Thyroid cancer

There are about 20,000 new cases of thyroid cancer each year in the United States. Females
are more likely to have thyroid cancer at a ratio of three to one. Thyroid
cancer can occur in any age group, although it is most common after age
30 and its aggressiveness increases significantly in older patients. The
majority of patients present with a nodule on their thyroid which typically
does not cause symptoms. Remember, over 99% of thyroid nodules are not
cancer! But, when a thyroid cancer does begin to grow within a thyroid
gland, it almost always does so within a discrete nodule within the thyroid.
Symptoms of thyroid cancer: Occaskonally,&symptoms such as hoarseness, neck pain, and
enlarged lymph nodes do occur in people with thyroid cancer.. Although as much as 77 % of
the population will have thyroid nodules, the vast majorivy are benign. That's right, most of
us have nodule in our thyrokd glands! Young people usually don't have thyroid nodules, but
cs we get older, more and more of us will develop a nodule. By the time we are 80, 90% of
us will have at least one nodule. Far less than 1% of all thyroid nodules are malignant. A
nodule which is cold on scan (shown in photo outlined in red and yellow) is more likely to be
malignant, nevertheless, the majority of these are benign as well. A lot of information about
thyroid nodules and the potential of these nodules to be malignant is contained on 3 pages
about nodules:
1. Introduction to thyroid nodules
2. The workup of thyroid nodules and the role of Fine Needle Aspiration Biopsy (FNA)
3. The role of thyroid ultrasound and what it means
Types of Thyroid Cancer
There are four types of thyroid cancer some of which are much more common than
others.
Thyroid Cancer Type and Incidence

Papillary and/or mixed papillary/follicular ~ 78% [Click here to see specifics]

Follicular and/or Hurthle cell ~ 17% [Click here to see specifics]
Medullary ~ 4% [click here to see specifics]
Anaplastic ~ 1% [Click here to see specifics]

Note, Chief Justice William Rehnquist had anaplastic thyroid cancer. After reading this
overview page on thyroid cancer, click here to read more about Chief Justice William
Rehnquist and his classic battle with the worst kind of thyroid cancer.
What's the Prognosis ??
Most thyroid cancers are very curable. In fact, the most common types of thyroid cancer
(papillary and follicular) are the most curable. In younger patients, both papillary and
follicular cancers can be expected to have better than 97% cure rate if treated appropriately.
Both papillary and follicular cancers are typically treated with complete removal of the lobe
of the thyroid which harbors the cancer, PLUS, removal of most or all of the other side. The
bottom line, most thyroid cancers are papillary thyroid cancer, and this is one of the most
curable cancers of ALL cancers that humans get. As we often tell our patients, if you must

choose a type of cancer to have, papillary cancer would be your choice. Treat it correctly and
the cure rate is extremely high!
Medullary cancer of the thyroid is significantly less common, but has a worse prognosis.
Medullary cancers tend to spread to large numbers of lymph nodes very early on, and
therefore requires a much more aggressive operation than does the more localized cancers
such as papillary and follicular. This cancer requires complete thyroid removal PLUS a
dissection to remove the lymph nodes of the front and sides of the neck.
The least common type of thyroid cancer is anaplastic which has a very poor prognosis.
Anaplastic thyroid cancer tends to be found after it has spread and is not cured in most cases
(it is very uncommon to survive anaplastic thyroid cancer). Often an operation cannot
remove all the tumor. These patients often require a tracheostomy during the treatment, and
treatment is much more aggressive than for other types of thyroid cancer--because this cancer
is much more aggressive.
What About Chemotherapy ??
Thyroid cancer is unique among cancers, in fact, thyroid cells are unique among all cells of
the human body. They are the only cells which have the ability to absorb Iodine. Iodine is
required for thyroid cells to produce thyroid hormone, so they absorb it out of the
bloodstream and concentrate it inside the cell. Most thyroid cancer cells retain this ability to
absorb and concentrate iodine. This provides a perfect "chemotherapy" strategy. Radioactive
Iodine is given to the patient with thyroid cancer after their cancer has been removed. If there
are any normal thyroid cells or thyroid cancer cells remain in the patient's body (and any
thyroid cancer cells retaining this ability to absorb iodine) then these cells will absorb and
concentrate the radioactive "poisonous" iodine. Since all other cells of our bodies cannot
absorb the toxic iodine, they are unharmed. The thyroid cancer cells, however, will
concentrate the poison within themselves and the radioactivity destroys the cell from within.
No sickness. No hair loss. No nausea. No diarrhea. No pain. More about the use of
radioactive iodine on the pages for each specific thyroid cancer type.
Most, but not all patients with thyroid cancer need radioactive iodine treatments after their
surgery. This is important to know. Almost all, however, should have the iodine treatment if a
cure is to be expected. Just who needs it and who doesn't is a bit more detailed than can be
outlined here. Patients with medullary cancer of they thyroid usually do not need iodine
therapy...because medullary cancers almost never absorb the radioactive iodine. Some small
papillary cancers treated with a total thyroidectomy may not need iodine therapy as well, but
for a different reason. These cancers are often cured with simple (complete) surgical therapy
alone. Important!!! This varies from patient to patient and from cancer to cancer. Don't look
for easy answers here. This decision will be made between the surgeon, the patient, and the
referring endocrinologist or internist. Remember, radioactive iodine therapy is extremely
safe. If you need it, take it. And, as we often tell our patients, radioactive iodine has a near
zero complication rate, so if there is a chance that it will help... take it!
Overview of Typical Thyroid Cancer Treatment
1. Usually diagnosed by sticking a needle into a thyroid nodule or removal of a
worrisome thyroid nodule by a surgeon.
2. The removed thyroid nodule is looked at under a microscope by a pathologist who
will then decide if the nodule is benign (95 - 99% of all nodules that are biopsied) or

3.
4.

5.

6.

