MedStar Health Blog

PET-CT  (positron emission tomography and computed tomography) often is referred to as the gold standard of cancer imaging. This tool brings together two powerful technologies to give us advanced information about whether a patient has cancer and, if so, where the cancer is located in the body.

Your doctor may order a PET-CT scan after noticing something unusual during another test, such as an X-ray or MRI (magnetic resonance imaging) scan, or they may order one after you’ve reported unusual symptoms leading to a physical examination. For example, I’ve seen patients who visited their regular doctor for a little tickle in their throat, and their doctor saw a small, worrisome-looking growth during an exam, prompting the need for a biopsy and subsequent PET-CT scan to look for other sites of tumor. Sometimes it turns out that the tickle was caused by cancer within a patient's neck and the patient may also have disease elsewhere, for example in the chest.

A combined PET-CT scan can give us more information about a tumor than a PET or a CT alone. It combines two of the most important features of any lesion that is worrisome for cancer: its anatomy and its metabolism (presence of live cells). A true example of how these two features can be combined and then distinguished from one another is when you see a large mass or tumor on a CT scan, but a PET scan might show that only the inner part of the mass is cancerous. This allows us to focus radiation, for example, in just the diseased area of the mass, reducing damage to healthy surrounding tissue. Our hybrid scanner combines (fuses) these images to give us the whole picture, which improves the accuracy of the diagnosis and can reduce the number of scans a patient needs.

LISTEN: Dr. Garcia discusses the benefits of PET-CT scans in the Medical Intel podcast.

How a PET-CT scan works

The CT portion works just like a regular CT scan, using multiple X-ray images to provide a clearer, more detailed image than a single X-ray picture. A CT scan shows anatomic images of tumors or masses, but occasionally it may fail to detect tissue damage or changes that occur in the early stages of cancer. That’s where the PET portion of the scan becomes important.

PET detects the presence of positrons, which are particles smaller than an atom that have a positive electrical charge. Positrons are emitted by radioactive materials as they’re broken down. All cells use glucose, or sugar, for energy. We use a radioactive form of glucose called Fluorodeoxyglucose (FDG) attached to a radioactive substance called fluorine-18. As the cells absorb the sugar as an energy source, the fluorine-18 will break down, and give off positrons and gamma rays that will shine or glow, if you will, on imaging.

Cancer cells tend to be more active than normal cells because they are growing and multiplying faster than normal, so they take in more sugar and give off more positrons and gamma rays. This causes them to glow brighter than normal cells on a PET-CT scan. Some of the cancers that are most easily detected on a PET-CT scan are breast cancer, lung cancer and lymphoma.

Chris Furin has a sweet job.

A self-taught cake designer, he runs his own business, Cakes by Chris Furin. Chris bakes and decorates extraordinary custom-made confections and delivers them all over the Washington, D.C., area. He has even baked for the White House.

For years, however, daily and debilitating shoulder pain made his life anything but a piece of cake. It started in his 20s, a constant ache caused by intense bodybuilding and weightlifting. By the time he was in his 40s, the pain was so bad that delivering cakes was becoming difficult and sleeping felt impossible.

“I’d wake up every night. My shoulder would be stiff, and I would be in so much pain. Nothing would fix it,” Chris recalls. “That was the point where I said, ‘I can’t take this anymore, I have to do something.’”

Chris reached out to Brent Bowie Wiesel, MD, chief of the Shoulder Service at the MedStar Orthopaedic Institute at MedStar Georgetown University Hospital, to learn about total shoulder replacements.

“You don’t realize how much you move your shoulder until you have a problem,” Dr. Wiesel says. “You can rest a bad ankle or knee, but a painful shoulder hurts all the time.”

Dr. Wiesel knows this firsthand. He injured his own shoulder while preparing for the 1996 Olympics as a member of the USA Canoe/Kayak whitewater slalom team. The injury and two subsequent surgeries prevented him from competing in the Olympics, but he returned to the sport recreationally and went on to focus his medical practice on helping others with similar injuries.

“You know it’s time for a replacement when joint surfaces that used to be smoother than ice start to look like a gravel road. That is what causes the pain,” Dr. Wiesel explains. “Many people put off surgery hoping the pain will go away, but it just worsens over time.”

Specialized computer software allows Dr. Wiesel and his team to plan out surgeries in 3D, create custom surgical instruments, and use patientspecific implants that closely replicate each individual patient’s own bone. These advanced technologies allow for the best possible outcomes, with 85 percent of modern shoulder replacements working well even after 15 years.

