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Newbie with Multinodular Goiter TSH & Ultrasound question
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Newbie with Multinodular Goiter TSH & Ultrasound question

Hi all. I'm new here and completely overwhelmed. About a month ago I developed hoarseness and coughing which I still have and around 2 weeks ago I noticed a swelling in my throat. Went to my regular doc, she ordered TSH and Thyroid Ultrasound and I just got results today. I was referred to an endo but can't get in with them until mid January.

My TSH was 0.277L with lab reference range of 0.450 - 4.500

The ultrasound shows multinodular goiter

Right lobe 4.1 x 1.3 x 1.9 cm
in mid aspect is a heterogeneous hypoechoic solid appearing nodule measuring 1.6 x 1.2 x 1.3 cm hypovascular to surrounding thyroid tissue. Wider than tall.

Isthmus measures 0.2 cm in width. Just to the lateral and right of ishmus is a prominent isoechoic nodule measuring 0.8 x 2.6 x 2.5 cm wider than tall also hypovascular

Left lobe is enlarged and measures 5.9 x 2.5 x 1.4 cm

within inferior aspect is an isoechoic appearing nodule measuring 2.1 x 1.7 x 1.3 cm wider than tall. Slightly hypovascular to surrounding tissue.

Within the mid aspect is an isoechoic appearing nodule measuring 2.4 x 1.7 x 1.2 cm. winder than tall and hypovascular to surrounding thyroid tissue.

No lymphadenopathy seen within the visualized portions of the thyroid bed.

I am 39 yrs old with no prior history of thyroid issues. I have been under a lot of stress lately as I am a single mom, just lost my job and my 31 yr old sister is currently battling stage iv breast cancer. Could stress have triggered this do you think?

My questions:
(1) How do I know if my nodules are greater or less than 1 cm? Do I add the measurements or multiply them somehow or does it go by one of the 3 measurements?
(2) Since I seem to be symptomatic with hoarseness, coughing and low TSH...do you think surgery will likely be recommended to remove the goiter/lump on my neck? I'm wondering because I just was given notice of lay off at work and I have only 2 months of health insurance left so a mid-January initial appointment with endo might not be soon enough.
(3) From the results above, does there seem to be a dominant nodule. I can't tell, don't know what to look for. I'm trying to do my research but am so confused. My regular doc just says its a multinodule goiter and she doesn't know anything else beyond that.
(4) If I do need another endo, any referrals for someone good in Houston?

Thank you in advance for your answers.
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12 Comments Post a Comment
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1144849_tn?1395458766
Hello oscarmaya, Welcome to the group.  My Ultrasound is strikingly similar to yours. I have 6 nodules,  MY TSH is now about .25

Do you have the blood work numbers for your Free T3  and Free T4 ?

I am very new to this forum also but I might be able to help you with a few of your questions.

1) Nodules are usually not symmetrical depending on the type.  So I think you kind of figure it as a 3d picture of a marble. The length the width and the depth.

2) So sorry to hear that you have lost your job. I have faith that you will get through this alright. What you have is most likely Toxic Multinoduler Goiter, thought the report states one nodule appears to be solid. (is this the complete report? Normally there is a Radiologist summery at the bottom) I had to wait 6 weeks to see an endo also.

The "Toxic" part i mentioned is if any of these nodules are cystic they likely are producing their own thyroid hormone within the thyroid which spills into the blood stream and the pituitary gland tries to adjust and you end up with low TSH (Thyroid Stimulating Hormone)

You have several options, which I will get to next.

3) I would guess that the nodule of most importance is the "solid appearing nodule measuring 1.6 x 1.2 x 1.3 cm"  Since this nodule is "solid appearing" The endo's next step might be to 1) order a Thyroid Uptake and Scan which is a Nuclear Medical study that measures the thyroid function to see how productive it is and if the nodules are "cold" or "hot". Then the next step would possibly be to do a fine needle biopsy of that Solid appearing nodule to determine if it is benign or not.  if it is not then Surgery would likely be indicated.  Often times cancer is more common if there is a Single nodule and is a bit more rare with Multinoduler Goiter.  In either case this is an extremely treatable condition with very good successes rate.

If the nodules are benign the endo would likely prefer to do an Ablaition RAI (you drink radiation that basically kills off the thyroid)

A third option is a medication such as Methimazole but this is difficult to regulate and not considered a long term solution.  

Given your situation I would call the endo and explain what you have to work with and that is urgent you get in under the circumstances.  At the very least the endo might read the radiology report and give you some answers that might help you plan. Sometimes, though rare, there are  cancellations and you might be able to get in sooner if you call the endo office often.

