I have tried to answer several posts regarding pain and swelling of the nodule after the FNA . Below is the example of similar case that went wrong:
A forty year old lady with an unremarkable history [...] presented with a ten year history of thyroid nodules, the largest of which being in her right lobe. She was asymptomatic with thyroid function within normal limits. She had regular thyroid ultrasounds and one previous needle aspiration four years ago.
All tests indicated a diagnosis of “multinodular colloid-cystic goiter”.
Last year the patient had a thyroid ultrasound with the following results: “Slightly dysmorphic thyroid due to the size of the right lobe which has a 3.8 cm colloid cyst formation with a solid part of 15 mm on the anterior side. A needle aspiration biopsy is advised in the solid part for evacuation and diagnostic purposes. In the right lobe and isthmus there are at least three other adenomatous hyperplastic nodules of 9, 10 and 12 mm respectively. The structure is homogeneous in the left thyroid lobe. There is no lymphadenopathy.”
As recommended a needle aspiration was carried out. The biopsy showed a “hemorrhagic colloid nodule with a solid part anterior to the right thyroid lobe”.
Immediately after the needle aspiration was performed, swelling appeared in the nodule on the right lobe. The patient reported that the swelling developed to the size of a “tangerine” and with this dyspnea which worsened on lying supine.
She informed the physician who had performed the procedure and a repeat ultrasound was performed. Given the considerable increase in size of the nodule, the endocrinologist advised that therapy should be started immediately with thyroxine.
The patient was did not wish to take the therapy, so she had another ultrasound performed at another center where she was seen by another endocrinologist. He aspirated bloody serum from the nodule and the swelling promptly subsided.
However, as predicted by the endocrinologist, the swelling gradually reoccured, resulting in the patient consulting with various specialists. They have provided various options including a hemithyroidectomy, a total thyroidectomy, removal of the single nodule and thyroxine therapy.
It should be emphasized that the patient is not in favour of taking the hormone therapy for the rest of her life.
1) What therapies do you recommend?
2) What is the prognosis?
3) Where are the centres of excellence for this condition?
The expert´s opinion :
I had the pleasure of reviewing this case in order to provide for a second opinion.
Unfortunately, her ultrasound (US) images were not clear and my comments are only based on the historical information that is provided to me.
I will review the provided information first: The patient is 40 years old female with a
several year history of a multinodular goiter. She did not have any clinical or
biochemical evidence of hypo or hyperthyroidism. Four years ago, she underwent a fine needle aspiration of the dominant right sided nodule. It is unclear if only one nodule was aspirated or multiple nodules were tested for malignancy. The final conclusion was that it was a multinodular colloid-cystic goiter.
Also, it is unclear if the patient was on any anti coagulation therapy or had any known bleeding disorders. She underwent a repeat fine needle aspiration of the right dominant thyroid nodule that was consistent with a “hemorrhagic colloid nodule”.
Immediately post aspiration she had an increase in the size of the neck associated with dyspnea. She was seen at another center and hemorrhagic fluid was drained from the right side leading to reduction in the nodule size with substantial symptomatic improvement. However, swelling recurred and now the question is how to proceed. She has been asked to consider hemithyroidectomy or total thyroidectomy. Another opinion is to use thyroxine supplementation. The patient is not in favor of taking any thyroid supplementation for the rest of her life.
1. What therapies do you suggest?
My clinical impression is that patient had bleeding during procedure (FNA) leading to a sudden increase in the size of the nodule compressing the trachea causing dyspnea. The symptoms were relieved with cyst aspiration but there was re-accumulation of fluid within a short period of time.
There is no definite evidence that supplementation of levothyroxine will lead to significant reduction in the size in a mixed cystic-solid thyroid nodule. The levothyroxine supplementation in my mind is only required if patient has clinical and biochemical evidence of hypothyroidism. I would check that by testing her thyroid function tests.
As far as the treatment for thyroid cystic nodule is concerned, there are few possibilities.
If patient has persistent compressive symptoms like dyspnea, swallowing difficulty etc then she should consider re-aspiration of fluid vs. hemi-thyroidectomy.
My feeling is that right hemithyroidectomy is more appropriate for the following reasons:
-It will preserve the left lobe of the gland which will be enough to keep her euthyroid (though that will need to be monitored post operatively)
-it will remove the abnormal lobe with multiple nodules and hence will not require close monitoring
-it will give a definite diagnosis of these nodules.
The disadvantage is that it is more aggressive therapy, will require hospitalization, may make her permanently hypothyroid (unlikely, unless left side is also involved).
The advantage of cyst aspiration is that it is fairly straightforward; however, the disadvantage is that there is a risk of bleeding and there is likelihood that there will be re-accumulation of fluid within a short period of time.
Total thyroidectomy should only be considered if the whole gland is affected. In that case she would require life-long levo-thyroxine supplementation.
Cystic nodules that have a definite capsule can sometimes be treated with alcohol injections. In the United States we do not have much experience with this procedure but this is relatively common in Italy. I would defer that decision to the local endocrinologists as we do not have much experience with the procedure.
If patient does not have any symptoms but the size of the nodule is increasing then she should consider right hemithyroidectomy. On the other hand, if the size of the nodule is decreasing then patient can be monitored with serial ultrasounds and monitoring her TSH to ensure biochemical euthyroid status. However, in that case these nodules need to be monitored for malignancy and compressive symptoms.
Finally, it should be ensured that patient is not on any anti-coagulation therapy and does not have any bleeding disorder.
Excellent, with appropriate treatment.
3. What are the Centres of excellence for this condition?
In the United States, University of Pennsylvania ( Philadelphia, Pennsylvania), Johns
Hopkins University ( Baltimore, Maryland), Mayo Clinic ( Rochester, Minnesota).
Thanks to these who read this article to the end.
I am adding some notes;
As in most complex cysts the soled matter lies next to the wall of the cyst, the needle must be inserted from that side to minimize travel trough the fluid portion.[ultrasound MUST be used with this]
Cysts with thin walls or longstanding ones are poorly responding to PEI procedure.
Unlike under skin bleeding that follows bumps and bruises, the intranodular bleeding does not cause skin discoloration, however the home treatment should be similar in both cases [unless it is same as described in the article]
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