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What Should My Tsh Level Be After Thyroid Cancer

Thyroid Levels After Thyroidectomy

Thyroid Cancer: Thyroid Hormone Replacement. Research, When To Suppress TSH. Dr. Klopper.

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What Are The Symptoms Of Thyroid Cancer

You or your healthcare provider might feel a lump or growth in your neck called a thyroid nodule. Dont panic if you have a thyroid nodule. Most nodules are benign . Only about three out of 20 thyroid nodules turn out to be cancerous .

Other signs of thyroid cancer include:

Managing Tsh Levels After Total Thyroidectomy

    How should thyroid-stimulating hormone be managed so its levels can be maintained within the normal range after total thyroidectomy for cancer of the papillary thyroid? Despite monthly monitoring of T3, my patient experienced hypo/hyperthyroidism three times in a year. What would be the ideal TSH level for these patients? Should we monitor for other biomarkers? Name withheld on request

    Suppression of thyroid-stimulating hormone after thyroidectomy for low-risk cancer can increase the risk of osteoporosis in women without cutting back on cancer recurrence, according to some reports.1TSH suppression was defined as a median level of 0.4 mU/L or less. According to a retrospective study, those women who were found to suppress their TSH levels had a more than three-fold increased risk of osteoporosis than those whose levels were not suppressed.1


    1. Fiore K. TSH suppression: More harm than good after cancer surgery? Medpage Today Web site. 2015. . Accessed September 2, 2015.

    2. Endocrine surgery: Long-term follow-up of thyroid cancer. Weill Cornell Medical College Web site. . Accessed September 2, 2015.

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    What Is A Tsh Test

    Thyroid testsBlood tests to measure thyroid hormones are readily available and widely used. Not all thyroid tests are useful in all situations.

    TSH TestThe best way to initially test thyroid function is to measure the TSH level in a blood sample. Changes in TSH can serve as an “early warning system” often occurring before the actual level of thyroid hormones in the body becomes too high or too low.

    A high TSH level indicates that the thyroid gland is not making enough thyroid hormone . On the other hand, a low TSH level usually indicates that the thyroid is producing too much thyroid hormone . Occasionally, a low TSH may result from an abnormality in the pituitary gland, which prevents it from making enough TSH to stimulate the thyroid . In most healthy individuals, a normal TSH value means that the thyroid is functioning properly.

    How Is Thyroid Cancer Managed Or Treated

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    Treatments for thyroid cancer depend on the tumor size and whether the cancer has spread. Treatments include:

    • Surgery: Surgery is the most common treatment for thyroid cancer. Depending on the tumors size and location, your surgeon may remove part of the thyroid gland or all of the gland . Your surgeon also removes any nearby lymph nodes where cancer cells have spread.
    • Radioiodine therapy: With radioiodine therapy, you swallow a pill or liquid containing a higher dose of radioactive iodine than whats used in a diagnostic radioiodine scan. The radioiodine shrinks and destroys the diseased thyroid gland along with cancer cells. Dont be alarmed this treatment is very safe. Your thyroid gland absorbs almost all of the radioiodine. The rest of your body has minimal radiation exposure.
    • Radiation therapy: Radiation kills cancer cells and stops them from growing. External radiation therapy uses a machine to deliver strong beams of energy directly to the tumor site. Internal radiation therapy involves placing radioactive seeds in or around the tumor.
    • Chemotherapy: Intravenous or oral chemotherapy drugs kill cancer cells and stops cancer growth. Very few patients diagnosed with thyroid cancer will ever need chemotherapy.
    • Hormone therapy: This treatment blocks the release of hormones that can cause cancer to spread or come back.

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    Physiology Of Thyroid Hormone

    Thyroid hormone plays a critical role in the development and function of virtually every organ system in humans., This process is stimulated by TSH. The anterior pituitary releases TSH in response to thyroid-releasing hormone, which is secreted by the hypothalamus. The thyroid gland secretes both thyroxine and triiodothyronine , which exert a negative feedback on TSH releasing hormone and TSH secretion.,

    The thyroid gland secretes mainly T4, which is deiodinated intracellularly to the active hormone T3 which then binds to thyroid hormone receptors and functions as a transcription factor for many cellular processes. In the absence of a thyroid gland, exogenous L-T4 is efficiently converted to T3. Serum T3 levels remain stable after L-T4 administration but vary widely after oral administration of liothyronine . Moreover, L-T4 is a better regulator of TSH secretion as it is more likely than T3 to pass the bloodbrain barrier. This is why L-T4 has been the drug of choice for long-term treatment of athyreotic individuals.

