78. He or she is the best person to care for you.
79. The low risk patient will not die from this cancer with or without radioiodine. The radiation is only an unnecessary expense, and adds a radiation burden to bear for the rest of their life, including a cancer risk above the normal population.
80. This is a major fact: If you have one of those bad cancers, you need the expert advice obtained at a center that deals with severe cancer of the thyroid.
81. There is MD Anderson, Sloan Kettering, and Mayo Clinic, where teams are expert in treating advanced cases with spread to the lungs, bone and other distant areas. They are the Thyroid Cancer Oncologists with access to potent research therapy protocols, and newer methods of local therapy to distant sites.
82. Medullary thyroid cancer patients have one chance to influence the course of the disease. They need a real thyroid cancer surgeon to remove everything including the nodes. Go to the above named centers, or if you are on the west coast see Dr. Orlo Clark and his team at UCSF San Francisco.
83. A total thyroidectomy and bilateral neck surgery is mandated.
84. There is no other therapy for this disease.
85. Screening all family members with RET proto-oncogene if you are positive.
86. All positive relatives need thyroidectomy, even if they are 6 months old!
87. If you have the gene you will get medullary thyroid cancer some day.
88. They will be spared cancer, as they may have pre-cancer only at surgery and be cured.
89. The follow up is similar to papillary and follicular cancer, except there is no radioiodine therapy for medullary thyroid cancer, and the cancer marker followed is calcitonin, not thyroglobulin. The neck ultrasound is a major tool to search for recurrence.
90. Aggressive Anaplastic thyroid cancer is a rapidly fatal disease in a few months.
91. There is no hope for cure. Either do nothing, and only treat symptoms, or go to one of the centers for a research therapy protocol. It may extend your life a few months, but weigh that against the side effects of the therapy.

Now you have my road map to extract the best diagnostic and therapy plans for your long-term wellbeing. Copy this and use it when you talk to the physicians.

Good Luck
Dr.G.