Since 1974 I have been working to decrease the number, and extent of surgery on patients with thyroid disease. The surgeons operated on almost all patients with nodules, large goiters, and of course cancer. At a major hospital in Los Angeles in 1974, I found they look out 100 thyroid nodular goiters and found only 5 cancers. This was unacceptable to me. The first alternative was radioiodine for Graves’ and toxic nodular goiter. Later It could shrink large benign goiters without surgery before better methods were available. 1978 I began doing FNA biopsies after training thyroid cytology with several leading cytopatologists, was recommended to the Cytology society by on of my mentors.The finding that there was a high rate of over-diagnosis of suspicious nodules, I began reviewing all the prior FNAs and found many to be of poor quality. The use of big needles to do the biopsy by many radiologists caused many to be sent to surgery for suspicious results due to artifact from bloody samples causing over-read of the slides. Also liquid prep came along and added new problems. Recent study found the bloody sample put in Cyto-Lyte was also prone to over diagnosis. They used a color system.The red/brown color had the highest inadequate rate. Liquid prep also had the additional problem of changing the DX from papillary thyroid cancer to follicular neoplasm due to loss of characteristic finding on pap smears.
For 6 years Dr.John Abele (pioneer thyroid cytologist) and I taught a workshop on thyroid cytology to endocrinologists for American College of Endocrinology ACE. The number of surgeries for nodules had a dramatic decrease due to FNA.
The next advance which I was involved in was diagnostic endocrine neck ultrasound and USG FNA and the movement in the 90’s to realize the full potential of Ultrasound for diagnosis and treatment of all forms of thyroid, parathyroid and neck lymph node thyroid cancer. I was involved in writing the first test for endocrinologists to get certified in endocrine neck ultrasound ( ECNU). Even with USGFNA there still were too many surgeries on thyroid patients with benign disease, and the wrong surgery on many with thyroid cancer. The local surgeons are relentless in pushing surgery for even benign thyroid nodules. I supplied 150 thyroid nodules for the first study on classifiers Afirma, and was author on the first molecular marker study showing utility in finding cancer molecular markers BRAF, RET/PTC RAS in needle washouts from thyroid nodules (Thy-Gen-X Interpace).
ECNU certified sonologists have shown the need for pre-op neck ultrasound. Finding metastatic nodes before surgery can change the surgeon’s plan to include modified radical neck dissection. This prevents the dreaded 1-2 year re-op to treat the nodes that were there before the first surgery.
Finally since 1998 I have used ethanol ablation PEI to treat benign mixed cyst solid nodules, and parathyroid cysts. 10 years later using Mayo clinic studies as the reason I injected small amounts of ethanol in FNA proven cancer lymph nodes to prevent more neck dissections in patients with neck lymph node recurrence. In 2014 we began to explore the use of radiofrequency ablation RFA for the more solid benign nodules. We have network of expert RFA physicians on call to treat solid benign symptomatic nodules until it is FDA approved in the USA.
Interventional Thyroidology
Dr. Richard Guttler, a thyroid cancer specialist, is the director of the Thyroid Center of Santa Monica, where he has seen patients since 1974. He is board certified in endocrinology and certified in endocrine neck ultrasound (ECNU). He is the only endocrinologist also trained in thyroid cytopathology, meaning he can also interpret thyroid nodule biopsy specimens.
Having taught thyroid cytopathology for endocrinologists at the American College of Endocrinology (ACE), Dr. Guttler has developed the test questions for the certifications of endocrinologists attending ACE. He teaches one-on-one Masters classes for endocrinologists with an interest in interventional thyroidology.
He is doing research on radiofrequency ablation (RFA) for nodules and cancer so it will be available in the USA. Now, he screens candidates to determine if RFA or echotherapy HIFU is appropriate. He will arrange for therapy in Europe Italy or Korea with his contacts overseas for those willing to fly for a two-day treatment visit.
