Rapid Diffuse Unilateral Enlargement of Thyroid (Right) With FNAC of Nodule Showing Hurthle cells

I am a 37 yr old female with two children both girls ages 7 and 16.  I have a long (14yr diagnosed) history of "intractable" Hashimoto's with intermittent significant enlargements always bilateral and never more than 7 cm at largest part, a couple thyroid storms, and many pin cushion days of hormone adjustment.  I am on .125 daily synthorid and .05 cytomel twice daily.

Feb 21, 08 on ultrasound a solitary non-papable nodule presented in right lobe with calcifications size approx .9 x .7 x .6 cm.  Diagnosis Hashi's and monitor  TSH about 12.  Add Cytomel to prescription.

One year later Feb 08, 09 second scan of now palpable nodule presents with peri-nodular flow, microcalcifications and size is stable.  Both scan showed that both lobes were not enlarged much each were approximately ~4 x ~2 x ~2.  Diagnosis Nodule and Ultrasound FNAC ordered... TSH at 4 which is clinically normal and first time TSH this low in 7 years.

March 23, 09 TSH at 9, scan and FNAC present the following characteristics....  

Thyroid is easily palpable from long standing chronic inflammation and is moderately firm.

Ultrasound

Both sides of lobe have hetergeneous echotexture with normal vascular flow.

1. Right lobe of thyroid signficantly enlarged @ 2.1 x 12.6 x 2 cm
2. Left lobe essentially same size 1.7 x 4.4 x 1.6 cm
3. A slightly enlarged adjacent lymph node identified 1 x 1.4 x .4 cm (no increased vascular flow or calcification)
4. No lymphadenopathy in bilateral anterior jugular chains
5. Two small nodules inferior to both lobes seen "may represent small lymph nodes"
6. Nodule is adjacent to carotid artery and is compressing area especially when speaking (less) or swallowing (more).
7. Nodule has some intra-nodular but mostly perinodular blood flow
8. No size change

FNAC of Nodule is performed

The FNAC was very difficult and a minimally sufficient sample was obtained after two different attempts (four total).  The procedure was also painful because they couldn't get at it easily, used a different syringe after biopsy syringe from first pass didn't work.

1. First two passes are inadequate and mostly lymphcytes.
2. Second pass shows mostly lymphcytes and "a few hurtle cells"

Of course I have symptoms from the enlargement and the now firm nodule mostly when swallowing etc.  

1. Significant irritation and some difficulty swallowing.
2. Tenderness especially in midline and right lobe.
3. More frequent severe headaches (one required hospitalization).

I have two completely different treatment recommendations from two board certified endrocrine surgeons.  I would like a Dr's perspective that is a human's perspective not a clinical one.  As in if this was you what would you do.  I don't want to be told statistics I just want to know what a recommended treatment would be (third opinion) and I really want to know the potential causes of the rapid growth of one side when I have never had that before.  

I googled unilateral goiter and some scary things relative to thyroid lymphoma and Hodgkins came up, and of course possible Hurthle cell cancer.

Final cytopathology is pending and the waiting is driving me crazy.  So maybe you can offer some additional thoughts, and I really appreciate your time in helping me with this.  No one has given me a reason for the unilateral enlargement!  Hashi's is "suspect" but it is "unsual" is what I am told.

[ChitChatNine]

We have some great members here who have some technical knowledge of ultrasound matters who may be able to help you out .. I'm not well versed but wanted to welcome you to our fine community where I'm sure you'll get some great advice!

C~
Partial Thyroidectomy 1/07

[Marin600]

Hi.  So sorry you're having these worries.  You can count on us for moral support, but if I were in your shoes, I'd ask my primary care physician---assuming that he/she has both reports and that you have a good rapport with him/her---to contact Mayo Clinic in Rochester, MN, for a consult.  Your primary provider's office can facilitate getting the info to Mayo's and they'll have a consultation with your physician.  Normally the time of the consultation call can be determined when arrangements are made for them to get your current test results, so that you can be present at the time of the consultation, and ask any questions that you may have.  They see thousands of these thyroid abnormalities (or any other condition) and I think you can trust whatever they tell you.  Many surgeons across the country have learned their specialty from training at Mayo's.  I think that they're the best of the best and cannot imagine that you'd ever regret going there, which is like going to another world.  They have all the i's dotted and all the t's crosses and can help you with every aspect of your visit with them, including where you'll stay.  If you elect not to go there, they can recommend the best place to go closer to your home.  Your travel and lodging would likely be the only expenses that your insurance won't cover, and some insurance plans cover a portion of those items.  You need an expert, and they are experts.  Anyone who has read many of my comments will tell you that I'm not keen on the medical establishment, in general, but I am very favorably impressed by Mayo's.  Please do keep us posted, and good luck to you.
Good luck, and please keep us posted.

[898]

the significant compression symptoms may rquire surgical removal of the lobe.
SOME Hurtle cells are commonly found among Hashimoto's patients, however the clusters of them and if they compose 75% of the FNAB sample can suggest Hurtle cell neoplasm which requires surgery.