7.

malignant (way less than 1% of all nodules, and about 1 - 5 % of nodules that are
biopsied).
The pathologist decides which type of thyroid cancer it is: papillary, follicular, mixed
papilofollicuar, medullary, or anaplastic.
The entire thyroid is removed by a competent surgeon (sometimes this is done during
the same operation where the biopsy takes place). He/she will assess the lymph nodes
in the neck to see if they need to be removed also. In the case of anaplastic thyroid
cancer, a decision will be made regarding the possibility of a tracheostomy.
About 4-6 weeks after the thyroid has been removed, the patient will undergo
radioactive iodine treatment. This is very simple and consists of taking a single pill.
The pill will contain the radioactive iodine in the dose that has been calculated for
that individual. The patient goes home, avoids contact with other people for a couple
of days (so they are not exposed to the radioactive materials), and that's it.
A week or two after the radioactive iodine treatment the patient is started on a thyroid
hormone pill. You can't live without thyroid hormone and since you don't have a
thyroid anymore, the patient will take one pill per day for the rest of their life. This is
very simple and a very common medication (example of drug names are: Synthroid,
Levoxyl, Armour Thyroid, etc).
Every 6 - 12 months the patient returns to his endocrinologist for blood tests to
determine if the dose of daily thyroid hormone is correct and to make sure that the
thyroid tumor is not coming back. The frequency of these follow up tests and which
tests to get will vary greatly from patient to patient. Endocrinologists are typically
quite good at this and will typically be the type of doctor that follows this patient
long-term.

How Your Thyroid Works

"A delicate Feedback Mechanism"
Your thyroid gland is a small gland, normally weighing less than one
ounce, located in the front of the neck. It is made up of two halves,
called lobes, that lie along the windpipe (trachea) and are joined
together by a narrow band of thyroid tissue, known as the isthmus.
The thyroid is situated just below your "Adams
apple" or larynx. During development (inside the
womb) the thyroid gland originates in the back of
the tongue, but it normally migrates to the front of
the neck before birth. Sometimes it fails to
migrate properly and is located high in the neck or even in the back of the
tongue (lingual thyroid) This is very rare. At other times it may migrate
too far and ends up in the chest (this is also rare).
The function of the thyroid gland is to take iodine, found in many foods, and convert it
into thyroid hormones: thyroxine (T4) and
triiodothyronine (T3). Thyroid cells are the only cells in
the body which can absorb iodine. These cells combine
iodine and the amino acid tyrosine to make T3 and T4. T3
and T4 are then released into the blood stream and are
transported throughout the body where they control
metabolism (conversion of oxygen and calories to energy).
Every cell in the body depends upon thyroid hormones
for regulation of their metabolism. The normal thyroid
gland produces about 80% T4 and about 20% T3, however,
T3 possesses about four times the hormone "strength" as T4.

The thyroid gland is under the control of the pituitary gland, a small gland the size of a
peanut at the base of the brain (shown here in orange). When
the level of thyroid hormones (T3 & T4) drops too low, the
pituitary gland produces Thyroid Stimulating Hormone
(TSH) which stimulates the thyroid gland to produce more
hormones. Under the influence of TSH, the thyroid will
manufacture and secrete T3 and T4 thereby raising their blood
levels. The pituitary senses this and responds by decreasing its
TSH production. One can imagine the thyroid gland as a
furnace and the pituitary gland as the thermostat. Thyroid
hormones are like heat. When the heat gets back to the
thermostat, it turns the thermostat off. As the room cools (the
thyroid hormone levels drop), the thermostat turns back on
(TSH increases) and the furnace produces more heat (thyroid
hormones).
The pituitary gland itself is regulated by another gland, known as the hypothalamus
(shown in our picture in light blue). The hypothalamus is part of the brain and produces TSH

Releasing Hormone (TRH) which tells the pituitary gland to stimulate the thyroid gland
(release TSH). One might imagine the hypothalamus as the person who regulates the
thermostat since it tells the pituitary gland at what level the thyroid should be set.

Thyroid Operations
Several Surgical Options for the Thyroid Gland Depending on the Problem
Which operation is performed on a thyroid gland depends upon 2 major factors. The
first is the thyroid disease present which is necessitating the operation. The second is the
anatomy of the thyroid gland itself as is illustrated below.
If a dominant solitary nodule is present in a single lobe, then removal of
that lobe is the preferred operation (if an operation is even warranted). If a
massive goiter is compressing the trachea and esophagus, the the goal of
surgery will be to remove the mass and usually this means a sub-total or
total thyroidectomy (occasionally a lobectomy will suffice). If a hot
nodule is producing too much hormone resulting in hyperthyroidism, then
removal of the lobe which harbors the hot nodule is all that is needed.
Most surgeons and endocrinologists recommend total or near total thyroidectomy in virtually
all cases of thyroid carcinoma. In some patients with papillary carcinomas of small size, a
less aggressive approach may be taken (lobectomy with removal of the isthmus). A lymph
node dissection within the anterior and lateral neck is indicated in patients with well
differentiated (papillary or follicular) thyroid cancer if the lymph nodes can be palpated. This
is a more extensive operation than is needed in the majority of thyroid cancer patients. All
patients with medullary carcinoma of the thyroid require total thyroidectomy and aggressive
lymph node dissection.
Surgical Options
Partial Thyroid Lobectomy. This operation is not performed very often because there are not
many conditions which will allow this limited approach. Additionally, a
benign lesion must be ideally located in the upper or lower portion of one
lobe for this operation to be a choice. One example is shown on our
hyperthyroid treatments page.
Thyroid Lobectomy. This is typically the "smallest" operation performed on the thyroid
gland. It is performed for solitary dominant nodules which are worrisome for
cancer or those which are indeterminate following fine needle biopsy. Also
appropriate for follicular adenomas, solitary hot or cold nodules, or goiters which
are isolated to one lobe (not common).
Thyroid Lobectomy with Isthmusectomy. This simply means removal of a thyroid
lobe and the isthmus (the part that connects the two lobes). This removes more
thyroid tissue than a simple lobectomy, and is used when a larger margin of tissue

