Symptoms Ignored because of age?

[Adepta]

Hi, I have a fam history of thyroid cancer (grandmother at age 28, I am currently 25) which I mentioned to my GYN at the age of 16 and from there was recommended to be on watch for any changes. By age 21 I was referred to ultrasound due to symptoms. At the time they found a single oval-shaped 5mm hypoechoic nodule in the medial left parenchyma which was serrated (?). My TSH, FT3 and FT4 were all within normal limits. I was referred to an ENT to possibly do a FNA and get a better answer. They refused the FNA citing the nodule was too small and decided to 'wait and see' claiming that it was extremely rare for any adenoma under 1cm to be cancerous and claimed it would go away and they would do an ultrasound in 6 months. This cycle repeated for about two years. Last January during my 'checkup' they found a second, 5mm hypoechoic nodule on the right anterior medial lateral parenchymal margin, also oval in shape, and the first had not changed in size. Thyroid panels were still normal. By this time I had developed an on and off hoarseness in my voice, still watch and wait. Last November I randomly developed painless cervical lymphadenopathy. I ignored it until this February when I noticed not only were the nodes larger, they spread. Full blood workup came back normal (with some exceptions: a thrombocyte count at 500 for 4/mo.) Another ultrasound read that my entire L posterior cervical chain, most of the L deep cervical chain, and the lowest node of the R posterior cervical chain all within 1.2 to 1.9 cm, most very elongated, and one just below the sternocleidomastoid on the L deep cervical chain just inferior to the jawline was 1.1 x 0.7 x 1.2cm. All with increased doppler flow around the margins. The thyroid nodules had increased by about a millimeter or two. After excisional biopsy, results revealed a diagnosis of "focal, sinus histiocytosis." ie reactive. I have not seen/spoken to my actual doctor since. I need to know what they're reactive to. (I am pre-med eg lingo)

[Adepta]

The nodules have two suspicious features (three if you count the fact that they're cold,) but again they won't FNA due to size. I have been pressing the doctors to do TPO and Tg for three years now, they refuse to do them because I "do not look like a Hashimoto's patient." Should I continue to press? I called patient advocates, my doctors are not returning my calls.

[Mark Lupo, M.D.]

PET is not very helpful for the evaluation of thyroid nodules.
Current guidelines would recommend ultrasound followup of the nodules and FNA biopsy if the reach >1cm and have any suspicious features.

The most common cause of reactive lymph nodes to a thyroid problem is Hashimoto's -- so would consider a TPO and Tg antibody test.

[Adepta]

Since I kind of ran out of room, the full question should have been given that sinus histiocytosis in a lymph node is (given what a histiocyte is) caused by bits of tissue being carried with the lymph at an accelerated rate, what's the chance that the lymph nodes in question are "reacting" to my thyroid? I'm aware the anterior thyroid does drain to one of the chains that contain confirmed adenopathy according to US.

I also already understand that the lymph nodes themselves are benign (thankfully,) that was never my concern. My true worry is, again due to strong family history, that I have a metastatic cancer. I'm not trying to get my ENT to do a complete thyroidectomy or some such, that would be going overboard, but if he'd put any effort into looking into this I'd be much more confident in my chances. I understand there are some imaging techniques such as the PET which are better able to determine cancers without doing bodily damage, would that be asking far too much?

[Mark Lupo, M.D.]

reactive lymph nodes are common -- often due to virus, sinusitis, dental problems. etc.  The ultrasound description was most c/w benign nodes.

The thyroid nodules are still on the small side to FNA, though tecnically possible.  Even small nodules can be cancer, but we usually do not FNA until they are about 8mm.

The more difficult issue to follow is that of the lymph nodes -- numerous reactive nodes can be tough to track over time even with good ultrasound.  Sometimes a CT scan can help complement the US in this setting.  Would ask your ENT how to go about following these.

[Adepta]

I forgot to mention the nodes were biopsied, not the thyroid, they still refuse to do the FNA.