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Can you be certain that thyroid nodules are benign without biopsy?
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Can you be certain that thyroid nodules are benign without biopsy?

I just had an ultra-sound on my thyroid and 3 nodules were found.  The thyroid specialist also stated my thyroid is enlarged.  The only reason I saw a specialist was because after a recent physical when my GP said my hypothyroid numbers were dangerously high at 38.6, with the normal range (the doctor stated) being 0.35 to 5.5, I decided to educate myself better on this disease and noticed I had all the symptoms for thyroid "cancer".  I realize completely that this did not mean I had cancer of the thyroid, but I thought I should be tested, so after meeting with my GP again, she had me do more blood test and an ultra-sound.  The ultra-sound indicated I had what I thought was "a" nodule, but when I went back for an appointment for which I understood was for a biopsy, this thyroid specialist only did another ultra-sound, at which point I learned there are 3 nodules along with an enlarged thyroid.  When he learn that I had only been on my meds for a week and my numbers were so high, he stated that I should give the meds 3 months, because he believes the meds are going to take care of everything. My question is, How can he be so sure these nodules are benign without a biopsy?  If he can't be completely certain without a biopsy, do you have any idea why he did not proceed with the biopsy?  It seems to me that he can't be completely certain if at my appointment in 3 months he plans to do a biopsy if the nodules are still there.  Thank You kindly for you input.
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Avatar_f_tn
Do more research, and keep vigilant.  Even if you get a benign biopsy result (I did) you may still have cancer (I did, it was not in the nodules, it was in the thyroid tissue).  What other symptoms have you had?  Hormone levels are important, but mine were all within normal range, but I did pop positive for TPOab, indicating Hashi's and sometimes cancer.  How big are the nodules?  You can have a biopsy after they get to be 1 cm or larger, but as I say, it may or may not tell you anything.  Are the nodules all on one side?  If so, you could gamble on a lobectomy where they would take out the one side and do a thorough biopsy on the tissue to tell you for sure. The nodules will NOT go away, so you may only be delaying the inevitable by keeping them.  My thyroid was not going to be working very much longer anyway, the Hashi's would have killed my thyroid function.
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Avatar_n_tn
Thank You so very much for sharing.  I hate to admit it, but I never thought to ask the size of the nodules, but as far as the location, I believe he stated there were 2 on one side and one in the middle.  When you suggest I do more research, precisely what is it that I need to research?  When I stated that I educated myself on this disease, I really was just interested in whether or not this disease could be dangerous if left untreated, which I concluded it could be. The symptoms I've had include a constant sore throat - shortness of breath - on and off hoarse voice - numbness in my extremities - sensitive to cold - COMPLETE fatigue - constantly falling asleep, but this may be due to the removal of my pineal gland, which was removed during brain surgery along with a brain tumor back in 2007. My GP told me something I found a bit curious. She said that if only ONE tumor had been found, then cancer may have been suspected, but since there are 3, they don't believe this is the case. They believe the synthroid is going to shrink the nodules and heal the inflammation of the thyroid gland. Can you tell me a bit more about how they found your cancer since it wasn't in the nodules? What was the indicator that made them check the thyroid tissue. It seems to me that when I go back in 3 months, if the nodules are still there and they biopsy them and there is no sign of cancer, I would imagine they'll probably just give me a higher dosage of meds instead of thinking to biopsy the thyroid tissue, since the don't seem to suspect cancer now, I presume they're not going to suspect it then if the nodules are benign. Of course this is only speculation on my part. As far as Hash's and TPOab, I'm sorry to say that I have no clue what any of this is. If you feel like sharing more, that would be very much appreciated. It seems you're the only one so far that's taken any interest in sharing.  Thanks again!!  
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Avatar_f_tn
I would be asking the Endo to arrange a FNA (fine needle aspiration).
This will give you some idea as to whether the nodules cells are changing.
