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Hot nodules
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Hot nodules

I am a past Cushings pt., with no adrenal glands and only a 1/4 of pit gland. I have been DX in past with an autonomously functioning thyroid nodule. It has been ultrasounded and biopsied as recently as a month ago, (again). A radioactive scan indicates a hot nodule that has taken over the entire left lobe of the thyroid gland.  My tsh is 0.8, but now I am experiencing  suddenly; insomnia, tremors, and a high BP, with a sort of vibration feeling in my head. Endo says that TSH is normal, not to worry. I have been evaluated by a Cardiologist who states my EKG and status is normal.I replace my cortisol with cortef in a divided dosage of 20mg. Should I pursue the "thyroid avenue", or look elsewhere for this very troubling constellation of symptoms?

Thank you for your time.
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In mild cases, a hot nodule may not be producing sufficient amounts of thyroid hormone to suppress (0.1 or lower) TSH production and secretion from the pituitary, hence the TSH may be normal or towards the lower end of the normal range. As the nodule enlarges, becomes more metabolically active and produces increasing amounts of thyroid hormone, the TSH will become gradually lower, and if hyperthyroidism ensues, the TSH will be suppressed (0.1 or lower). Hot nodules are almost always benign. The risk of thyroid cancer development in a hot nodule is extremely low, but rare cases of functioning hot nodules that turned out to be follicular cancers of the thyroid have been reported.

If the nodule is quite large, if it causes compressive symptoms, or if clinical hyperthyroidism is present, then treatment of the hot nodule needs to be considered. In the US the principal treatment options for management of thyroid nodules are radioactive iodine versus surgery.
A "hot" nodule, RAI would be effective since the only place in the thyroid taking up iodine IS the hot nodule, that's where it would all go and that's the ONLY area it would destroy. Typically people who have RAI treatment for nodules can return to normal thyroid function (no artificial hormone), since once the nodule is gone, the rest of the thyroid "wakes up" and functions in response to TSH levels, just as it did before.

Many patients will not develop hypothyroidism and  some patients will, depending on the size of the nodule and the dose of radioactive iodine administered. In some instances the rate of hypothyroidism after treatment of a hot nodule can eventually approach 50-60%.

The surgical option may be superior if one wishes to completely remove a large nodule that may be causing compressive symptoms. Radioactive iodine will often result in resolution of the hyperthyroidism, but may not always result in a significant decrease in size or disappearance of the nodule.

Hope this helps your question.
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