    Dissenting Opinions On Suppressing And Replacing Tsh

    It turns out that most individuals with differentiated thyroid cancer are at low risk to begin with, and dont have residual , he said. So there would be no reason to maintain a low TSH level in these patients. However, for the small fraction of patients with more advanced thyroid cancers, there is some evidence that TSH therapy might result in an improved outlook. But for the vast majority of patients, TSH therapy really wont matter, Dr. Cooper told EndocrineWeb.

    Among the many studies cited by Dr. Cooper is a meta-analysis of 10 studies on which the researchers concluded that suppression therapy helped reduce morbidity and mortality for adverse events pertaining to combined disease progression/recurrence and death. However, these older studies failed to differentiate thyroid hormone replacement from thyroid hormone suppression and, modern technology such as ultrasound and thyroglobulin measurement were also lacking, he said.

    Results of studies falling under the umbrella of the National Thyroid Cancer Treatment Cooperative Study Group suggest that the most aggressive suppression therapy was of no value in patients at low risk for recurrence but was of benefit in high-risk patients.3,4

    Potential adverse events to consider include effects of suppressive therapy with levothyroxine. When patients with DTC were given excessive L-T4 doses, serum free thyroxine was often at the upper limit of the reference range or even elevated.6-8

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    What Is The Treatment For Thyroid Cancer

    Surgery. The primary therapy for all types of thyroid cancer is surgery . The extent of surgery for differentiated thyroid cancers will depend on the size of the tumor and on whether or not the tumor is confined to the thyroid. Sometimes findings either before surgery or at the time of surgery such as spread of the tumor into surrounding areas or the presence of obviously involved lymph nodes will indicate that a total thyroidectomy is a better option. Some patients will have thyroid cancer present in the lymph nodes of the neck . These lymph nodes can be removed at the time of the initial thyroid surgery or sometimes, as a later procedure if lymph node metastases become evident later on. For very small cancers that are confined to the thyroid, involving only one lobe and without evidence of lymph node involvement a simple lobectomy is considered sufficient. Recent studies even suggest that small tumors called micro papillary thyroid cancers may be observed without surgery depending on their location in the thyroid. After surgery, most patients need to be on thyroid hormone for the rest of their life . Often, thyroid cancer is cured by surgery alone, especially if the cancer is small. If the cancer is larger, if it has spread to lymph nodes or if your doctor feels that you are at high risk for recurrent cancer, radioactive iodine may be used after the thyroid gland is removed.

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    External Beam Radiation Therapy

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    While it remains the standard of care in many cancers of the head and neck, external beam radiation therapy is not often recommended for the treatment of thyroid cancer. For well-differentiated thyroid cancers, radioactive iodine therapy is preferred, because it is a more targeted form of radiation that attacks only thyroid cells and has fewer side effects. However, in select patients with aggressive cases of thyroid cancer that do not take up iodine and/or present with recurrent disease, adjuvant external beam radiation therapy may be considered.

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    What Is Thyroid Hormone

    Thyroid hormone is made by the thyroid gland, a butterfly-shaped endocrine gland normally located in the lower front of the neck. Thyroid hormone is released into the blood where it is carried to all the tissues in the body. It helps the body use energy, stay warm and keeps the brain, heart, muscles, and other organs working as they should.

    Thyroid hormone exists in two main forms: thyroxine and triiodothyronine . T4 is the primary form of thyroid hormone circulating in the blood . To exert its effects, T4 is converted to T3 by the removal of an iodine atom this occurs mainly in the liver and in certain tissues where T3 acts, such as in the brain. T3 normally accounts for about 5% of thyroid hormone circulating in the blood.