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Avatar_f_tn
TPOab is Thyroperoxidase Antibodies, this will tell you if you have Hashimoto's syndrome, and it is sometimes an indication of cancer as well.  In my case, I am a singer, I have known since 2001 that I have nodules, and had a RAIU test, where they give you a slightly radioactive form of Iodine then photograph you to see if your thyroid is working properly.  At that time, mine was, but late in 2008 I started having swallowing issues (food would stick in my throat where the thyroid is, I would get massive rapid hiccups until I flushed it down with water.) I also was getting hoarse after singing three hours at rehearsal, which was not good, but it went away after a few hours. I also started getting hot/cold, night sweats, wacky periods, blood pressure spikes, started loosing weight, joint pain in elbows.  There were so many things, but these are the main ones.  I went to doc to see if I was menopausal (I was 44 at the time) and have my thyroid hormones checked.  All levels came back in normal range, however my TPOab was positive, Hashi's...my dad and two bros had it, too.  Did an ultrasound and found four large nodules, three in right side, one on the left.  Ranged from .8 mm up to 2.1 cm, and three on right were solid, vascular, smooth, one on left was complex and vascular.  FNA Biopsy revealed "benign follicular clusters" but that did not tell them whether the nodule was cancerous or not, only removing it and doing a thorough biopsy would reveal that.  I did not have surgery right away, I did research on every word and combinations of words in my chart, I also had my brother who is a radiologist look at my ultrasound, he thought they were follicular adenomas.  After about two months, the hoarseness got so bad that I was getting hoarse for 5 days after having a long day, so I decided to have the right side removed to 1) check for cancer and put my mind at ease and 2) to see if those three nodules were causing my problems.  I thought that if I did that and I wasn't hoarse anymore, I could still have thyroid function and be fine.  Everything went great, I was walking 2 miles three days after surgery and singing fine after about 5 days, a little weakness in the midrange, but all the notes were still there.  I was optimistic!  Then the two-week post op appointment came around, the doctors were waiting for me...it was cancer, although very small micro-tumors, 1 and 2 mm.  All were found in the THYROID TISSUE, not the nodules...THE NODULES WERE NOT CANCEROUS - follicular adenomas, just as my brother said, and the surgeons all suggested taking out the other side.  My brother also said take it out, get it over with, you are only delaying the inevitable.  The Endocrinologist, however, wanted to watch and wait. He did an ultrasound in his office, did not see anything that concerned him, but I went ahead with the second surgery.  In the left side after surgery, the path's found the mother-lode, a tumor 1.5 cm as well as another small micro-tumor, and that was not good. It is still stage 1, but now I was in the RAI 131 category...glad I listened to the surgeons and not the Endo.  Endo's think they can control everything through hormone manipulation.  So here I sit and wait, I am five weeks post op and have to wait two more weeks to go. I am extremely hypo and tired.  But hopefully after RAI and a full body scan I will be done with this mess and feeling better.  Good luck, any other questions, just let me know.
