Multiple thyroid nodules

[michyneck]

I have had several us over the years, each showing something different.  Recently I had an us that showed 4 nodules all about 1cm.  The doctor states since they are so small I shouldnt be concerned.  How can I not be concerned when I have 4 nodules?  Is it unreasonable at this point to consider having the thyroid removed?  Or should I just deal with it and realize that i have a multi nodular goitar... Any advise would be great.  I have moved to a new city and am having a very hard tme finding a thorough doctor.  

[898]

Some doctors just tossing out the medical journals; even worse some never like to answer patient's questions.
Thanks for your blessings!

[Shari4]

*Cries*  I can't believe you did all of that research for me...  I feel like printing it out and pasting it to my endo's forehead!  My friend is pushing me to go to her ENT - and now I think I will.  I'm sure I'll be bothering you with more questions as I go along, but at least know that your advice is well received and much appreciated.  I hope you are well, and many blessings to you for helping so many people who are trying to figure all of this out!

Gratefully,
Shari

[898]

(from article: Goiter, Toxic Nodular)
Article Last Updated: Nov 18, 2005
Physical:
A dominant nodule or multiple irregular, variably sized nodules are typically present. In a small gland, multinodularity may be apparent only on a sonogram.

Labs:
Some patients may have normal free T4 levels (or free T4 index) with an elevated T3 level (T3 toxicosis); this may occur in 5-46% of patients with toxic nodules. Note that the total T3 and T4 levels may often be within the reference range but may be higher than the normal range for a particular individual; this is especially true in patients with nonthyroidal illness in which T3 levels are decreased
· Imaging: Sonography
· Sonography is a highly sensitive procedure for delineating discrete nodules not palpable during thyroid examination. Sonography is helpful when correlated with nuclear scans to determine functionality of nodules.
·
·
o
o By determining the amount of thyroid uptake, nuclear scans allow determination of the cause of hyperthyroidism. Patients with Graves disease usually have homogeneous diffuse uptake. Glands with thyroiditis have LOW uptake.
o In patients with TNG, the scan results usually reveal PATCHY uptake, with areas of both increased and decreased uptake. The uptake rate of radioiodine in 24 hours averages approximately 20-30%.  
· Treatment: Pharmacotherapy: Antithyroid drugs and beta-blockers are used for short courses in the treatment of TNG; they are important in rendering patients euthyroid in preparation for radioiodine or surgery and treating hyperthyroidism while awaiting full clinical response to radioiodine. Patients with subclinical disease at high risk of complications (eg, atrial fibrillation, osteopenia) may be given a trial of low dose methimazole (5-15 mg/d) or beta-blockers and monitored for a change in symptoms or for progression of disease that requires definitive treatment.
·
o Thioamides: The role of therapy with thioamides (eg, propylthiouracil, methimazole) is to achieve euthyroidism prior to definitive treatment with either surgery or radioiodine therapy. Data suggest that pretreated patients have decreased response to radioiodine. The general recommendation is to stop antithyroid agents at least 4 days prior to radioiodine therapy to maximize the radioiodine effect.
§ Antithyroid drugs are often administered for 2-8 weeks before radioiodine therapy to avoid the risk of precipitating thyroid storm. Although many physicians no longer consider this treatment necessary, general consensus is that elderly patients or patients with high risk of cardiac complications should receive this treatment.
§ Both antithyroid drugs and beta-blockers have side effects—most commonly pruritic rash, fever, gastrointestinal upset, and arthralgias. More serious potential side effects include agranulocytosis, drug-induced lupus and other forms of vasculitis, and liver damage.
o Beta-adrenergic receptor antagonists: These drugs remain useful in the treatment of symptoms of thyrotoxicosis; they may be used alone in patients with mild thyrotoxicosis or in conjunction with thioamides for treatment of more severe disease.
§ Propranolol, a nonselective beta-blocker, may help lower the heart rate, control tremor, reduce excessive sweating, and alleviate anxiety. Propranolol is also known to reduce the conversion of T4 to T3. [trade name: Inderal (propranolol hydrochloride)}
§ In patients with underlying asthma, beta-1 selective antagonists, such as atenolol or metoprolol, would be safer options. [end of quote]

The other known alternative could be the treatment by ethanol injection [PEI] (in your case into the largest nodules). Although not commonly accepted, in 2002 this method was put on trial, and according to the article “Treatment of hyperfunctioning thyroid nodules by percutaneous ethanol injection” the success rate was 91% (little too optimistic, because the group was only of 44 members]. However this method is commonly offered for treatment of the thyroid cysts.In my opinion, even if this method will make the largest hot nodules in your thyroid “quiet” for the period you are planning your pregnancy, it would be very good choice; later you may decide if you want surgery or radiation. With the proper preparation, the radiation treatment will not be so destructive to the thyroid tissue.