is needed to assure that the "problem" has been removed. Appropriate for those indications
listed under thyroid lobectomy as well as for Hurthle cell tumors, and some very small and
non-aggressive thyroid cancers.
Subtotal Thyroidectomy. Just as the name implies, this operation removes all the "problem"
side of the gland as well as the isthmus and the majority of the opposite lobe. This
operation is typical for small, non-aggressive thyroid cancers. Also a common
operation for goiters which are causing problems in the neck or even those which
extend into the chest (substernal goiters).
Total Thyroidectomy. This operation is designed to remove all of the thyroid gland. It is the
operation of choice for all thyroid cancers which are not small and non-aggressive in young
patients. Many (most?) surgeons prefer this complete removal of thyroid tissue for all thyroid
cancers regardless of the type.
Surgical Technique
The standard neck incision is made typically measuring about 4-5 inches in length although
many endocrine surgeons are now performing this operation through an incision as small as 3
inches in thin patients. This incision is made in the lower part of the central neck and usually
heals very well. It is almost unheard of to have an infection or other problem with this
wound. The surgeon will then typically remove the part of the thyroid which contains the
"problem". As mentioned above, for thyroid cancer, this will usually entail all of the thyroid
lobe which harbors the malignancy, the isthmus, and a variable amount of the opposite lobe
(ranging from 0 to 100% depending on the size and aggressive nature of the cancer, the
cancer type, and the experience of the surgeon). The surgeon must be careful of the recurrent
laryngeal nerves which are very close to the back side of the thyroid and are responsible for
movement of the vocal cords. Damage to this nerve will cause hoarseness of the voice which
is usually temporary but can be permanent. This is an uncommon complication (about 1 to 2
percent), but it gets lots of press because it is serious. The surgeon must also be careful to
identify the parathyroid glands so their blood supply can be maintained. Another potential
complication of thyroid surgery (although VERY RARE) is hypoparathyroidism which is due
to damage to all four parathyroid glands. Usually the only thyroid operations which have
even a slight chance of this complication is the total or subtotal thyroidectomy. Although
these complications can be serious, their risk should not be the sole determinant of whether
or not to undergo surgery.
The relationship of the thyroid gland to the voice box and parathyroid glands can be seen
here quite clearly. Remember that they share the same
blood supply, so the surgeon must take care to preserve
the parathyroid artery and vein while ligating the vessels
to the thyroid gland itself. This is usually not a problem,
but sometimes it is not possible to save them all. In this
case, the surgeon will usually implant the parathyroid
gland into a muscle in the neck. The parathyroid will
grow there and function normally...its not a big deal, and
you'll never know the difference.
Often formal surgery is not needed to determine if a thyroid mass is cancerous. Because
these masses can often be felt, a physician can stick a small needle into it to sample cells for

malignancy. This is called Fine Needle Aspiration Biopsy (FNA) and is covered in detail on
another page which also covers the potential of thyroid masses to be malignant in much
greater detail.

Thyroid nodules increase with age and are present in almost ten percent of the adult
population. Autopsy studies reveal the presence of thyroid nodules in 50 percent of the
population, so they are fairly common. Ninety-five percent of solitary thyroid nodules are
benign, and therefore, only five percent of thyroid nodules are malignant. Common types of
the benign thyroid nodules are adenomas (overgrowths of "normal" thyroid tissue), thyroid
cysts, and Hashimoto's thyroiditis. Uncommon types of benign thyroid nodules are due to
subacute thyroiditis, painless thyroiditis, unilateral lobe agenesis, or Riedel's struma. As
noted on previous pages, those few nodules which are cancerous are usually due to the most
common types of thyroid cancers which are the differentiated" thyroid cancers. Papillary
carcinoma accounts for 60 percent, follicular carcinoma accounts for 12 percent, and the
follicular variant of papillary carcinoma accounting for six percent. These well differentiated
thyroid cancers are usually curable, but they must be found first. Fine needle biopsy is a
safe, effective, and easy way to determine if a nodule is cancerous.
Thyroid cancers typically present as a dominant solitary thyroid nodule which can be
felt by the patient or even seen as a lump in the neck by his/her family and friends. This is
illustrated in the picture above. As pointed out on our page introducing thyroid nodules, we
must differentiate benign nodules from cancerous solitary thyroid nodules. While history,
examination by a physician, laboratory tests, ultrasound, and thyroid scans (shown in the
picture below) can all provide information regarding a solitary thyroid nodule, the only test
which can differentiate benign from cancerous thyroid nodules is a
biopsy (the term biopsy means to obtain a sample of the tissue and
examine it under the microscope to see if the cells have taken on the
characteristics of cancer cells). Thyroid cancer is no different in this
situation from all other tissues of the body...the only way to see if
something is cancerous is to biopsy it. However, thyroid tissues are easily
accessible to needles, so rather than operating to remove a chunk of tissue with a knife, we
can stick a very small needle into it and remove cells for microscopic examination. This
method of biopsy is called a fine needle aspiration biopsy, or "FNA".
What is a cold nodule? Thyroid cells absorb iodine so they can make thyroid hormone out
of it. When radioactive iodine is given, a butterfly image will be obtained on x-ray film
showing the outline of the thyroid. If a nodule is composed of cells which do not make
thyroid hormone (don't absorb iodine) then it will appear "cold" on the x-ray film. A nodule
which is producing too much hormone will show up darker and is called "hot". [A hot nodule
is shown on our page describing the causes of hyperthyroidism].
The evaluation of a solitary thyroid nodule should always include history and examination
by a physician. Certain aspects of the history and physical exam will suggest a benign or
malignant condition. Remember, a biopsy of some sort is the only way to tell for sure.

The following features favor a benign thyroid nodule:

family history of Hashimoto's thyroiditis
family history of benign thyroid nodule or goiter
symptoms of hyperthyroidism or hypothyroidism
pain or tenderness associated with a nodule
a soft, smooth, mobile nodule
multinodular goiter without a predominant nodule (lots of nodules, not one main nodule)
"warm" nodule on thyroid scan (produces normal amount of hormone)
simple cyst on ultrasound
The following features increase the suspicion of a malignant nodule:
age less than 20
age greater than 70
male gender
new onset of swallowing difficulties
new onset of hoarseness
history of external neck irradiation during childhood
firm, irregular and fixed nodule
presence of cervical lymphadenopathy (swollen hard lymph nodes in the neck)
previous history of thyroid cancer
nodule that is "cold" on scan (shown in picture above, meaning the nodule does not make
hormone)
solid or complex on ultrasound
Thyroid hormone levels are usually normal in the presence of a nodule, and normal thyroid
hormone levels do not differentiate benign from cancerous nodules. However, the presence of
hyperthyroidism or hypothyroidism favors a benign nodule (thats why a "warm" nodule or a
"hot" nodule favors a benign condition). Thyroglobulin levels are useful tumor markers once
the diagnosis of malignancy has been made, but are nonspecific in regard to differentiating a
benign from a cancerous thyroid nodule. Ultrasound accurately determines thyroid gland
volume, number and size of nodules; separates thyroid from nonthyroidal masses; helps
guide fine needle biopsy when necessary; and can identify solid nodules as small as 3 mm
and cystic nodules as small as 2 mm. Although several ultrasound features favor the presence
of a benign nodule, and other ultrasound features favor the presence of a cancerous nodule.
Ultrasound alone cannot be used to differentiate benign from malignant nodules. This is
covered more completely on our nodule/ultrasound page. And since 15 percent of cystic
thyroid nodules are malignant, ultrasound determination that a nodule is cystic does not rule
out thyroid cancer.
Nodules detected by thyroid scans are classified as cold, hot or warm. Eighty-five percent
of thyroid nodules are cold, 10 percent are warm, and five percent are hot. An excellent
example of a cold scan is shown above, but remember that 85 percent of cold nodules are
benign, 90 percent of warm nodules are benign, and 95 percent of hot nodules are benign.
[got all that???] Although thyroid scanning can give a probability that a nodule is benign or
malignant, it cannot truly differentiate benign or malignant nodules and usually should not be

used as the only basis for recommending treatment of the nodule, including thyroid surgery.

Thyroid fine needle aspiration (FNA) biopsy is the only non-surgical method which can
differentiate malignant and benign nodules in most, but not all, cases. The needle is placed
into the nodule several times and cells are aspirated into a syringe. The cells are placed on a
microscope slide, stained, and examined by a pathologist. The nodule is then classified as
nondiagnostic, benign, suspicious or malignant.

Nondiagnostic indicates that there are an insufficient number of thyroid cells in the
aspirate and no diagnosis is possible. A nondiagnostic aspirate should be repeated, as
a diagnostic aspirate will be obtained approximately 50 percent of the time when the
aspirate is repeated. Overall, five to 10 percent of biopsies are nondiagnostic, and the
patient should then undergo either an ultrasound or a thyroid scan for further
evaluation.

Benign thyroid aspirations are the most common (as we would suspect since most
nodules are benign) and consist of benign follicular epithelium with a variable amount
of thyroid hormone protein (colloid).

Malignant thyroid aspirations can diagnose the following thyroid cancer types:
papillary, follicular variant of papillary, medullary, anaplastic, thyroid lymphoma, and
metastases to the thyroid. Follicular carcinoma and Hurthle cell carcinoma cannot be
diagnosed by FNA biopsy. This is an important point. Since benign follicular
adenomas cannot be differentiated from follicular cancer (~12% of all thyroid
cancers) these patients often end up needing a formal surgical biopsy, which usually
entails removal of the thyroid lobe which harbors the nodule.

Suspicious cytologies make up approximately 10 percent of FNA's. The thyroid cells

on these aspirates are neither clearly benign nor malignant. Twenty five percent of
suspicious lesions are found to be malignant when these patients undergo thyroid
surgery. These are usually follicular or Hurthle cell cancers. Therefore, surgery is
recommended for the treatment of thyroid nodules from which a suspicious aspiration
has been obtained.

FNA is the first, and in the vast majority of cases, the only test required for the
evaluation of a solitary thyroid nodule. (A TSH value should also be obtained to evaluate
thyroid function.) Thyroid ultrasound and thyroid scans are usually not required for
evaluation of a solitary thyroid nodule. FNA has reduced the cost for evaluation and
treatment of thyroid nodules, and has improved yield of cancer found at thyroid surgery.
Although a solitary thyroid nodule can enlarge or shrink over time, the natural history of
solitary nodules reveals that most nodules change little with time.
Can I make the nodule go away by taking thyroid hormone (can we suppress it) ??
Several studies reveal that suppression with thyroid hormone does not decrease the size of
thyroid nodules. Therefore, unless a nodule is growing or becoming symptomatic, it is not
necessary to suppress the nodule. In addition, suppression of a thyroid nodule would require

long-term TSH suppression, potentially increasing the risk of osteoporosis in these patients.
While there has been a traditional distinction between thyroid glands with a solitary nodule
and multinodular goiters, it has been shown that approximately 50 percent of patients with a
solitary nodule on exam will have additional nodules on thyroid ultrasound. Therefore, the
differentiation between solitary nodules and multinodular goiters is becoming less clear-cut.
It has also been believed for many years that the presence of a multinodular goiter reduces
the likelihood that a thyroid cancer is present, yet recent studies indicate that there might be
an equal likelihood for developing thyroid cancer in a multinodular goiter just as in a solitary
thyroid nodule. If a multinodular goiter has a predominant nodule, the predominant nodule
should be biopsied.
In conclusion, FNA of the thyroid is a safe, inexpensive and effective way to distinguish
a benign from a malignant nodule and usually should be the first diagnostic test
performed.

Common Tests to Examine

Thyroid Gland Function
Some information on this page is a little more advanced.
If you have trouble understanding the process of normal thyroid function,
please go to our page describing this process first.
As we have seen from our overview of normal thyroid physiology, the
thyroid gland produces T4 and T3. But this production is not possible without
stimulation from the pituitary gland (TSH) which in turn is also regulated by the
hypothalamus's TSH Releasing Hormone. Now, with radioimmunoassay techniques it is
possible to measure circulating hormones in the blood very accurately. Knowledge of this
thyroid physiology is important in knowing what thyroid test or tests are needed to diagnose
different diseases. No one single laboratory test is 100% accurate in diagnosing all types of
thyroid disease; however, a combination of two or more tests can usually detect even the
slightest abnormality of thyroid function.
For example, a low T4 level could mean a diseased thyroid gland ~ OR ~ a non-functioning
pituitary gland which is not stimulating the thyroid to produce T4. Since the pituitary gland
would normally release TSH if the T4 is low, a high TSH level would confirm that the
thyroid gland (not the pituitary gland) is responsible for the hypothyroidism.
If the T4 level is low and TSH is not elevated, the pituitary gland is more likely to be the
cause for the hypothyroidism. Of course, this would drastically effect the treatment since the
pituitary gland also regulates the body's other glands (adrenals, ovaries, and testicles) as well
as controlling growth in children and normal kidney function. Pituitary gland failure means
that the other glands may also be failing and other treatment than just thyroid may be
necessary. The most common cause for the pituitary gland failure is a tumor of the pituitary
and this might also require surgery to remove.