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Avatar_n_tn
I'm so sorry for all that your going through and it's extremely kind of you to share.  If you're up to it, I do have a few questions.  First, I'm not sure if I understand clearly. From what I understand, the cancer was not found until one side of your thyroid was removed, at which point it was biopsied and the cancer was found in the tissue. When the other side of the thyroid was removed a couple more tumors were found and were cancerous?  If this is correct, then why weren't these tumors detected during the ultra-sound?  Are nodules not another term for tumors?  Do I understand that you had tumors in your thyroid which the ultra-sound did not pick up?  What do you think about my doctor's comment about if I had only "ONE" nodule, there would have been the suspicion of possible cancer, but since I have three, it's far less likely.  When you stated that a biopsy of the nodules indicated they were benign, but was not a confirmation that there was no cancer, how and why did they conclude this?  I'm sorry for my ignorance, but I thought benign meant no cancer.  I'm asking this because when I go back for my 3 month check up, if the nodules have not shrunk, which the doctor says should occur after being on synthroid for 3 months, if he then decides to do a biopsy, which I'm told will be done with a needle and the nodules are benign, can I or should I assume everything's fine or should I request additional tests?  Are there possible indications from the way a nodule looks on the ultra-sound that would give the doctor a good indicator that there is no cancer present?  Do you suggest i ask for this hashimoto test BEFORE my appointment in 3 months or wait until then to see if the medicine does indeed shrink the nodules as the doctor suspects will occur?  I'm truly sorry if it seems I didn't read everything you wrote, because I did, I just am trying to be more clear on everything from someone with your knowledge.  I suppose I keep thinking that something in the ultra-sound and/or blood tests must have been a strong indication of NO cancer, otherwise, why wouldn't he have performed a biopsy?  It's not like I'm not insured.  On the other hand, it's those awful stories we hear about doctor's mistakes, which may be rare, but making it a bit more difficult to not question something as simple as why would a doctor not choose to biopsy these nodules, if indeed this is the only way to be certain.  Although, after listening to you, it sounds as if even the biopsy is not conclusive.  As I may have stated before, a part of me thinks this doctor surely must have a great deal of experience reading ultra-sounds and his choice not to perform a biopsy should tell me that he is very confident that there is no need for concern and for me to think otherwise makes me pathetically paranoid.  As I'm sure you've noticed, I'm obviously a bit reluctant to doubt him, so I want to be certain I have a legitimate reason, before I do.  Thanks again, so much for your time.
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Avatar_f_tn
You are correct.  No cancer was seen on ultrasound.  My cancer was in the thyroid tissue, not the nodules.  Two tumors were found when they examined the right half removed on April 21, two other tumors were found after June 9th surgery.  It is not an exact science yet.  Thyroid cancer has not really been studied that much, probably because it usually does not metastisize, it is slow growing, and most people do not even know they have it until they either die and have an autopsy or find it looking for other things. My cancer did not show up on ultrasound.  There was one very small "perhaps microcalcification" in one picture, but like I say, unless it is a large one, you won't see it on the ultrasound.  I don't know why they could not see it, maybe it was hiding behind the solid nodule, they might not gotten the wand in a position that it could be seen.  Benign does mean no cancer, but when you are talking about tumors that are 1 mm, it takes a direct hit with the Fine Needle Biopsy to get any cancer cells.  Think of the ball end of a writing pen, then think of hitting that in the neck with a very small needle...kind of a "needle in a haystack" moment.  If they do not strike the small tumor directly, they will not get cancer cells.  Apparently, benign follicular cells look exactly like cancerous cells...it is the way they behave that indicates whether or not they are cancerous.  Three of my four tumors were less than 2 mm.  The only one that could probably have been seen was the 1.5 cm tumor, it was marble sized, but still they did not see it, even after two ultrasounds.  We even knew I had cancer when the second ultrasound was performed, and still did not see it. Regarding one vs. several nodules, that's what the odds are, but remember, thyroid cancer diagnoses are not really an exact science right now, they are trying to improve the way they diagnose it, but really the only way they can tell for sure at this time is to take out the thyroid or at least some of it and do a thorough biopsy.  There are surgeons who will take out a small portion of the thyroid, say a half-lobectomy when the nodule is located in a part of the lobe that is easily removed, but my surgeon did not do this work and I was not a candidate anyway, too many nodules.  The thyroid is a very vascular gland and there could be bleeding.  The things they look for on the ultrasound that may indicate cancer are: solid composition, vascularity (cancer needs a blood supply), irregular borders (indicating invasion into other places) calcifications, age, gender, you can look this up on line.  Google Thyroid cancer symptoms statistics, etc. My brother happens to be a Radiologist, I sent him up a copy of the full ultrasound, he went over it and did not seem too concerned, he told me that it looked like I had benign follicular adenomas, and he was correct.  He is a 20+ year radiologist and sees these all the time, but as I said, looking for a 1 mm tiny ball behind a 2.1 cm nodules is almost impossible on ultrasound, and if the nodule is solid, you cannot see through it, so things can hide behind them.  He was stunned, too, that I had cancer, especially after they found the 1.5 cm one, he said it must have been hiding behind something, because he saw no indication that there was anything to be concerned about.  Before I knew I had cancer, I had a terrible time making the decision to let them remove half my thyroid, I did not want to be on drugs the rest of my life. But I could not ignore the hoarseness and swallowing difficulties I had, and due to having a positive TPOab test, I knew that Hashimotos would eventually destroy my thyroid anyway, so for me I was only delaying the inevitable.  No matter what they tell you, your nodules will not disappear, even if they do shrink, they will still be there.  So there is really no way to know for sure unless you remove a part and biopsy it, I know it does drive you crazy, just remember, it is probably not something that will metastisize, it will probably not kill you, and you probably will eventually get an answer. You just have to keep at it, be really in tune with your body and when you have things that you can no longer stand, then it may be time to deal with it.  Good luck, any other questions I can answer let me know.
