Biopsy now, or wait?

[flippet]

My recent thyroid ultrasound came back showing multiple nodules, 4 of which are larger than one centimeter, some are larger.  The radiologist feels they are benign and can be followed with another ultrasound in 6 months.  My family doctor added that I might want to se a surgeon for biopsy, however, since these are large and growing.

I want to know--what's the benefit to waiting for another ultrasound, versus doing a biopsy now?  Would you recommend a FNA, or go straight to a surgical biopsy?  

Also, I have no idea what my hormone levels are--haven't had blood work done (that actually made it to the lab, grr) in years, and it was 'normal' then--although I was convinced I had symptoms of hypo.  If my levels ARE normal, why would the goiter be growing?  Doesn't that signify that something, somewhere, is 'off'?  It seems no one has taken my concerns about my thyroid seriously until last year, when my doctor noticed the goiter just by looking at me.

Over the last 6 months-year, I have had occasional difficulty swallowing, feeling like I had a lump in my throat, and it would be "sore without the 'sore'" as I heard someone else put it.  

[Mark Lupo, M.D.]

First -- get TSH, Free T4 & antiodies and if TSH is elevated (>3) and the antiodes positive then a trial of meds with repeat US in 4-6 months.

FNA is preferred over a "surgical biopsy" -- would procede with FNA of the larger nodules if the TSH/antibodies normal now.

[hazelhurst]

I had a very similar situation. The doctor recommended FNA, and results were benign. I waited about 8 months, had another ultrasound, which showed the nodules had been growing "rapidly." I had no other symptoms and normal blood tests (in a word, I felt fine). At that point, I had to decide whether to do surgery to be 100 percent certain that the nodules were benign, or simply monitor the situation with regular ultrasounds and FNA. I did a lot of research, read medical studies. I found out thyroid problems, esp. HUGE goiter/nodules, run in my family. I opted for surgery so that I won't have to worry about the nodules in the future. Of course, now I'm on thyroid medicine for the rest of my life. It was a difficult decision that could have gone either way, but I am the kind of person who would have obsessed over my condition, and I'm glad I had the surgery 3 weeks ago. The nodules were completely benign, as is the case the vast majority of nodules. I feel great so far. I hope this is helpful. Do the FNA at the very least, and get the blood test before that. Your condition is very common, and completely manageable.

[hazelhurst]

Just another thought--have you seen an endocrinologist? The FNA was conducted by my endocrinologist in his office, not by a surgeon. Also, it's reassuring to consult with a specialist, and your case warrants one.

[Yimmie]

I am not a Doctor! I just went to have the standard 50 year old male check-up. My blood test came back with the tsh levels that point to "Hyper-thyroid" or over active, that was May-1 this year, then CT scan with iodine then the ultra sound.
they found 3 nodules one is 10 mm or 1cm the other two are smaller.

I read toooooooo much on the internet but can tell you this. AND remember I am not a doctor, I am a programmer.

Reading your letter over and over. If I understand, LAST year the nodule was visible to the doctor but just lately you have a ultra sound?

The most common type of nodule (95%) is "cystic"

Thyroid cysts represent enlarged fluid-filled regions of the thyroid that may be small (less than 1 cm) or quite large and sometimes arise very suddenly. A cyst, by definition, contains fluid. Thyroid nodules may be entirely cystic, in which case there are no solid components detectable within the fluid. Alternatively, the nodule may be complex, and contain both fluid and solid components. Cystic nodules may expand and enlarge suddenly sometimes due to hemorrhage or bleeding within a smaller pre-existing nodule. In some cases, rapidly enlarging cysts may produce symptoms in the neck, including pain, trouble swallowing, and rarely, compression of vocal cords leading to a change in voice quality.

About 5% of thyroid nodules are malignant

Most thyroid cancers are well-differentiated papillary or follicular tumors with an excellent prognosis.

Of the 5% above 3% of those are anaplastic and about 75% of those who have that are dead within a few months of detection, 24% are shortly there after. very sad but extreamly rare.

Fine-needle aspiration biopsy of the thyroid is the most cost-effective diagnostic tool. Bang for the buck.

This is what I would do......

Thyroid-stimulating hormone (TSH) blood test

AND

Fine needle Aspiration


Wive's tales on Fine needle aspiration

I understand there is risk that if the mass is cancerous, the methodology can result in leaving a trail of cancerous cells when the needle is withdrawn.

The truth

If the needle biopsy does show cancer, then the full lump will have to be removed. During that surgery, the surgeon usually also removes the tissue along the pathway of the needle biopsy procedure, to ensure that any cancer cells remaining are also removed.

You also mentioned that...

I was convinced I had symptoms of hypo

Here are the symptoms of Hypohyroid, Under-active

  * Weight gain
  * Puffy face
  * Loss or thinning of eyebrows
  * Cold intolerance
  * Low sex drive
  * Depression
  * Abdominal bloating
  * Cold hands or feet
  * Dry or thinning hair
  * Joint or muscle pain
  * Thickening of the skin
  * Thin, brittle fingernails

Here are the symptoms of Hyperthyroid, over-active

    * nervousness
    * irritability
    * restlessness
    * muscle weakness and fatigue
    * shortness of breath
    * feeling hot and sweaty
    * difficulty sleeping
    * heart palpitations
    * abnormal heart rhythm
    * trembling hands
    * moist warm palms
    * frequent bowel movements
    * difficulty concentrating
    * poor memory
    * weight loss
    * hair loss
    * an enlarged thyroid gland
    * drawn back eyelids
    * decreased flow during menstruation
    * infertility and miscarriage

The tsh levels have nothing to do with the Nodule or goiter, it is the nodule or goiter that deals with the over or underproduction of the levels.