Chris had his right shoulder replaced in November 2015. It reduced his pain so dramatically that he got the left one replaced just over a year later. After surgery, patients typically spend one night in the hospital, six weeks in a sling, and four months improving their strength and range of motion in physical therapy.

“I would definitely recommend this to someone who is considering it. I never wake up at night in pain anymore and to not be in constant discomfort is just amazing,” he says.

Chris says Dr. Wiesel was realistic, telling him he would regain 70 percent of his mobility and drastically reduce his pain. Post-surgery life has required a few adaptations, such as exercising in other ways instead of lifting weights, but it’s been worth it.

“My wife says I am less grumpy now,” he says with a laugh. “She’s right. Life had gotten a little rough because when you are in pain for so long, it affects everything. It’s about so much more than your shoulder. You can’t do the things you love and that is tough psychologically. It’s all so much better now.”

Dr. Wiesel hears this often. “After surgery, patients often tell me that the only thing they are upset about is that they didn’t do it sooner. When they’re no longer living with shoulder pain, life is so much better.”

MedStar Georgetown University Hospital is part of the MedStar Orthopaedic Institute, with more than 35 orthopaedic surgeons and locations throughout D.C., Maryland, and Virginia. Visit MedStarOrthopaedicInstitute.org for a complete listing of physicians and locations.

According to the Centers for Disease Control, over 9 percent of the adult population of Washington, D.C., has a diabetes diagnosis. About 90 percent of diabetes cases nationwide are type 2 diabetes, a condition that is often preventable.

Below, you’ll find some tips on reducing your risk from the Centers for Disease Control (CDC) and my experience in the MedStar Georgetown Emergency Department.

What does it mean to have diabetes or prediabetes?
The body breaks down food into glucose, a type of sugar. A hormone called insulin allows glucose to leave the blood and enter cells, fueling the body’s functioning. People with diabetes produce too little insulin or cannot use insulin effectively.

There are three types of diabetes: gestational diabetes, a temporary form of the disease that can affect women during pregnancy; type 1 diabetes, a non-preventable autoimmune disease; and type 2 diabetes, a metabolic condition that begins as a condition called prediabetes. Prediabetes is diagnosed when a person’s blood sugar levels are unusually high, but not high enough to qualify for diabetes diagnosis.

Risk factors for prediabetes
Prediabetes typically does not cause any symptoms, so many people do not know that they have this condition. It is important to know whether you are at risk.

Risk factors for prediabetes include a high body mass index (BMI), infrequent exercise, a family history of the disease, a personal history of developing gestational diabetes during pregnancy, polycystic ovary syndrome (PCOS), and high blood pressure. People aged 45 and older are at elevated risk, as are people of African American, Alaska Native, American Indian, Asian American, Hispanic, or Pacific Islander heritage.

Prediabetes can be diagnosed with a simple blood test. If you have a high body mass index (BMI) and one or more other risk factor, you should talk to your primary care physician about whether a blood test might make sense for you.

Healthy habits make a difference
If left untreated, most people with prediabetes will develop type 2 diabetes within ten years. Lifestyle changes can often stop prediabetes from progressing. By managing your weight, exercising, and eating a healthy diet, you can dramatically lower your risk for type 2 diabetes.

Possible complications of type 2 diabetes
Type 2 diabetes can be managed by carefully monitoring blood sugar, making lifestyle changes, and taking medication and/or insulin injections. If the disease is left untreated or improperly treated, however, it causes serious issues. These include problems affecting the heart, kidneys, eyes, circulatory, and nervous systems. Even prediabetes can cause damage to the body over time.

In the Emergency Department, we sometimes see the most severe effects of untreated or poorly controlled diabetes. Dangerously high or low levels of insulin or glucose in the blood can trigger medical emergencies, including kidney failure, strokes, and comas. Although these severe diabetic complications are rare, they are a reminder that it is important to take prediabetes seriously.

Visit MedStarGeorgetown.org/ED for more information about the Emergency Department. 

The Early Childhood Innovation Network (ECIN) is dedicated to helping the smallest members of our community grow up to accomplish big things.

Formed as a partnership in 2016 between MedStar Georgetown University Hospital and Children’s National Health System, ECIN develops strategies to support children and caregivers in Washington, D.C., and advocates for positive changes to public policy. ECIN has grown into a network that includes community organizations, educators, government and social services agencies, and local healthcare providers. Matthew Biel, MD, MSc, chief of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital, serves as co-director with Lee Beers, MD, a pediatrician and Medical Director of Municipal and Regional Affairs at Children’s National Health System.