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Avatar_f_tn
Thanks for sharing your story! I am stunned that your nodules were benign but that the cancer was in the tissue.  Your posts are informative and its so interesting to hear of your brother's inputs. Must have been a comfort to have a brother that's a Radiologist.

I have a large adenoma on one side and two ill-defined baby nodules on the other side.  I have a strong gut feel that I need to have it all taken out and just get this behind me. Reading about where your cancer hid really strengthens this resolve!
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Avatar_n_tn
Hello again. Boy, that was extremely informative and much appreciated!  I'm sure you must have told me some where in all that you shared, but I don't seem to remember how it is that they found the cancer.  I know you said they found it in the tissue and not the nodules, but did they just get lucky that the small area that was biopsied indicated cancer?  Am I wrong in thinking that even if they take out the entire thyroid gland and biopsy it, isn't it possible they could still miss the cancer or do they actually biopsy the entire gland. Just so you know, it's already been determined that my thyroid does NOT work properly. I was told the normal reading is 0.35 - 5.5 and mine is 38.6, which is another reason they don't think there's any cancer. They're thinking that it's possible that since my thyroid has been trying to work extra hard to produce the necessary hormones, that maybe this has caused the inflammation and nodules, which is why there hoping the medicine will shrink them. Although, this is not to say that I don't believe what you told me about the medicine not being able to, I'm just reiterating what I was told.  Also, it doesn't really bother me to have it all taken out, if necessary, because I'm told, because of my hypothyroidism, I will need to be on medication the rest of my life anyway to provide the necessary hormones my body supposedly needs. It's not so much that I'm worried about existing cancer in my thyroid, because like you stated, it seems to be easy to cure.  What I'm worried about is since my doctor is so nonchalant about it, in the sense that it's so rare, I just don't want it to be over looked. Do you believe it might be common for no biopsy to be performed on the nodules found?  Is it likely that the ultra-sound may have given him an indication of no cancer, which is why he did not choose to do the FNA at the time?  After he did the ultra-sound and indicated to me that I did indeed have 3 nodules, all he said is that he wanted to see me back in 3 months, at which point if they have not shrunk, he will then do a biopsy.. The thing is, I was already told about the nodules from an ultra-sound a few days prior.  This appointment with I think was a surgeon was for what I was told to be a biopsy.  I asked him if he was not going to do a biopsy, he said not today, that since I hadn't been on any medication, he seemed to think the medication would take care of everything. Naturally I trusted his decision, but after going on-line and noticing that a FNA is so common, I wondered why he just didn't do it to be 100% certain.  Although, after reading your information, it sounds that even with the FNA you can't be certain, because the cancer may not even be in the nodule.  The bottom line is, like I said, I just don't want them to over-look anything. Even though I'm understanding the chances are slim, especially since my reading was so high, because it seems that when cancer is present, there is usually no indication of such.  In other words, it sounds like the thyroid is usually working just fine, which is not the case with me.  So, I realize the chances are low, I just would like it to be checked thoroughly is all.  I truly don't mean to sound paranoid, but it's those stories you hear of; if only the doctor had..... or if only the patient had ......  I would like to avoid any "if only (s)" if that makes any sense.  Thanks again for taking the time to share with me, you're absolutely wonderful!!!