[Shari4]

No wonder people on this board rave about you.  You have told/taught me more than my endo, who scares the cr@p out of me with her mysterious silence.  She told me I have hyperthyroidism, and see her in 4-6 weeks.  And continue the Inderal.  I asked if I have cancer.  She said "No".  I said, "I heard you say during my sonogram that I have mulitple lesions and nodules"; she said, "Don't listen to me dictate".  I left there hysterical.  I know that I do NOT have elevated TPO or TG AB's.  How could she use Hashi's  as a diagnosis?  By the way, she didn't even mention Hashi's to me; I demanded my written sono report two weeks after I had it, and that's where I heard about Hashimoto's Thyroiditis for the first time in my life.  

If these two nodules are producing too much hormone causing hyper, what is the usual treatment in my case?  You are a complete angel, and I really REALLY appreciate your help!!!

Sincerely,

Shari

[898]

If elevated TPO and TG AB's are present, then sooner or later the person may develop the Hashi condition; these AB 's are often elevated BEFORE the beginning of the disease. Beacuase they are less then 1cm, by the today's trend, they not need to be biopsed.
From the article:
The normal range for the RAI-U is 8% to 35% although the ranges are different in various geographic locations, relative to dietary iodine concentrations. Some researchers say that with the increased iodine content of the American diet, the RAI-U may no longer show clear abnormalities.

. [E.Moore, RAI scan, 2000]
Patients with hyperthyroidism and multinodular goiters may have normal to increased iodine uptake. The nodules can be very small, often only a few millimeters in size, or the nodules can be larger, perhaps several cm each. {My thyroid *******}
Patients with toxic nodular goiter have NONE of the autoimmune manifestations or circulating antibodies observed in patients with Graves' disease. {Merk manual}
Based of all of this I just have read, in my opinion, most likely  these 2 nodules began to produce too much hormones causing the hyperthyroidism.

[Shari4]

Thank you so much for ressponding.  I've been refreshing for an hour, lol!  So, if I understand correctly, if my next blood test is the same regarding TPO an TG, it's not Hashi's?  Is it possible that this is just thyroiditis?  Am I getting the right treatment (no FNA, only Inderal and repeat blood tests next month)?  The RAI Scan was normal, as it was 31% on a scale of 6 to 35% being "Normal Range", and found no masses.  Just that darn ultra sound with the "multiple sub-cm nodules throughout the thyroid bed", and one on each lobe measuring .075 (under 1 cm).  THANKS SO MUCH FOR ANY ADDITIONAL COMMENT!!!!

[898]

Many small nodules are often observed during the thyroiditis (thyroid inflammation). Non-elevated TPO and TG antibodies may eliminate Hashimoto’s condition. During the early stage or reoccurrence of silent or sub-acute thyroiditis, the inflammation ruins the follicles which causes many small cysts and leakage of hormones into the bloodstream.[the later causes the thyroid hormones to be elevated with hyperthyroidism , and low TSH].
The iodine uptake is reduced during the hashimoto’s condition and very low in sub-acute or silent thyroiditis.  
Other cases of spontaneous hyper-  condition happens if the person has longstanding multinodular non-toxic thyroid ; latter in life these nodules are “gaining” autonomy [a.k.a hot nodules] and responsible for hyper condition.

[Shari4]

Or if 898 is out there, please comment :)

[Shari4]

I am 42 yrs old.  After my annual physical, my blood test came back with a TSH level of 0.085.  I was sent to an Endo.  I had a RAI Thyroid Scan.  It came back normal.  Then I had a thyroid sonogram, which revealed a multinodular goiter.  I asked about the fine needle biopsy, and the endo said no.  My nodules were sub-centimeters.  The endo says I am HYPER, yet her report (she interpreted it - not a radiologist) said I have Hashi's thyroiditis.  I am only on Inderal for the mild hyper symptoms I have.  I guess size is key in getting a FNB?  Blood tests are as follows:

TSH, 3rd generation  0.01 Low
T4 Free  1.7 Normal (although I see the range is 0.8-1.8; is this high normal?)
T3 Free   462 High (scale says 230-420)
Thyroid Peroxidase AB (this is TPO, correct?)  <10 normal
Thyroglobulin  AB <20.0  Normal

Should I be doing something else other than taking 10mg Inderal  three times a day?  Is it okay NOT to have a FNB?  Only thing that is scheduled is repeat blood tests in July, and follow-up sonon in one year, or as clinically necessary.

Sorry to jump on this thread, but I can't help being nervous about all of this.  I had very few symptoms of hyper (never cold, slight breathlessness during exercise), but the Inderal "masked" that completely.  The only thing that's making me ill seems to be the diagnosis!!!!   Thanks!

[utahmomma]

It is estimated that 20% of 20 year olds have thyroid nodules; 30% of 30 year olds, and on it goes according to age (so if you make it to 100 you're pretty sure you have nodules).

Of those, 90-95% of thyroid nodules are BENIGN (non cancerous).

What would be helpful is if you could get your hands on any test results you've had (especially ultrasounds, uptake scans, CT scans, etc.) and list what the results were here.  There are a few things that make nodules a bit more suspicious than others.

Here's a great web site that can help:  http://www.endocrineweb.com/thyroid.html

Meanwhile, are they causing you any problems?  Why were they found?

A bit more information can help us to help you.

Utahmomma