ECIN was created to promote new strategies to address Adverse Childhood Experiences (ACEs) in marginalized communities in the nation’s capital. ACEs are highly stressful events that commonly impact children and families, including untreated maternal depression, abuse or violence at home, hunger, and unsafe housing. When pregnant women or young children are exposed to ACEs, these experiences can trigger changes in children’s development, a reaction known as toxic stress.

Toxic stress is associated with longterm changes to a child’s brain functioning, behavior, and educational achievement—as well as increased risks for chronic health conditions later in life, including obesity, cancer, and mental illness. More than half of children in Washington D.C., experience at least one ACE. However, positive adult support and strong relationships between children and caregivers can mitigate the negative effects of ACEs.

“During the first five years of life, the brain is developing more rapidly than at any other time,” says Dr. Biel. “Early life experiences—both positive and negative—have a lasting effect on physical and mental health. In order to support children’s well-being at this critical age, we need to develop effective strategies to best support the adults who care for them.”

Collaborating closely with community leaders and families, ECIN supports safe and nurturing environments in order to buffer against the effects of ACEs and enhance resilience. This work includes mental health and developmental supports for children and parents in pediatric clinics; training and support for early childhood educators; training parents and teachers in mindfulness skills to improve adult well-being and enhance caregiver-child relationships; and mental health screening and treatment for pregnant women. ECIN includes a strong clinical research team and a legislative advocacy group to promote citywide policies in health and education that will promote child and family well-being.

A $6 million, five-year commitment to MedStar Georgetown and Children’s National Health System from the J. Willard and Alice S. Marriott Foundation in 2016 set the stage for philanthropic support of ECIN. Since the Marriott family’s groundbreaking gift, the Howard and Geraldine Polinger Family Foundation, the Bainum Family Foundation, and D.C. Health have all joined the community of ECIN funders.

“The J. Willard and Alice S. Marriott Foundation's investment has sparked a wave of giving,” says Pam Maroulis, the Hospital’s vice president of Philanthropy. “With ongoing philanthropic support from foundations and individuals, ECIN will sustainably expand its reach and services to children and their families for years to come.”

To support ECIN, visit MedStarGeorgetown.org/Contribute or call the Office of Philanthropy at 202-444-0721.

It’s no exaggeration that there’s an obesity epidemic among U.S. teens. The Centers for Disease Control and Prevention notes that more than 20 percent of 12 to 19-year-olds are obese. Over time, obesity is a major risk factor for many serious medical conditions, including:

• Cancer, including colorectal cancer, endometrial cancer, and kidney cancer
• Heart disease
• Type 2 diabetes

The way we live as a society, from fast food to sedentary time spent on devices, makes it difficult for teens to avoid obesity and to handle it on their own if it develops. Teens need support, and I’ve put together a quick list of tips for parents and guardians to help teens achieve a healthy weight.

1. Get active as a family

Teenagers in past generations used to get a lot more exercise than teens today: soccer with the neighborhood kids, pickup basketball games, swimming at the local pool. But today’s teens get an average of nine hours of screen time a day, including:

• Checking social media
• Playing video games
• Texting
• Watching TV and movies

Nine hours is longer than the vast majority of teens spend on school, sleeping, or being physically active. Some teens naturally gravitate toward organized sports, but if your child isn’t athletically inclined, it’s still important to help them get at least 60 minutes of physical activity every day:

• Consider a family bike ride or walk around the neighborhood a few nights a week
• Play Pokémon Go or try geocaching to find hidden treasures at specific outdoor locations based on GPS coordinates
• Try a yoga class or low-impact aerobics at the local community center

2. Eat well together

There’s so much junk food out there, and that’s naturally what many teens want. It doesn’t help that super-sized sodas, greasy burgers, and sweets are cheap and convenient. Support your teen’s weight goals by making a family commitment to eating healthy:

• Avoid large meal portions at home and when eating out
• Buy large bags of frozen vegetables or bulk canned vegetables to save money
• Choose sweet, crunchy fruits and vegetables for snacks instead of chips or cookies
• Serve popcorn without butter as a cost-effective snack
• Skip soda in favor of sugar-free flavored ice water
• Swap out the fried, fatty meats for lean cuts or beans
• Use resources like the U.S. Department of Agriculture’s ChooseMyPlate to plan nutritious meals

Related reading: 3 Tactics to Battle Food Portion Distortion

Make one change out a time. Reducing fried foods, chips, and soda often is the most difficult change for teens. Start with one temptation, and once that’s mastered, move to the next.