    Most thyroid hormone in the blood is bound by protein, while only a small fraction is “free” to enter tissues and have a biologic effect. Thyroid tests may measure total or free hormone levels.

    Lt4 Dosing Schemes After Total Thyroidectomy

    Most of literature regarding the LT4 dosage deals with the treatment of primary hypothyroidism, whereas only few studies handle the issue of thyroxine replacement after total thyroidectomy . As reported by Del Duca et al. in a longitudinal study including 23 goitrous patients treated with LT4, the therapeutic dose of T4 after total thyroidectomy must be increased by one-third compared with the presurgical one. This additional amount of T4 may be the substrate for the peripheral deiodinase network to compensate the absence of T3 production from the gland .

    Table 1 Main proposed schemes for the prediction of LT4 requirement after total thyroidectomy.

    In particular, Olobuwale et al. and Jin et al. developed two different weight-based schemes to calculate the proper LT4 dose in patients who underwent thyroidectomy. Nevertheless, when retrospectively applied by other authors, the rate of patients being reported to be euthyroid at the first postsurgery follow-up was amendable, ranging between 23 and 53.2% . Furthermore, Jin et al. included patients who had undergone total thyroidectomy or lobectomy, making their data not homogeneous.

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    Patients Unable To Achieve A Suppressed Tsh Despite Proper Thyroid Hormone Therapy

    There are some patients on adequate or even high doses of thyroid hormone therapy who are unable to achieve TSH suppression. The differential diagnoses include malabsorption, non-compliance, factors increasing the medications metabolism, or increased serum levels of T4-binding globulin. In addition, when the TSH cannot be suppressed in spite of adequate doses of thyroid hormone, the physician should consider the presence of heterophile antibodies and interference with the laboratory measurement including anti-mouse antibodies, rheumatoid factor, and autoimmune anti-TSH antibodies. Finally one could consider the coexistence of adrenal insufficiency, which may induce TSH elevation reversible with glucocorticoid replacement.

    Defects in thyroid hormone absorption are rare without a history of previous gut surgery, celiac disease, lactose intolerance, autoimmune gastritis, or Helicobacter pylori infection. A serum free T4 peak at 2 hours rising above the upper limit of normal after the administration of 100 g of L-T4 suggests proper absorption, but unfortunately there are no well-established standards for this test. A radioisotope-labeled L-T4 tracer technique may be used to test absorption more accurately, but this technique is not readily available. Prior studies looking into this matter have shown that oftentimes patients suspected to have absorption problems actually exhibit a factitious disorder and have compliance issues.

    Medications After Thyroid Cancer Removal

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    Your situation is unique if your thyroid was removed because of thyroid cancer. Your doctor will give you “suppressive” levels of thyroid hormone replacement medications. This is done to prevent cancer recurrence.

    Suppressive levels of medication keep your TSH levels low or even undetectable. According to the way thyroid lab tests are usually interpreted, you would be considered hyperthyroid.

    Because you do not have a thyroid gland, though, you still need to follow the advice for managing hypothyroidism.

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    How Can I Prevent Thyroid Cancer

    Many people develop thyroid cancer for no known reason, so prevention isnt really possible. But if you know youre at risk for thyroid cancer, you may be able to take these steps:

    • Preventive surgery: Genetic tests can determine if you carry an altered gene that increases your risk for medullary thyroid cancer or multiple endocrine neoplasia. If you have the faulty gene, you may opt to have preventive surgery to remove your thyroid gland before cancer develops.
    • Potassium iodide: If you were exposed to radiation during a nuclear disaster, such as the 2011 incident at Fukushima, Japan, taking potassium iodide within 24 hours of exposure can lower your risk of eventually getting thyroid cancer. Potassium iodide blocks the thyroid gland from absorbing too much radioiodine. As a result, the gland stays healthy.