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Avatar_f_tn
It is my understanding that your thyroglobulin TG will go up if you are at risk for cancer, but I could be wrong.  That is why in your case they may just watch and wait. Also, the more nodules you have does not increase the cancer risk...more nodules does not mean more cancer or more risk. If your thyroid no longer works, then a TT might be a good choice, at least then you can be sure. Your nodules will NOT go away, and eventually they will probably have to be removed if they grow, so you are delaying the inevitable.  If you do go for surgery, you will get a total pathology report on what they take out, ie, your whole thyroid, and they will test it for cancer.  About a week after your surgery, if you are not already on your synthroid, you will get your thyroid hormone, as long as no cancer is present.  If you do have cancer, they will need to determine the stage and scope, then decided if you are warranted to go through RAI.  If the cancer is very small and stage 1, most doctors will not do the RAI, my cancer was stage 1, however I had a 1.5 cm tumor, that is the threshold for going ahead with RAI, so here I wait until I am dosed.
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Avatar_m_tn
Hi just read your post...I recently had a total thyroidectomy...and I did have thyroid cancer...
I would have never known had it not been that I had a series of xrays for complex oral surgery i was about to undergo...the tests revealed multiple nodules on both sides of my thyroid...all different cm's...at first they did asparations...3 months apart...then a biopsy...6 months apart...finally I had to go to cooper Hospital in Camden ti have  a biopsyy involving several needles....it didn't hurt...they said it was a 1 %  they had to biopsy more after tests were read...and I was the 1 % ...they had to do a second multi needle biopsy...even though I had several nodules...they were only biopsying the right side of my thyroid...it took exactly 2 weeks for the pathology report to come back.  I got the call that "there was enough suspicious evidence" of possible cancer...usually they give you the option of having partial or total thyroid removal...since they were only biopsying my right side...I couldn't undersatand why i was never given that option...lucky for me however,,,good thing I had my whole thyroid removed because the right side came back benign...however,,,2 of the nodules on the left side came back malignant...I had early stages of papillary thyroid cancer. ( papillary is the most common and easiest curable)...the strange part was I had no signs or symptoms of any thyroid problem ...had it not been for accidentally seeing the nodules in xray scans...I would have never known...even worse...had I been given the option for a partial thyroid removal...since they were only suspecting cancer of the right nodule..I would have thought I was fine...all the while my cancer would have been growing.   definitely have the biopsy....even though they'll tell you they can not be completely sure without removing your thyroid...if there is the slightest bit of suspicion...I would advise you to have the surgery...thyroid surgery was actually no where near as bad as my oral surgery (which ended up becoming emergency bone transplant surgery.)...now I just have to take a tiny thyroid pill the rest of my life...no big deal...hope this helps :)
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Avatar_m_tn
Hi just read your post...I recently had a total thyroidectomy...and I did have thyroid cancer...