3. Encourage teens to make healthier choices at school

Schools often have to strike a difficult balance between the cost and nutrition of meals. Less-expensive food tends to be less healthy. Encourage your teen to let school administrators know they prefer healthier foods whenever possible. You also can teach them to come to pack healthy snacks and lunches themselves, including fruit, vegetables, whole grains, and lean proteins.

Snacks and drinks in school vending machines often are another source of unhealthy calories. Thankfully, there are nutrition standards in place for vending machines and other snack-selling locations in District of Columbia, Maryland, and Virginia schools that allow only healthy, nutritious foods and drinks during the school day, which is a step in the right direction. Help your teen avoid the urge to splurge by encouraging them to carry a water bottle. Consider sending them to school with sugar-free, single-serving flavor packets to make drinking water more fun.

4. Score healthy snacks for teens’ sports programs

Depending on the sport your teen plays and how frequently they play, they might not always burn off the same amount of energy they consume through their post-game snacks. That can lead to weight gain. For example, my son played baseball when he was younger, and parents were responsible for bringing snacks for the kids. Many brought chips and cookies – not the best choices for low-intensity practices shorter than an hour.

Work with your young athlete’s coach and other parents to provide healthier alternatives, such as:

• Celery with peanut butter instead of protein bars
• Smoothies or yogurt instead of cookies and candy
• Water instead of soda

Teens still depend on their parents to take care of them. Achieving and maintaining a healthy body weight is the whole family’s responsibility. It’s not always easy, but committing to a healthier lifestyle is important to teach your teen healthy habits for life.

Most patients respond well to standard therapies for thyroid cancer. The five-year survival rate is more than 98 percent, and thyroid cancer is responsible for less than 0.5 percent of all cancer-related deaths. Even in advanced stages, we have many effective weapons in the fight against thyroid cancer.

Thyroid nodules are common and generally are detected during an imaging test performed for some other reason, such as a CT scan after a car accident or during a physical exam of the patient’s neck. Nodules will then be examined by ultrasound and subsequently biopsied depending on their appearance to determine whether the nodule is cancerous, and if so, what type of cancer it is.

Determining a patient’s specific cancer type helps us plan the appropriate treatment. There are four main types of thyroid cancer:

• Papillary thyroid cancer: 80 to 85 percent of cases (a differentiated thyroid cancer)
• Follicular thyroid cancer (including Hurthle cell thyroid cancer): 10 to 15 percent of cases (a differentiated thyroid cancer)
• Medullary thyroid cancer: 1 to 2 percent of cases
• Anaplastic thyroid cancer: less than 2 percent of cases

Every case is different, and we closely work with each patient and their entire care team to determine the most effective treatment options. I’ve outlined our general approach to thyroid cancer as well as more advanced treatment options below.

LISTEN: Dr. Rao discusses treatments for standard and advanced thyroid cancer in the Medical Intel podcast.

Treatment of differentiated thyroid cancers

Thyroid surgery

The type of thyroid surgery is based on the extent of the of thyroid cancer. For smaller, single-nodule thyroid cancers, often a lobectomy (removing only part of the thyroid gland) is sufficient, followed by close monitoring. However, a total thyroidectomy with or without lymph node dissection is recommended for larger, multi-foci thyroid cancers.

Following surgery, we evaluate the full pathology report and determine the specific type of thyroid cancer, the extent of the disease (including sites of local invasion), and its stage. If we confirm a diagnosis of differentiated thyroid cancer (papillary, follicular, or Hurthle cell), then, based on the extent of disease, we could recommend radioiodine therapy.

Radioiodine therapy 

Radioiodine therapy, also known as RAI therapy, is an important treatment step in differentiated thyroid cancers. Because thyroid cells love iodine, the intent of using a radioactive form of iodine is to “kill” or “ablate” any remaining thyroid cells after surgery.

In preparation for this treatment, a patient needs to refrain from consuming foods with iodine for a few weeks in an effort to “starve” the thyroid cells of iodine, so that they will be “hungry” when the treatment dose is delivered. Additionally, we also want the thyroid stimulating hormone (TSH) to rise, either naturally by withdrawing the thyroid hormone replacement or synthetically using a drug known as Thyrogen®. This will stimulate any remnant or recurrent thyroid cells.