    Liquid And Soft Gel Formulations

    Beyond the classic tablet, new formulations of thyroxine can now be prescribed as a soft gel capsule and oral solution, which have been shown to overcome the food and beverages interference with absorption of LT4 tablets. In addition, the liquid formulation was of particular interest in case of malabsorption resulting from atrophic gastritis, proton-pump inhibitors, or after bariatric surgery. Malabsorption induced by lactose intolerance or drug interference can also be avoided . In particular, Benvenga et al. addressed this topic in a study of 19 hypothyroid patients with tablet LT4 malabsorption caused by calcium and/or iron supplements and who were switched to liquid LT4 at the same dose. The authors reported that the TSH level was lower with the liquid LT4 compared with tablet LT4 form, concluding that liquid LT4 is resistant to the sequestration by calcium or iron. Moreover, the high rate of TSH normalization at the first check should avoid frequent adjustments in LT4 doses, with consequent financial savings.

    The liquid LT4 also seems to be more active than tablets in the control of TSH even in hypothyroid patients without malabsorption, drug interference, or gastric disorders, leading to the hypothesis that absorption of liquid LT4 is also higher in this cohort .

    Table 2 Prospective studies dealing with liquid or soft gel formulation of LT4 administered post total thyroidectomy.

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    Preparing For Radioactive Iodine Treatment For Thyroid Cancer

    Radioactive iodine treatment is a type of internal radiotherapy. It uses a radioactive form of iodine called iodine 131 . It is a useful treatment in thyroid cancer because the thyroid gland absorbs and stores most of the iodine in your body. The thyroid gland gets iodine from certain foods and uses this to make essential thyroid hormones.

    Radioactive iodine is a targeted treatment. The radioactive iodine circulates throughout your body in your bloodstream. But it is mainly taken up by thyroid cells, having little effect on other cells. Thyroid cancer cells in your body pick up the iodine. The radiation in the iodine then kills the cancer cells.

    It is only suitable for some types of thyroid cancer. It is a treatment for:

    • follicular thyroid cancer
    • papillary thyroid cancer

    It can treat the cancer even if it has spread. But even if you have one of these types of thyroid cancer, this treatment may not be necessary or suitable for you. Not all of the cancer cells take up the iodine so you may have a test dose to see if they do.

    The Thyroid: What Your Tsh Number Means

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    In our last blog we talked about some of the things that can happen when your thyroid is sluggish or overactive. Today were going to talk about the TSH test and its results. TSH stands for Thyroid Stimulating Hormone a standard blood test will produce a number of how well your thyroid is performing. Normal range for an adult is typically considered to be between .4 and 4.0 however, in my practice I would say ideal is between 0.5 and 1.5.

    In my experience with patients, Ive found that symptoms begin to occur in my patients well within the typically accepted range of 0.4 and 4.0 in fact, if the TSH level is over 1.5 or 2.0, I consider that to be a sign that the thyroid isnt working well enough. It would be easy to think that if your TSH level was higher it would be a sign that youre doing ok however, when the thyroid is underactive your body compensates for this sending your TSH levels skyrocketing. So even though your number might look okay in the generally accepted range, its a sign that imbalance is occurring.

    If youre feeling poorly all the time and think your thyroid might having some trouble, ask your doctor for a TSH test .

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    What Is Thyroid Medication

    Thyroid Hormone Treatment Levothyroxine is thestandard of care in thyroid hormone replacement therapy and treatment of hypothyroidism. Levothyroxine is equivalent to the T4 form of naturally occurring thyroid hormone and is available in generic and brand name forms.

    How do I take levothyroxine? To optimize absorption of your thyroid medication, it should be taken with water at a regular time each day. Multiple medications and supplements decrease absorption of thyroid hormone and should be taken 3-4 hours apart, including calcium and iron supplements, proton pump inhibitors, soy, and multivitamins with minerals. Because of the way levothyroxine is metabolized by the body, your doctor may ask you to take an extra pill or skip a pill on some days of the week. This helps us to fine tune your medication dose for your body and should be guided by an endocrinologist.

    For patients with celiac disease or gluten sensitivity, a gluten free formulation of levothyroxine is available.

    Some individuals may have genetic variant that affects how the body converts T4 to T3 and these individuals may benefit from the addition of a small dose of triiodothyronine.

    Liothyronine is replacement T3 thyroid hormone. This medication has a short half-life and is taken twice per day or in combination with levothyroxine. Liothyronine alone is not used for treatment of hypothyroidism long term.


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