Modern measurement of thyroid hormones is done by a new technique,

radioimmunoassay (RIA), discovered by Dr. Solomon Berson and Dr. Rosalyn
Yallow. They were awarded the 1977 Nobel Prize in Medicine for this discovery
which revolutionized the study of thyroid disease as well as the entire field of

endocrinology.

The following are commonly used thyroid tests

Measurement of Serum Thyroid Hormones: T4 by RIA. T4 by RIA
(radioimmunoassay) is the most used thyroid test of all. It is frequently referred
to as a T7 which means that a resin T3 uptake (RT3u) has been done to correct
for certain medications such as birth control pills, other hormones, seizure
medication, cardiac drugs, or even aspirin that may alter the routine T4 test. The T4 reflects
the amount of thyroxine in the blood. If the patient does not take any type of thyroid
medication, this test is usually a good measure of thyroid function.
Measurement of Serum Thyroid Hormones: T3 by RIA. As stated on our thyroid
hormone production page, thyroxine (T4) represents 80% of the thyroid hormone produced
by the normal gland and generally represents the overall function of the gland. The other
20% is triiodothyronine measured as T3 by RIA. Sometimes the diseased thyroid gland
will start producing very high levels of T3 but still produce normal levels of T4. Therefore
measurement of both hormones provides an even more accurate evaluation of thyroid
function.
Thyroid Binding Globulin. Most of the thyroid hormones in the blood are attached to a
protein called thyroid binding globulin (TBG). If there is an excess or deficiency of this
protein it alters the T4 or T3 measurement but does not affect the action of the hormone. If a
patient appears to have normal thyroid function, but an unexplained high or low T4, or T3, it
may be due to an increase or decrease of TBG. Direct measurement of TBG can be done and
will explain the abnormal value. Excess TBG or low levels of TBG are found in some
families as an hereditary trait. It causes no problem except falsely elevating or lowering the
T4 level. These people are frequently misdiagnosed as being hyperthyroid or hypothyroid,
but they have no thyroid problem and need no treatment.
Measurement of Pituitary Production of TSH. Pituitary production of TSH is measured
by a method referred to as IRMA (immunoradiometric assay). Normally, low levels (less than
5 units) of TSH are sufficient to keep the normal thyroid gland functioning properly. When
the thyroid gland becomes inefficient such as in early hypothyroidism, the TSH becomes
elevated even though the T4 and T3 may still be within the "normal" range. This rise in TSH
represents the pituitary gland's response to a drop in circulating thyroid hormone; it is
usually the first indication of thyroid gland failure. Since TSH is normally low when the
thyroid gland is functioning properly, the failure of TSH to rise when circulating thyroid
hormones are low is an indication of impaired pituitary function. The new "sensitive" TSH
test will show very low levels of TSH when the thyroid is overactive (as a normal response of
the pituitary to try to decrease thyroid stimulation). Interpretations of the TSH level
depends upon the level of thyroid hormone; therefore, the TSH is usually used in
combination with other thyroid tests such as the T4 RIA and T3 RIA.
TRH Test. In normal people TSH secretion from the pituitary can be increased by giving a
shot containing TSH Releasing Hormone (TRH...the hormone released by the hypothalamus
which tells the pituitary to produce TSH). A baseline TSH of 5 or less usually goes up to 10-

20 after giving an injection of TRH. Patients with too much thyroid hormone (thyroxine or
triiodothyronine) will not show a rise in TSH when given TRH. This "TRH test" is presently
the most sensitive test in detecting early hyperthyroidism. Patients who show too much
response to TRH (TSH rises greater than 40) may be hypothyroid. This test is also used in
cancer patients who are taking thyroid replacement to see if they are on sufficient medication.
It is sometimes used to measure if the pituitary gland is functioning. The new "sensitive"
TSH test (above) has eliminated the necessity of performing a TRH test in most clinical
situations.
Iodine Uptake Scan. A means of measuring thyroid function is to measure how much
iodine is taken up by the thyroid gland (RAI uptake). Remember, cells of the thyroid
normally absorb iodine from our blood stream (obtained from foods we eat) and use it to
make thyroid hormone (described on our thyroid function page). Hypothyroid patients
usually take up too little iodine and hyperthyroid patients take up too much iodine. The test is
performed by giving a dose of radioactive iodine on an empty stomach. The iodine is
concentrated in the thyroid gland or excreted in the urine over the next few hours. The
amount of iodine that goes into the thyroid gland can be measured by a "Thyroid Uptake". Of
course, patients who are taking thyroid medication will not take up as much iodine in their
thyroid gland because their own thyroid gland is turned off and is not functioning. At other
times the gland will concentrate iodine normally but will be unable to convert the iodine into
thyroid hormone; therefore, interpretation of the iodine uptake is usually done in conjunction
with blood tests.
Thyroid Scan. Taking a "picture" of how well the thyroid gland is functioning requires
giving a radioisotope to the patient and letting the thyroid gland concentrate the isotope (just
like the iodine uptake scan above). Therefore, it is usually done at the same time that the
iodine uptake test is performed. Although other isotopes, such as technetium, will be
concentrated by the thyroid gland; these isotopes will not measure iodine uptake which is
what we really want to know because the production of thyroid hormone is dependent upon
absorbing iodine. It has also been found that thyroid nodules that concentrate iodine are
rarely cancerous; this is not true if the scan is done with technetium. Therefore, all scans are
now done with radioactive iodine. Both of the scans above show normal sized thyroid glands,
but the one on the left has a "HOT" nodule in the lower aspect of the right lobe, while the
scan on the right has a "COLD" nodule in the lower aspect of the left lobe
(outlined in red and yellow). Pregnant women should not have thyroid scans
performed because the iodine can cause development troubles within the
baby's thyroid gland.