At the time of treatment, we begin with a low-dose of RAI and a diagnostic scan to help us identify the presence of thyroid cells that take up iodine. If the scan proves there is evidence of uptake, we proceed with the higher ablative dose of RAI. One week later, a post-treatment scan is obtained, and we often will use the results of this scan to further stage the cancer. This can show evidence of thyroid cells located outside the thyroid bed, indicating both regional and/or distant spread of the disease that hopefully will be treated with the ablation. The ablative effect on the thyroid cells may take up to six months to notice structural or biochemical changes. RAI after surgery has been shown to reduce tumor recurrence and improve patient outcomes compared with patients who don’t receive postoperative RAI treatment.

Following ablative RAI therapy, the patient must take precautions for one week to protect others from radiation exposure, especially young children and household pets. We provide detailed instructions, which can include:

• Arrange childcare for infants and young children
• Avoid public transportation
• Avoid sharing plates, cups or eating utensils
• Refrain from kissing and physical contact

After surgery and RAI therapy, we want to reduce the risk of recurrence by preventing any remaining thyroid cells from getting larger. Simultaneously, we need to replace the patient’s thyroid hormone following the removal of the thyroid gland. We accomplish both goals through thyroid-stimulating hormone (TSH) suppression therapy.

TSH suppression after thyroid cancer surgery

The dose of thyroid hormone replacement (T4) after surgery is weight based, however the calculated dose for a patient with benign disease is lower than those with thyroid cancer. The higher dose is prescribed to suppress the TSH, which is made in the pituitary, from stimulating any remnant thyroid cells after surgery and RAI therapy. Patients need regular blood tests to make sure their TSH levels are well-controlled.

Concurrently, we also are measuring the protein known as thyroglobulin (which is normally made by the thyroid cells) and the thyroglobulin antibody. In the absence of the gland after surgery and RAI therapy, a patient’s level should be low to undetectable. Hence, we use the thyroglobulin as a tumor marker for differentiated thyroid cancer.

Treatment options for recurrent thyroid cancer

The following options often are necessary to treat recurrent differentiated, medullary, or anaplastic thyroid cancer. We also may need to use these tactics for patients whose papillary or follicular thyroid cancer recurs or doesn’t respond to RAI therapy. Our treatment options in these cases include:

• Surgery: We may be able to resect medullary or anaplastic thyroid tumors or recurrent cancers that are localized in the neck, and this treatment offers the best survival.
• Alcohol ablation: This percutaneous treatment can be used to treat localized differentiated thyroid cancer that has failed the standard therapies by focally ablating the patient’s nodule with an ethanol injection.
• Radiation therapy: If the patient’s thyroid cancer metastasizes to bones, such as the spine or ribs, it can be difficult to resect the lesions surgically. Radiation therapy, though less commonly used, can target these sites.
• Targeted therapies: For cases in which the patient’s thyroid cancer recurs after RAI ablation and are considered RAI-refractory disease (which means their disease no longer responds to RAI therapy) and for disease not surgically resectable, we may turn to tyrosine kinase inhibitors, such as lenvatinib (Lenvima®) or sorafenib (Nexavar®) where these agents have been approved for use in differentiated thyroid cancer. Additionally, vandetanib (Caprelsa®) and cabozantinib (Cometriq®) have been approved for use in advanced medullary thyroid cancers. These oral chemotherapy medications provide systemic therapy for patients with rapidly progressive or metastatic disease. Patients with resectable or non-resectable cancer or anaplastic thyroid cancer should also be considered for clinical trials.

Active monitoring

In cases of asymptomatic but persistent thyroid cancer, active surveillance is very important. Close monitoring can give the patient peace of mind and allow the doctor to quickly act if the cancer begins to grow or spread. However the decision to operate or initiate a more aggressive medication, such as those listed above, depends on several factors, including the patient’s symptoms, location of disease, and how fast the disease is growing. In many cases, especially if the patient is asymptomatic and their known sites of disease are remaining stable, it may be preferable to spare the patient the financial cost and stress of treatment for what may be little or no noticeable benefit.

There are many effective methods available to treat patients with advanced thyroid cancer. Through a team-based decision-making process that includes the patient, their endocrinologist, surgeon, nuclear medicine specialist and potentially other providers, we can create a plan that addresses each patient’s unique concerns and provides the best chance for a successful outcome.