4) Sorry I do not know any Endo in Houston.

In my case, for my treatment. I refused the thyroid uptake and scan since my Ultrasound and blood work says there is likely no cancer involved in my case. I wanted to do the research to learn what I am dealing with so I also refused the Ablation.  I opted to go on Methimazole (against my Endo's wishes. She has never NOT done an Uptake and Scan before prescribing a medication or procedure.)

So I have learned a lot fromt he great people on this list. I am sure there re some that will share about sucsessful surgeries and Ablations.  I have not decided yet what I will do.

Some important things that you can do right away are - Cut way down on your slat intake, stay away from goiterous raw vegetables like Cauliflower and Broccoli (cooked they a fine), Stop eating all sea food for now. Se food contains high amounts of Iodine and Iodine in our case is a problem. Drink lots of water, Cut way back on caffeine and any carbonated drinks. Stop eating fast food. A Milti vitamin is a good idea too. As soon as I did these simple things, my hoarseness went away and some of my fatigue and other symptoms got a bit better.


(anyone feel free to jump in if I am misguided in my understandings.)

I hope that helps some :-)

-McMIllan
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1153642_tn?1266257589
thank you for the response McMillan as well as the suggestions for things I can do now while I wait.
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1153642_tn?1266257589
I got my bloodwork back so additional information is this:

TSH 3rd Generation .63    range .40 - 4.5
T4 Free 1. 0    range .8 - 1.8
T3 Free 322    range 230 - 420
Thyroglobulin Antibodies <20   range <20
Thyroid Peroxidase Antibodies <10   range <35

Thoughts? I have been on no thyroid medication so don't understand how my TSH is .27 and then 1 week later .63 unless they are totally different tests. Confused.
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929504_tn?1332589534
I was in the same situation as you until I had mine removed (Total Thyroidectomy)...You listed the sizes of your nodules in your post and they are over 1cm on both sides. Once you meet with the Endo, she/he will order you to have a fna (fine needle aspiration) biopsy to determine whats inside of the nodule and to check for cancerous cells. I had different "abnormal" cells on both sides (follicular) on the right and (hurthle cell) on the left...although my fna's were all benign for cancer, fna's are not proven to be 100% accurate and the only way to find cancer "if it's there" is to remove the entire thyroid gland (if there are abnormal cells on both sides) or one side (if there are abnormal cells on one side). Before you meet with the endocrinologist, write down every question that you want to ask and are curious about. Be sure to keep copies of your lab testings and scans for your records. Always get at least a second opinion. I had three before determing my decision. All will go well, however, be sure to stay on top and never just "let it go"....as I was told, the older we get, the harder it is to handle (i was 39 at diagnosis of Goiter w/mulitinodules) and 42 when i had the surgery. The "mass" did bother me a bit whenever i wore something over my neck but my labs were all normal and my surgeon explained that they would be.
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1181812_tn?1264624265
You shouldn't tell people to take a multi-vitamin. Most people will assume all multi's are okay. However, I made the mistake of taking a multi-vitamin with 100% DV of iodine in it. Most do contain iodine and this sent me into the most extreme tremors ever. I too have toxic multinodular goiter. However, no health insurance (new grad) and thought I would take some vitamins for the terrible Michigan winter.
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393685_tn?1325870933
Amy - I am not certain on what you are saying here to McMillian? Are you Hashimoto with a multi nodular goiter?
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393685_tn?1325870933
There are a few thoughts I'd like to add off the original post.

With the solid component of the nodule on both  - probably moving forward with the biopsy and skipping the uptake would be best. This is if you need a quicker turn around on finding out this information quicker. The other is cystic and could be hot - producing thyroid hormones in its own. If I read it right.. the left lobe is enlarged with the cystic nodule.. right? - that may be more to worry about than the right side with thyroid hormones. - even through the other side has the solid nodule.

Biospy the solid one.

Another thing I am not quite understanding on the comment back is suggesting ablation or hyperthyroid medications. I am not seeing the thought process here. I do not see anything on the additional labs posted by oscarmaya that warrents ablation quite yet. If there is discomfort or breathing difficulties with this situation then surgery would be more opted talked about than any ablations. It's clear based off the labs there is no Hashimoto in this situation - my thought here would definately have a Graves test as precaution to see that confirms anything in case of pre TED could be lurking and then for sure RAI should NOT be considered.