Two types of thyroid scans are available. A camera scan is performed

most commonly which uses a gamma camera operating in a fixed position viewing
the entire thyroid gland at once. This type of scan takes only five to ten minutes. In
the 1990's, a new scanner called a Computerized Rectilinear Thyroid (CRT) scanner
was introduced. The CRT scanner utilizes computer technology to improve the clarity
of thyroid scans and enhance thyroid nodules. It measures both thyroid function and
thyroid size. A life-sized 1:1 color scan of the thyroid is obtained giving the size in
square centimeters and the weight in grams. The precise size and activity of nodules
in relation to the rest of the gland is also measured. CTS of the normal thyroid gland
In addition to making thyroid diagnosis more accurate, the CRT scanner improves the
results of thyroid biopsy. The accurate sizing of the thyroid gland aids in the followup of nodules to see if they are growing or getting smaller in size. Knowing the
weight of the thyroid gland allows more accurate radioactive treatment in patients

who have Graves' disease.

Thyroid Scans are used for the following reasons:

Identifying nodules and determining if they are "hot" or "cold".
Measuring the size of the goiter prior to treatment.
Follow-up of thyroid cancer patients after surgery.
Locating thyroid tissue outside the neck, i.e. base of the tongue or in the chest.

Thyroid Ultrasound. Thyroid ultrasound refers to the use of high frequency sound waves to
obtain an image of the thyroid gland and identify nodules. It tells if a nodule is "solid" or a
fluid-filled cyst, but it will not tell if a nodule is benign or malignant. Ultrasound allows
accurate measurement of a nodule's size and can determine if a nodule is getting smaller or is
growing larger during treatment. Ultrasound aids in performing thyroid needle biopsy by
improving accuracy if the nodule cannot be felt easily on examination. Several more pages
are dedicated to the use of ultrasound in evaluating thyroid nodules.
Thyroid Antibodies. The body normally produces antibodies to foreign substances such as
bacteria; however, some people are found to have antibodies against their own thyroid tissue.
A condition known as Hashimoto's Thyroiditis is associated with a high level of these thyroid
antibodies in the blood. Whether the antibodies cause the disease or whether the disease
causes the antibodies is not known; however, the finding of a high level of thyroid antibodies
is strong evidence of this disease. Occasionally, low levels of thyroid antibodies are found
with other types of thyroid disease. When Hashimoto's thyroiditis presents as a thyroid
nodule rather than a diffuse goiter, the thyroid antibodies may not be present.
Thyroid Needle Biopsy. This has become the most reliable test to differentiate the "cold"
nodule that is cancer from the "cold" nodule that is benign ("hot" nodules are rarely
cancerous). It provides information that no other thyroid test will provide. While not perfect,
it will provide definitive information in 75% of the nodules biopsied. A very extensive
discussion of Thyroid Needle Biopsy is found on another page.

Do I need to stop taking my thyroid pills for these tests?

Since Euthyrox or Synthroid (and most other thyroid pills) behave exactly as normal human
thyroid hormone, they are not rapidly cleared from the body as other medications are. Most
thyroid pills have a half life of 6.7 days which means they must be stopped for four to five
weeks (five half lives) before accurate thyroid testing is possible. An exception to the long
half life of thyroid medication is Cytomel - a thyroid pill with a half life of only forty-eight
hours. Therefore it is possible to change a person's thyroid replacement to Cytomel for one
month to allow time for his regular pills to clear the body. Cytomel is then stopped for ten
days (five half lives) and the appropriate test can then be done. Usually patients, even those

who have no remaining thyroid function, tolerate being off thyroid replacement only ten days
quite well.

INTRODUCTION TO HYPERTHYROIDISM
Hyperthyroidism is a large topic so we have split it into four manageable sized portions.
This page introduces hyperthyroidism. Subsequent pages are listed at the bottom which
address more specific details of making the diagnosis of hyperthyroidism, the causes of
hyperthyroidism, and different treatment options available for hyperthyroidism.

In healthy people, the thyroid makes just the right amounts of two hormones, T4 and
T3, which have important actions throughout the body.
These hormones regulate many aspects of our metabolism,
eventually affecting how many calories we burn, how
warm we feel, and how much we weigh. In short, the thyroid "runs" our
metabolism. These hormones also have direct effects on most organs,
including the heart which beats faster and harder under the influence of
thyroid hormones. Essentially all cells in the body will respond to increases
in thyroid hormone with an increase in the rate at which they conduct their business.
Hyperthyroidism is the medical term to describe the signs and symptoms associated
with an over production of thyroid hormone. For an overview of how thyroid hormone is
produced and how its production is regulated check out our thyroid hormone production
page.

Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on

tissues of the body. Although there are several different causes of hyperthyroidism, most of
the symptoms that patients experience are the same regardless of the cause (see the list of
symptoms below). Because the body's metabolism is increased, patients often feel hotter than
those around them and can slowly lose weight even though they may be eating more. The
weight issue is confusing sometimes since some patients actually gain weight because of an
increase in their appetite. Patients with hyperthyroidism usually experience fatigue at the end
of the day, but have trouble sleeping. Trembling of the hands and a hard or irregular heartbeat
(called palpitations) may develop. These individuals may become irritable and easily upset.
When hyperthyroidism is severe, patients can suffer shortness of
breath, chest pain, and muscle weakness. Usually the symptoms
of hyperthyroidism are so gradual in their onset that patients don't
realize the symptoms until they become more severe. This means
the symptoms may continue for weeks or months before patients
fully realize that they are sick. In older people, some or all of the
typical symptoms of hyperthyroidism may be absent, and the
patient may just lose weight or become depressed.

Common symptoms and signs of hyperthyroidism

Palpitations
Heat intolerance
Nervousness
Insomnia
Breathlessness
Increased bowel movements
Light or absent menstrual periods
Fatigue
Fast heart rate
Trembling hands
Weight loss
Muscle weakness
Warm moist skin
Hair loss
Staring gaze
Remember, the words "signs" and "symptoms" have different medical meanings. Symptoms
are those problems that a patient notices or feels. Signs are those things that a physician can
objectively detect or measure. For instance, a patient will feel hot, this is a symptom. The
physician will touch the patient's skin and note that it is warm and moist, this is a sign.