Dr. Guttler is the founder, secretary, and past president of the Academy of Clinical Thyroidologists. He is the sole owner of the Endocrine Neck Ultrasound Lab of Southern California, offering endocrine neck studies for endocrinologists and others interested in high-quality thyroid studies performed personally by Dr. Guttler.
As one of the few centers offering interventional thyroid treatments, Thyroid Center of Santa Monica is taking thyroid care into the next century with Dr. Guttler as the leader in this industry.
Education & Training
Personal Statement from Dr. Guttler:
I am your thyroid cancer expert. In the age of Patient Autonomy with internet and social media patient can help themselves to find the best treatment for their thyroid nodule or cancer care.Don’t let Primary care gatekeepers, surgeons, nuclear medicine specialists, or oncologists control your care.
- No more routine thyroid surgery, or radiation therapy for lower risk thyroid cancers.
- Most low risk patients will not need radiation therapy.
- Certain Low-risk micro-papillary thyroid cancer patients may not need surgery at all.
- A new program of Active surveillance AS is available to patients who seek an opinion BEFORE surgery to see if it is safe for them to be followed with ultrasound proven non-aggressive micropapillary cancer. Recent evidence that ethanol PEI and Radiofrequency RFA ablation can destroy small cancers and leave the thyroid gland intact as alternative to surgery or Active Surveillance.
I have 40 years of experience in thyroid cancer research and patient care. I use the world-famous thyroglobulin TG cancer marker testing by Carole Spencer, PhD at USC. Carole freezes prior samples to run simultaneously with your new sample to ensure accuracy. Any increase in TG will be easily noted when both samples are run together. Also needle washout tests for thyroglobulin from suspicious abnormal neck lymph nodes is a grat help in diagnosis of cancer even if the cytology is negative.
I personally review all slides from surgery to make a prognostic evaluation. I avoid the overuse of radiation therapy in low-risk cases. We use non-invasive ultrasound of the thyroid, and cancer marker testing with TG as our main follow-up testing on low-risk cases.
Recent advance was the finding that many follicular variants of PTC without capsule invasion were not cancer but a benign follicular tumor. The new classification is non-invasive folliclar tumor with “look a like” papillary cells or NIFT-P. These patients may need just a lobe to prove there is no invasion of the capsule. They will not be classified as cancer and will not need cancer follow up with all the expense and will not have a cancer diagnosis on their insurance records. Most will not need thyroid hormone as the other lobe, if normal will be enough.
I can review your case for a second opinion in my cancer center for a complete re-evaluation of your cancer therapy plan. Remember – it is never too late to see a thyroidologist if you have thyroid cancer!
Thyroidologists have advanced knowledge of thyroid disease including cytopathology (the study and diagnosis of thyroid disease at the cellular level) and pathology, as well as thyroid cancer.
Though most thyroid cases are handled by primary care physicians, internists, endocrinologists, surgeons, nuclear medicine physicians, otolaryngologists, or oncologists, a clinical thyroidologist is an expert in thyroidology and should be consulted by thyroid patients before proceeding with any treatments.
Because thyroid disease is rarely an emergency, taking the time to get a second opinion with a clinical thyroidologist can ensure you receive a proper thyroid diagnosis and allow you access to proper care.
Interventional thyroidologist additionally can use minimally invasive methods to treat benign thyroid nodules, parathyroid and thyroid cysts and thyroid cancer in an outpatient setting. Two breakthrough procedures are now treatment of choice for benign thyroid nodules, cysts, and cancer lymph nodes.( Ethanol PEI, and Thyroid radiofrequency ablation RFA)
A clinical thyroidologist is an endocrinologist who specializes in all manners relating to the thyroid gland. These physicians offer comprehensive treatments of all thyroid conditions and have received extensive training in diagnostic and treatment methods including neck ultrasound, nuclear medicine, thyroid blood tests, ultrasound FNA biopsy, and fine needle aspiration (FNA) biopsy techniques, and thyroid ablation.
A research thyroidologist specializes in the development of new techniques, diagnostics, and medicine for thyroid conditions, but does not typically treat patients.