No one seems to know why nodules form but they sure know what to do if they do form.

The procedure for nodule removal, I hear is outpatient
or an over-night stay.  It takes about 1.5 hours.

You were on about

"I have had occasional difficulty swallowing, feeling like I had a lump in my throat, and it would be "sore without the 'sore'" as I heard someone else put it"

This is what I have, it sometimes feels as if there is something stuck and I keep trying to swallow or flush it down with water. But in the morning, nothing. later, possibly yes, then gone. Sore sometimes, hard swallowing, sometimes.

I don't know where else to get more information like you have, My doctor told me that this feeling of something stuck is all in my mind. I have no one to talk to other then this guy that says I have an overactive imagination.

Thank You, you have been a great help.

Yimmie

[flippet]

Yimmie said: "Reading your letter over and over. If I understand, LAST year the nodule was visible to the doctor but just lately you have a ultra sound?"


No.  In April of 2006, my doctor noticed the goiter, and sent me in for an ultrasound.  That first ultrasound showed a multinodular goiter.  As I recall, the report said 'cysts and nodules', which I took to mean both fluid-filled cysts, and more solid nodules.  But I could be wrong about that.  I don't know what size they were at that time.  I was supposed to follow up with another ultrasound six months after that (October), but I had a baby in September, and then lost my insurance due to my husband losing his job, so the follow-up ultrasound didn't take place until a couple of weeks ago (the one I mention above)...so it was nearly 15 months after the first one.

As far as hypo symptoms, in 1998 I suddenly noticed that I had a lot of hair falling out.  However, I was just starting back to college, and had recently had a perm, so I chalked it up to that.  But the hair kept falling out, more than usual, I thought.  (I still seemed to have 'enough' on my head, no bare patches or anything like that, but it just comes out like crazy every shower, and brushing, and I've always got hair on my clothes--I'm constantly shedding.)  I had gained some weight that seemed very resistant to coming off, no matter how I exercised or how I ate--but I'd gotten married just the year before, so I chalked it up to that.  Either married=eating more, or maybe it was the birth-control pills.  The constant fatigue, I chalked up to my busy schedule.  See.....there always seems to be an excuse for any symptom you can come up with.  I've had other symptoms from time to time (cold extremities, seeming memory issues, etc), but not consistently.  The hair loss, weight gain, and fatigue are the main ones.

[flippet]

Okay, had to look at the list again.


* Weight gain--yes
* Puffy face--not really--just the 'fat neck'
* Loss or thinning of eyebrows--not noticeably
* Cold intolerance--at times, not consistently
* Low sex drive--more often than not
* Depression--yes
* Abdominal bloating--hard to tell if it's that, or just remnants of pregnancy
* Cold hands or feet--at times, not consistently
* Dry or thinning hair--not dry, but losing lots
* Joint or muscle pain--at times, not consistently
* Thickening of the skin--just in certain areas--soles of the feet, and while not thickening exactly, I do have keratosis pilaris on my arms that kicked in around 1998, and has gotten progressively worse
* Thin, brittle fingernails--have always had these.

[Yimmie]

Hi Flippit

I hope things are good at home now with Mr. Flippets job and all. I would strongly suggest the FNA and Blood test just because my quality of life has increased in ways I thought were only available at the fountain of youth. My doctor has me on a tsh over active thyroid adjusting drugs. Medical I am not. ha. Anyway my wife, Mrs. Yimmie has a hypo thyroid and her weight went down as her drive went up. She also had depression. She still complains about her nails but her hair stopped falling out and is doing quite well.
Me too.

Mrs. Yimmie's drugs and mine BOTH combined cost just under 16.00 a month. Congrats on little Flippet.

Let me know more if you have time, If you get the procedure for removal too. I would like to know. I will be thinking of you guys.

Yimmie

[Yimmie]

One more thing, did you have a CT iodine uptake scan?????

If so was it cold or hot nodules?

Yimmie

[flippet]

Nope, no scan other than the two ultrasounds.  i have no idea whether the nodules are hot or cold.  In looking at the ultrasound screen, the nodule or two that I watched them do looked pretty fluid-filled to me, but I'm certainly no specialist.

I wouldn't mind being on medication if it would help, especially with my energy levels.  But I'd really rather not remove anything unless it's necessary--to me there's a difference between taking meds because they help, and taking meds because you've destroyed the thyroid and now you have no other choice, y'know?

Thanks for the good thoughts!


(As a side note, I was just reading some articles on the controversy over fluoride in the water....and learning that too much fluoride can cause symptoms of hypothyroidism.  Yippee.  Nice stuff the government pours into the water, huh?  I think I'll be avoiding all sources of fluoride that I possibly can.  My teeth are already shot to heck, so no benefit there, LOL!)