On the right track for surgery/RAI

[Kristina538]

I have a visible 3.4 cm benign hot nodule ( rest of glad suppressed).

I've found myself in the position of having both RAI 18/11 booked through the public (free) system (the appt wasn't sent to me until now), and surgery booked 24th Nov privately which will cost me $7,000 (I went for a 2nd opinion).

All antibodies are neg. Baseline labs in Sept:  TSH .03 T4 and T3 both normal.

I started 7.5 mg  carbimazole 4 weeks ago and my TSH has risen to 2.1 T4 normal, T3 lowish normal. I'm feeling good at last.

The endo wants me on no more than 5 mg carbimazole, the sugeon would like me on 20mg carbimazole.

I would prefer surgery (hemithyroidectomy); my only concern is that I'm 55 and I read that surgery is recommended to younger patients.  (The surgeon is considered to be the best in this country and does this type of surgery all the time - he has even had a partial thyroidectomy for a hot nodule himself!!)

I've done a lot of research now and feel more empowered;  short term I'd rather the RAI but long-term the surgery.

I was very surprised that the carbimazole worked so quickly, and have weaned myself slowly off the betablockers I had been taking (low dose) since August.  Twice while taking the betablockers I lost half my sight in my left eye.  The lump in my neck has even shrunk slightly.  My BP is normal and h/rate around 67.All other blood work is normal, cholesterol a little high, Hemoglobin a little high. The only meds I'm on apart from the carbimazole is zoplicone half x 7.5mg nightly.

Will the RAI still work if my TSH has risen to normal?   Is Nov too long after the 1123 scan I had done in July?
Are there any contraindications for surgery regarding age?  
Can I put off both because the carbomazole is working so well, in the hope the nodule will disappear?

[Mark Lupo, M.D.]

The standard treatment options for a hot nodule are surgery or RAI.  In expert hands, surgery is very safe with about 1% risk of nerve injury to vocal cords.  RAI works well in most cases with a 5% risk of developing Graves' antibodies and a 1% risk of Graves' eye disease -- these are issues not usually discussed because of rarity.  It really boils down to patient preference.  At age 55, either treatment is reasonable.  

Normalizing TSH before surgery is preferred (which is why surgeon wanted to increase dose, but looks like the TSH is responding nicely.  The carbimazole (and normalizing TSH) does not decrease efficacy of RAI but must be stopped about a week prior to RAI.  Long-term carbimazole will not address a toxic nodule, so definitive treatment is preferred.

The July I-123 scan can be used, not necessary to repeat before RAI.

[Kristina538]

"'The endo wants me on no more than 5 mg carbimazole, the sugeon would like me on 20mg carbimazole.' "  

Sorry I meant to say the surgeon would like me on 10mg carbimazole

[Kristina538]

Sorry TSH has risen to .21 - I'm on the other side of the world (NZ) and stayed up late to try to get this post accepted.....