An endocrinologist can choose to focus on one or the other – treating patients (clinical) or research. Dr. Guttler does both. He is actively involved in the advancement of research, which he then uses to educate and treat his patients and train other doctors.
An interventional thyroidologist is able to look at all possible treatments and find the solution that is the least invasive with the most predictable results.
Rather than resorting to surgical treatment, an interventional approach can be the alternative many thyroid patients seek.
Dr. Guttler creates customized treatment plans for each patient using techniques that are non-invasive and can eliminate the need for surgery or hospitalization.
When you are told there is an abnormal thyroid blood result.
When your physician wants to treat you for hypo- or hyperthyroidism, request a consultation first. The most common mistake is failure to get a consultation when the TSH test is abnormal.
Both hypothyroidism and hyperthyroidism have abnormal TSH testing, but this is not enough reason for treatment until the cause is known. Treatment by your family physician can be risky without a thyroid consultation and a complete thyroid evaluation, including ultrasound.
When you are told there is a mass in the thyroid.
It is best to get a referral to a thyroid expert before you allow a biopsy or any further studies.
When you are told you need surgery.
A complete thyroid evaluation may render a different diagnosis. Ultrasound-guided biopsy should be the standard in thyroid needle biopsy, as it can determine whether surgery is necessary. Molecular markers for cancer can aid in diagnosis and even rule out cancer from a needle washout or scratch off from slides or even from liquid preps.
When you are scheduled for thyroid surgery.
A thyroidologist consultation will let you know whether the surgery is actually necessary and if so, whether your surgeon is qualified to offer low-risk care. Clinical thyroidologists will then recommend a thyroid surgeon if surgery is necessary.
Remember, thyroid surgery for nodules is not an emergency. It is an elective surgery and you have plenty of time to consult a specialist in the thyroid gland to determine whether surgery should be performed and to be referred to the most qualified thyroid surgeon.
If you are unable to see a thyroidologist, demand to have a pre-surgery lymph node check with high frequency ultrasound. A node can be biopsied and, if positive, cause a change in the surgery plan.
When you are told you have thyroid cancer.
Because thyroid cancer is a thyroid hormone cancer, it is best treated by a thyroidologist with extensive training in hormones related to the thyroid, which most oncologists do not have.
Chemotherapy drugs and external radiation therapy commonly used by oncologists are typically not helpful in treating thyroid cancer.
Because there is little proof to indicate the use of radioiodine for successful treatment of thyroid cancer and there is some evidence that it may cause leukemia, it should only be used after a comprehensive evaluation by a clinical thyroidologist.
Modern ultrasound can find the cause of elevated cancer marker, in the face of negative I-131 body scans, MRIs, PET scans, and CT scans, so you should see a thyroidologist with these capabilities.
When you are told to withdraw from thyroid hormone in order to have radioiodine testing and treatment for your cancer, for up to 6 weeks.
A consultation with a thyroidologist will determine whether you truly need to have the treatment or study. If the evaluation determines that the testing or treatment are essential, the thyroidologist will recommend modern methods that allow you to stay on thyroid medication during the testing and treatment.
When you have been determined to have thyroid antibodies in your blood, but your physician tells you other thyroid tests are normal.
In this case, typically your doctor will tell you to return in the future for more testing, but at this time, you should request a referral to a thyroidologist to begin treatment as soon as possible.
When you have a thyroid condition and you are pregnant or have just had a baby.
These situations can be dangerous for thyroid patients, even if your OB/GYN doesn’t think it is necessary to see a specialist. Problems that can occur include: child IQ losses due to early pregnancy hypothyroidism in the mother, fetal hyperthyroidism passed to the baby by a mother treated for Graves’ disease in the past, and hyper- or hypothyroidism occurring after delivery.
It may be necessary to change thyroid hormone dosage during pregnancy, and neonatal vitamin use with thyroid hormone can result in hypothyroidism; therefore, a thyroidologist should be consulted.