Introduction, Causes, and Symptoms of Hypothyroidism

Updated January 30, 2005
Hypothyroidism is a condition in which the body lacks
sufficient thyroid hormone. Since the main purpose of thyroid
hormone is to "run the body's metabolism", it is understandable
that people with this condition will have symptoms associated
with a slow metabolism. Over five million Americans have this
common medical condition. In fact, as many as ten percent of
women may have some degree of thyroid hormone deficiency.
Hypothyroidism is more common than you would believe...and, millions of people are
currently hypothyroid and don't know it! [For an overview of how thyroid hormone is
produced and how its production is regulated check out our thyroid hormone production
page.]

There are two fairly common causes of hypothyroidism. The first is a result of previous
(or currently ongoing) inflammation of the thyroid gland which leaves a large percentage

of the cells of the thyroid damaged (or dead) and incapable of producing sufficient hormone.
The most common cause of thyroid gland failure is called autoimmune thyroiditis (also
called Hashimoto's thyroiditis), a form of thyroid inflammation caused by the patient's own
immune system. The second major cause is the broad category of "medical treatments".
As noted on a number of our other pages, the treatment of many thyroid conditions warrants
surgical removal of a portion or all of the thyroid gland. If the total mass of thyroid
producing cells left within the body are not enough to meet the needs of the body, the patient
will develop hypothyroidism. Remember, this is often the goal of the surgery as seen in
surgery for thyroid cancer. But at other times, the surgery will be to remove a worrisome
nodule, leaving half of the thyroid in the neck undisturbed. Sometimes (often), this remaining
thyroid lobe and isthmus will produce enough hormone to meet the demands of the body. For
other patients, however, it may become apparent years later that the remaining thyroid just
can't quite keep up with demand. Similarly, goiters and some other thyroid conditions can be
treated with radioactive iodine therapy. The aim of the radioactive iodine therapy (for
benign conditions) is to kill a portion of the thyroid to [1] prevent goiters from growing
larger, or [2] producing too much hormone (hyperthyroidism). Occasionally, (often?) the
result of radioactive iodine treatment will be that too many cells are damaged so the patient
often becomes hypothyroid a year or two later. This is O.K. and usually greatly preferred
over the original problem. There are several other rare causes of hypothyroidism, one of
them being a completely "normal" thyroid gland which is not making enough hormone
because of a problem in the pituitary gland. If the pituitary does not produce enough Thyroid
Stimulating Hormone (TSH) then the thyroid simply does not have the "signal" to make
hormone, so it doesn't.
Symptoms of Hypothyroidism
Fatigue
Weakness
Weight gain or increased difficulty losing weight
Coarse, dry hair
Dry, rough pale skin
Hair loss
Cold intolerance (can't tolerate the cold like those around you)
Muscle cramps and frequent muscle aches
Constipation
Depression
Irritability
Memory loss
Abnormal menstrual cycles
Decreased libido
Each individual patient will have any number of these symptoms which will vary with the
severity of the thyroid hormone deficiency and the length of time the body has been deprived
of the proper amount of hormone. Some patients will have one of these symptoms as their
main complaint, while another will not have that problem at all and will be suffering from a
different symptom. Most will have a combination of a number of these symptoms.
Occasionally, some patients with hypothyroidism have no symptoms at all, or they are just so
subtle that they go unnoticed. Note: Although this may sound obvious, if you have these
symptoms, you need to discuss them with your doctor and probably seek the skills of an
endocrinologist. If you have already been diagnosed and treated for hypothyroidism and you

continue to have any or all of these symptoms, you need to discuss it with your physician.
Although treatment of hypothyroidism can be quite easy in some individuals, others will
have a difficult time finding the right type and amount of replacement thyroid hormone.
(More about this on the next page).
Potential Dangers of Hypothyroidism
Because the body is expecting a certain amount of thyroid hormone the pituitary will make
additional thyroid-stimulating-hormone (TSH) in an attempt to entice the thyroid to produce
more hormone. This constant bombardment with high levels of TSH may cause the thyroid
gland to become enlarged and form a goiter (termed a "compensatory goiter"). Our goiter
page goes into this topic in detail, and outlines that a deficiency of thyroid hormone is a
common cause of goiter formation. Left untreated, the symptoms of hypothyroidism will
usually progress. Rarely, complications can result in severe life-threatening depression, heart
failure or coma.
Hypothyroidism can often be diagnosed with a simple blood test. In some persons,
however, its not so simple and more detailed tests are needed. Most importantly, a good
relationship with a good endocrinologist will almost surely be needed. More about
treatment on another page.
Hypothyroidism is completely treatable in many patients simply by taking a small pill
once a day! Once again, however, we have made a simplified statement and its not always so
easy. There are several types of thyroid hormone preparations and one type of medicine will
not be the best therapy for all patients. Many factors will go into the treatment of
hypothyroidism and it is different for everybody. More about treatment on another page.

Thyroid Problems During Pregnancy Shows Up with Headaches, Anxiety,

Nervousness, and High Blood Pressure.
These are the signs of Thyroid disease of Pregnancy.
adrenal tumor cancer adrenal thyroid gland high blood pressure hypertension adrenal
adrenal adrenal
The most common thyroid disorder occurring around or during pregnancy is thyroid
hormone deficiency, or hypothyroidism. The details of hypothyroidism are covered on
several other pages on our site, so only those factors pertaining to pregnancy are discussed
here. Hypothyroidism can cause a variety of changes in a woman's menstrual periods:
irregularity, heavy periods, or loss of periods. When hypothyroidism is severe, it can reduce a
woman's chances of becoming pregnant. Checking thyroid gland function with a simple
blood test is an important part of evaluating a woman who has trouble becoming pregnant. If
detected, an underactive thyroid gland can be easily treated with thyroid hormone
replacement therapy. If thyroid blood tests are normal, however, treating an infertile woman
with thyroid hormones will not help at all, and may cause other problems.
Because some of the symptoms of hypothyroidism such as tiredness and weight gain are
already quite common in pregnant women, it is often overlooked and not considered as a
possible cause of these symptoms. Blood tests, particularly measuring the TSH level, can
determine whether a pregnant woman's problems are due to hypothyroidism or not.
Since thyroid medications (particularly Levothyroxine) are essentially identical to the thyroid
hormone made by the normal thyroid gland, a woman with an underactive thyroid gland can