I would have never known had it not been that I had a series of xrays for complex oral surgery i was about to undergo...the tests revealed multiple nodules on both sides of my thyroid...all different cm's...at first they did asparations...3 months apart...then a biopsy...6 months apart...finally I had to go to cooper Hospital in Camden ti have  a biopsyy involving several needles....it didn't hurt...they said it was a 1 %  they had to biopsy more after tests were read...and I was the 1 % ...they had to do a second multi needle biopsy...even though I had several nodules...they were only biopsying the right side of my thyroid...it took exactly 2 weeks for the pathology report to come back.  I got the call that "there was enough suspicious evidence" of possible cancer...usually they give you the option of having partial or total thyroid removal...since they were only biopsying my right side...I couldn't undersatand why i was never given that option...lucky for me however,,,good thing I had my whole thyroid removed because the right side came back benign...however,,,2 of the nodules on the left side came back malignant...I had early stages of papillary thyroid cancer. ( papillary is the most common and easiest curable)...the strange part was I had no signs or symptoms of any thyroid problem ...had it not been for accidentally seeing the nodules in xray scans...I would have never known...even worse...had I been given the option for a partial thyroid removal...since they were only suspecting cancer of the right nodule..I would have thought I was fine...all the while my cancer would have been growing.   definitely have the biopsy....even though they'll tell you they can not be completely sure without removing your thyroid...if there is the slightest bit of suspicion...I would advise you to have the surgery...thyroid surgery was actually no where near as bad as my oral surgery (which ended up becoming emergency bone transplant surgery.)...now I just have to take a tiny thyroid pill the rest of my life...no big deal...hope this helps :)
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Avatar_m_tn
Thank you so much for mentioning the issue you had with food getting stuck, and having the rapid hiccups until you were able to wash it down! I have mentioned that to my doctors and they all have me thinking I am crazy.
I am 47 now and was told as a child that I had a goiter. I had tests done every so often to monitor it, but it was never out of the normal range. At some point between my last tests about 4 years ago and now, things changed. I went to my GP when I noticed my goiter seemed to be larger than usual. They did the lab work and started me on 75 mcg of Levo, since my count was at 46, and told me I was Hypothyroid.
They also sent me for an ultrasound, which confirmed the enlarged thyroid and nodules. There is a 6 mm x 4 mm echogenic lesion on the right, and 2 hyperechoic lesions, largest of which is 6 mm x 6 mm, on the left.
At that point my GP sent me to an Endocrinologist. She confirmed their Hypo diagnosis, as well as informed me that I have Hashimoto's Disease. She said that she saw no need to do any further tests, except to check the numbers in a few weeks to adjust my dosage.
After 5 weeks, she did another lab, in which my number was 3.43, so she decided my dosage was correct and I didn't need to be seen until next year.
My concern is that she didn't do any further tests on the nodules, and dismissed them as benign automatically. I understand that it is almost always benign, but "almost always" scares me. What if I am one of the others?
I had told her of my issues with the food getting stuck and the rapid hiccupping until it cleared, but she dismissed it as a GERD issue. I don't know any better, so I let it go.
After reading your post though, I am more concerned that I should get another opinion.
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Avatar_m_tn
Typical Endo.  TSH is somewhere within some range, therefore you are okay.  Wrong!  TSH is a pituitary hormone that is supposed to reflect accurately the levels of actual thyroid hormones; however, TSH cannot be shown to correlate well with either of the biologically active thyroid hormones, Free T3 or Free T4 (not the same as Total T3 and T4), much less correlate with symptoms, which are the most important.  

Since your TSH was still 3.43, while taking 75 mcg of T4 med, I suspect that you are really still hypothyroid, thus some of your symptoms.  To find out, you should request to be tested for Free T3 and Free T4 and see if they are in the lower half of the range, which is often associated with being hypo.  If the doctor resists, justs insist on those tests and don't take no for an answer.  

While you are at it, I also suggest that you should request tests for Vitamin D, B12, ferritin, and a full iron test panel, since hypo patients are frequently too low in the ranges for those as well.  

Just for comparison to your treatment, I wanted to say that a  good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with after initial tests and evaluation.  The letter is then sent to the participating doctor of the patient to help guide treatment.  In the letter, please note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."

http://hormonerestoration.com/files/ThyroidPMD.pdf

If you will get those tests done and post results and their reference ranges, members will be glad to help interpret and advise further.

As for the nodules I'm sure other members can give you some insight.  I do know that lots of people have nodules that are not really a problem unless they grow or become malignant.  So occasional ultrasound tests may be all you need for now.
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