Your different TSH 's could be linked definately to you as a person. This is not a permanent number with anyone at all times and does change quite often through the day. Stress is a biggy. Its a measurement of pitutiary hormones and we all know hormones are not steady even in the healthiest of all people.

So is the discomfort the only thing that brought you to your doctor? - Was there any other discussions of anything else like symptoms?

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1144849_tn?1395458766
Hi Stella, oscarmaya has some newer posts regarding her situation. I believe she did have a fine needle biopsy but they could not get much to work with etc. that discussion thread is more up to date.  

In any case where there is a solid nodule, yes I agree it needs to be looked at and monitored to see if it is benign or not and if it is growing.  My comment about the Ablation, is for the Cyst if it is hyper-functioning, in my own experience, the doctor recommended ablation based on low TSH and (I think she said her  FT4 was fairly "normal") and the data from her ultrasound etc. So I was sort of outlining what was reccomended to me for the hyper-functioning cyst(s) if it turns out some of her's are.

Again I am certainly no expert but I personally have made a choice to learn as much as I can before I agree to any ablation or surgery at all, and in my case I chose to take Methiazole to counter act the effects of hyper-functioning cysts by shunting the normal thyroid production of hormone. This however is proving to be a task because most of my symptoms are Hypo anyway rather than Hyper, when the rouge nodule are not producing much hormone and the methimazole has basically shut off my thyroid it is very difficult to function, so I am questioning the wisdom of that plan.

In her case, Certainly the solid nodules need to be looked after but my point was if she had hyper-functioning nodules also, they may choose some of those other options if they were satisfied that the solid nodules were not a problem. Since the time of this post though I think that picture has changed a bit.

AmyRN29, Yes you are right I should be more clear if I am going to suggest a multi vitamin. Iodine is in every cell of the body, and I believe that an inability to easily absorb iodine or an iodine deficiency, along with heredity has a great deal to do with what causes many thyroid disorders. (my opinion)  At the time of this original post I was not as well educated about Iodine and I appreciate you pointing my comment out to me because I do personally take a multivitamin that does not contain Iodine but would probably still suggest that someone with Hashis that is hypo take a multi-vitamin that might contain iodine after they have discussed it with their doctor. People that have potential for  Hyperthyroid problems like you and I, are best to stay away from extra Iodine and probably Tyrosine too for that matter.  Thank you for your comment I will be sure to clarify in the future.

McMIllan
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649848_tn?1357751184
I've read that people with Hashi's should NOT take iodine, although I know that some do and it works for them.

I'm not "up" on the hyper side of things, but oscarmaya's Free T's do not indicate hyper.  I don't understand the need for a drug such as Methiazole, if there's no hyperactivity present.
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1153642_tn?1266257589
Thank you for all of the responses. McMillan posted to me prior to me posting additional test results so I believe that is where the confusion came from.

I have since had a thyroid scan with uptake which were both normal and a biopsy session. The endo selected 3 of the nodules to biopsy but 2 were too deep and after stabbing around in there for a while I couldn't take any more. So they only got one sample.

The one sample they got showed hurthle cells with no malignant cells showing and since they were not able to biopsy any of the others I was referred to a surgeon.

Met with the surgeon yesterday who told me "wow you have a big 'ole thyroid there" and that there are many more nodules than what the ultrasound report showed and that both sides were involved. He said it would be impossible to biopsy them all or follow them with any real degree of success so recommended total thyroidectomy. So that is where I am right now. I'm very freaked out by the idea of an operation on my neck, not sure what it involves or what to expect for recovery etc.

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1153642_tn?1266257589
Could you tell me what pre-TED is?
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393685_tn?1325870933
I don't think it is anything for you to put on your mind - but basically pre TEd - is un diagnoised Thyroid Eye Disease.

You see TED creeps up with hyperactive thyroid antibodies/ Graves... it doesn't in most cases start out as TED until later.... for most.

RAI ablation can bring on the onset of TED if you have these antibodies and if they are not found prior to RAI - the TED can become severe.

TED basically is the buldging eyes in Graves patients. It can be disfiguring for some too.

Mcmillian - that is why I intervened on this suggestion. As this post said - not her others.. Ablation was discussed and really no REAL antibody testing was done. A hyper functioning nodule doesn't have bearing persay on Graves or TED really - but precautions with ablation need to be looked at and antibody testing is in my eyes needed - prior to ablating the gland. and by the way - none of us are the experts here either... LOL

O-maya - it sounds like you have quite alot happening. This can be very unsettling. Its good to always get a second opinion - but I know you expressed an issue with losing insurance soon.

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