feel confident that it is perfectly safe to take thyroid hormone medication during
pregnancy. There are no side effects for the mother or the baby as long as the proper dose is
used. In the case where hypothyroidism in the mother is NOT detected, the thyroid will still
develop normally in the baby.
Women with previously treated hypothyroidism should be aware that their dose of
medication may have to be increased during pregnancy. They should contact their doctor,
who should check their blood level of TSH periodically throughout pregnancy to see if their
medication dose needs adjustment. Thyroid function tests should continue to be reviewed
every 2-3 months throughout the pregnancy. After delivery, the thyroxine dose should be
returned to the pre-pregnancy dose and thyroid function tests reviewed two months later.
Hyperthyroidism and Pregnancy
Hyperthyroidism refers to the signs and symptoms which are due to
the production of too much thyroid hormone. [Hyperthyroidism is
covered in great deal on other pages on this site (about 8 in all), so only
that part of hyperthyroidism which pertains to the pregnant mother will
be discussed here]. An overactive thyroid gland (hyperthyroidism)
often has its onset in younger women. Because a woman may think
that feeling warm, having a hard or fast heartbeats, nervousness,
trouble sleeping, or nausea with weight loss are just parts of being
pregnant, the symptoms and signs of this condition may be overlooked
during pregnancy.
In women who are not pregnant, hyperthyroidism can affect menstrual periods, making them
irregular, lighter, or disappear altogether. It may be harder for hyperthyroid women to
become pregnant, and they are more likely to have miscarriages. If a woman with infertility
or repeated miscarriages has symptoms of hyperthyroidism, it is important to rule out this
condition with thyroid blood tests. It is very important that hyperthyroidism be
controlled in pregnant women since the risks of miscarriage or birth defects are much
higher without therapy. Fortunately, there are effective treatments available. Antithyroid
medications cut down the thyroid gland's overproduction of hormones and are reviewed on
another page on this site. When taken faithfully, they control hyperthyroidism within a few
weeks. In pregnant women thyroid experts consider propylthiouracil (PTU) the safest drug.
Because PTU can also affect the baby's thyroid gland, it is very important that pregnant
women be monitored closely with examinations and blood tests so that the PTU dose can be
adjusted. In rare cases when a pregnant woman cannot take PTU for some reason (allergy or
other side effects), surgery to remove the thyroid gland is the only alternative and should be
undertaken prior to or even during the pregnancy if necessary. Although radioactive iodine is
a very effective treatment for other patients with hyperthyroidism, it should never be given
during pregnancy because the baby's thyroid gland could be damaged.
Because treating hyperthyroidism during pregnancy can be a bit tricky, it is usually best for
women who plan to have children in the near future to have their thyroid condition
permanently cured. Antithyroid medications alone may not be the best approach in these
cases because hyperthyroidism often returns when medications is stopped. Radioactive
iodine is the most widely recommended permanent treatment with surgical removal being the
second (but widely used) choice. It is concentrated by thyroid cells and damages them with
little radiation to the rest of the body. This is why it cannot be given to a pregnant woman,
since the radioactive iodine could cross the placenta and destroy normal thyroid cells in the

baby. The only common side effect of radioactive iodine treatment is underactivity of the
thyroid gland, which occurs because too many thyroid cells were destroyed. This can be
easily and safely treated with levothyroxine. There is no evidence that radioactive iodine
treatment of hyperthyroidism interferes with a woman's future chances of becoming pregnant
and delivering a healthy baby. For more information on the treatment options of
hyperthyroidism see our page on this topic.
Thyroid Problems After Pregnancy
One of every twenty women develop thyroid inflammation within a few months after
delivery of their baby, a condition called postpartum thyroiditis. This form of thyroid
inflammation is painless and causes little or no gland enlargement. However, the condition
interferes with the gland's production of thyroid hormones. Thyroid hormone may leak out of
the inflamed gland in large amounts, causing hyperthyroidism that lasts for several weeks.
Later on, the injured gland may not be able to make enough thyroid hormone, resulting in
temporary hypothyroidism. Symptoms of hyperthyroidism and hypothyroidism may not be
recognized when they occur in a new mother. They may be simply attributed to lack of sleep,
nervousness, or depression.
Thyroid Symptoms Occasionally Overlooked in New Mothers
Hyperthyroidism
Fatigue
Insomnia
Nervousness
Irritability
Hypothyroidism
Fatigue
Depression
Easily upset
Trouble losing weight
Postpartum thyroiditis goes away on its own after one to four months. While it is active,
however, women often benefit from treatment for their thyroid hormone excess or deficiency.
Some of the symptoms caused by too much thyroid hormone, such as tremor or palpitations,
can be improved promptly by medications called beta-blockers(e.g., propranolol).
Antithyroid drugs, radioactive iodine, and surgery do not need to be considered because this
form of hyperthyroidism is only temporary. If thyroid hormone deficiency develops, it can be
treated for one to six months with levothyroxine. Women who have had an episode of
postpartum thyroiditis are very likely to develop the problem again after future pregnancies.
Although each episode usually resolves completely, one out of four women with postpartum
thyroiditis goes on to develop a permanently underactive thyroid gland in future. Of course,
levothyroxine fully corrects their thyroid hormone deficiency, and when used in the correct
dose, can be safely taken without side effects or complications.
Thyroid Problems in the Baby
Rarely, a baby may be born without a thyroid gland. This birth defect is not caused by
thyroid problems in the mother. If an infant's hypothyroidism is not recognized and treated
promptly, he/she will not develop normally. Therefore, all newborn babies in the United

States routinely have a blood test to be sure that hypothyroidism is diagnosed and treated.
Most thyroid medications will have no effect on the baby. The exception to this generality is
the administration of radioactive iodine to the mother during pregnancy. Radioactive iodine
can cross the placenta and it can destroy thyroid cells in the fetus.