TOO MANY OPTIONS - PLEASE ADVISE

[stella5349]

Dear Dr Lupo,

Here are the questions I would appreciate some guidance on. It seems I am totally confused on how to go and need your opinion desperately.

A short background on my thyroid disorder. 2003 Dx/Graves - 2004 RAI - present Hypothyroid (3/2008 sub clinical 3.34) medically induced. Taking Armour meds since Oct 2007.  Feb 2008 I requested an ultra sound due to "feeling of something stuck in throat"  In the past have I expressed this with 2 endos- GI - ENT and many MD/PA's

Results/ Findings : on Feb 2008 US -  The right lobe measures 2.2c1.0c0.9cm It has mildly heterogeneous echo texture and margins are indistinct. There is an increase vascularity associated with it . Left lobe measures 3.4x1.6x0.9 cm In lower left pole well circumscribed oval isoechoic nodule 11x10x8 . Mildly increased vascularity. Remainder of left lobe /mildly heterogeneous echo texture. Isthmus appears quite atrophic.  There does not appear to be a mass effect by the thyroid or the left thyroid nodule upon adjacent strictures. Decreased size of the thyroid due to RAI or thyroiditis.

Solitary 1cc solid nodule in the lower left pole. It's isoechoic echo texture suggests benign lesion, but amenable to US-guided FNA if desired.

Attempt an FNA - March 3

Findings: Multiple attempts made at location with US guided needle biopsy but due to the deep posterior location and size I (the radiologist) was unsure if the needle tip was in the lesion itself. (this report just goes on on how he could not obtain a sample after 7 agonizing tries.)  He does note at the bottom that "Note is made that the lesion may represent a parathyroid adenoma."

Due to further tests the hyperparathyroid situation is not an issue. I had all the appropriate tests:
VitD (37.5),  (2) serum (9.3and9.5) and ionized calcium(1.26), phosphorus(3.5) PTH (25) all coming back normal.

During the FNA procedure they radiologist (s) and the US tech urged me not to continue the procedure due to the their thoughts of the parathyroid issue. It was the most traumatic biopsy anyone could have had and took over 30 minutes to finally stop trying. I was bruised from my Adam's apple to left collarbone and the pain during the attempt was unbelievable.  The FNA report goes on the say the due to the nodule being in the posterior left lobe adjacent to the carotid artery FNA is very risky to achieve a sample. After the FNA attempt I suffered 72hrs of complete hyperactivity and was told that may be due to the probing,

TSH or PTH (if parathyroid) may be leaking out into the blood stream.


From the US reports - what are your feelings about the nodule itself?
Should I be "overly concerned this is cancer by what the first US report says? (solid 1cc) RAI/2004 etc.
Due to the deep lesion and an attempt made with no success - should surgery be optional instead of a second FNA?
Can a nodule still produce TSH if the thyroid is in a hypo state due to RAI and medication induced?
Should a CT/MRI scan be preformed to determine a hot or cold status to the nodule prior to a risky second attempt with another FNA?


I am so unsure who to listen to- I have so many doctors and none of them are communicating with each other.

MD is not concerned on the findings of the original report. (wait and see approach)
ENT surgeon says I am a greater risk of it being cancer due to RAI - from the first report. urged FNA and ordered.
Radiologist states parathyroidism / do not advise another attempt-  (he even went as far to say - quote: "If you were my sister - this procedure would have never been done!"
Endo says nothing except repeat biopsy in 4 weeks and quit being anxious. ( not a very personable doctor)

What would you suggest?

[Mark Lupo, M.D.]

yes, 11mm was in the body text, 1cm in the conclusion - these are essentially the same as 10mm = 1cm.  By 1 "cc"  I assumed you meant 1cm.

[stella5349]

I looked back and it is a 1cm solid nodule.

[Mark Lupo, M.D.]

The nodule/thyroid does not produce TSH - that comes from the pituitary....also, you have had RAI, so it is unlikely there's thyroid hormone that could have "leaked" post FNA.  PTH leak is not likley either.  May have been post-traumatic symptoms for 72 hours.  It should not be that hard to FNA a nodule -- consider repeat by a thyroid specialist OR observation for change in size -- 11mm is not that large but follow-up or repeat FNA is necessary...would be reluctant to go for surgery at this point.