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Any help with these results is appreciated I understa

Any help with ultrasound report appreciated. I understand part but not all. I was sent after having tsh level at 0.07 and free t4 and t3 that were normal. They have put in urgent for referral to more than likely have biopsies .
Us results:
History: abnormal try
Thyroid ultrasound with color Doppler
Comparison: none
Findings: the isthmus measures about 2mm in width. The right lobe measures 4.0x2.4x1.5cm. A large heterogeneously hypoechoic solid nodule measures 3.0x2.1x1.3cm with internal vascularity.

The left lobe measures 3.7x1.3x1.2cm. A hypoechoic nodule in the midpole measures about 7x7x5mm . An adjacent similar hypoechoic solid nodule measures 5x5x3mm.

Impression: solid bilateral thyroid nodules. The largest on the right measures up to 3.0cm.

I'm 48 and a smoker. Had a tsh level of .23 year or so ago but was told to not worry about it. I don't understand if the heterogeneous part means it's location or if it's to do with shape? Any one think this is just graves or hashmoto disease?
Thank you in advance for any help
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Avatar universal
Hi Darmstrong72,

If you haven't already met with your doctor to discuss these results, I'll try to help clarify what the ultrasound means for you.

TSH 0.07 is low, which might indicate hyperthyroidism (too much thyroid hormone), however free T4 and free T3 are normal (although they might be on the high side of normal).  Hyperthyroidism is often associated with Graves disease, or a hyperfunctioning thyroid nodule  (also called a "hot nodule", a nodule that produces a lot of thyroid hormone).  I would not worry about TSH unless you are having symptoms of hyperthyroidism (anxiety, fast or irregular heartbeat, trouble sleeping, etc.).  If you wanted to share you free T3 and free T4 results with the test range listed, that can help some people figure out if you might have hyperthyroidism as well as list any symptoms you are experiencing.  If your doctors think that one of the nodules might be causing hyperthyroidism, there are some imaging tests they can do to see if it is "hot".  Hot nodules are usually not cancerous

As for your ultrasound results, your thyroid size is about normal (towards the small size of normal) and since they haven't made notes about the texture, it probably a normal texture (sometimes Graves or Hashimoto's can be detected by a heterogeneous texture of the entire thyroid).  

Thyroid nodules are very common, and often don't have anything to do with thyroid hormone or TSH levels. Hashimoto's or Graves can cause a multinodular goiter (whole thyroid is larger than normal and full of nodules), but that doesn't sound like what you have.  I was told by my ENT that 30% of women in their 30s have nodules, 40% of women in their 40s, 50% or women in their 50s, etc, so it is very, very common for a woman to have some nodules.  The majority of thyroid nodules are benign (90-95% are benign).  But, based on some factors (size, texture, and vascularity), the risk of cancer increases (this doesn't mean you have cancer!  But I will point out why they need to biopsy.)

Heterogenously hypoechoic solid nodule - this is the one to be concerned about and to do a biopsy on.  Heterogeneously means the texture is not consistent throughout the nodule itself.  Hypoechoic means the texture of the nodule appears darker on the ultrasound than the surrounding tissue.  Hypoechoic nodules have a greater chance of being malignant.  Since the nodule is heterogenous, this means parts are hypoechoic or darker, other parts of the nodule are probably similar to the rest of your thyroid, this makes it more suspicious than if it was a solid texture.  Internal vascularity means they can see blood flow inside the nodule, and this also increases the chance of being malignant.  Most smaller nodules (less than 1 cm or sometimes less than 1.5 cm) will not be biopsied because the chance of cancer increases once they are above about 2cm.  So because of size alone (3.0cm) the large nodule on the right lobe will need to be biopsied by a fine needle biopsy.

The two smaller nodules on the left lobe are both less than 1 cm each, and it is unlikely they will be biopsied (although they will probably want to monitor by ultrasound sometime in the future (1 year, 2 years?) to see if they change in size.

Again, I want to stress that there is still a low chance that your nodule is malignant, but it is important to check it out to make sure it is benign. If it comes back benign, they may recommend you have follow-up ultrasounds every so often to see if anything changes.

Good luck and take care,
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Thank you. I don't have the T3 and T4 results handy. Would they put heterogeneously if there was calcification or would they state that?  And is there a difference in intra nodular vascularity and internal vascularity? And also what is marked mean on ultrasound? Do they use term marked hypoechoic or just hypoechoic? I understand the heterogeneously part better . Thank you so much for your help. I have done a lot of reading since this all started a month ago but it is all so confusing.  I have found past results of tsh at 0.2 and 0.1 Spanning up to 4 years it had been that low and nothing ever done. Your help with all the questions is much appreciated. Also they didn't include a TIRADS score on report they gave me...
No problem - I learned how to read ultrasounds after my own in 2018.

They would put calcifications on the ultrasound if that is what they saw.  Sometimes nodules are heterogeneous with cystic components, which means part of the nodule is fluid filled and part is solid, but it would most likely say that if that is what they saw.

Internal vascularity was describing the nodule, so that means there is internal vascularity inside the nodule, which would be the same as intra nodular vascularity, that's just a different way to describe it.  

"Marked"  - I just looked this up, I assumed it meant the same thing but apparently does not.  From this paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781256/  They defined marked hypoechoic (or markedly hypoechoic) as: lower echogenicity than the adjacent strap muscles.  I think that means marked hypoechoic is darker than just "hypoechoic", and is used to classify nodules.  If you look at the rest of that paper which talks about a lot of different risk factors for determining whether to do a biopsy or surgery, I wouldn't draw any conclusions about your nodules.  Just having some factors that they describe as higher risk does not mean it is cancer.

I was never given a TIRADS score myself.  On the ultrasound, I had a ton of nodules (multinodular goiter), only one was hypoechoic at 1.3 cm in diameter, and a different one was larger (2.3 or 2.7 cm, I don't remember the size).  The hypoechoic one was give a "risk" category of higher risk, with a 25% likelihood of cancer, but I'm not sure how accurate that is, and the criteria for doing a biopsy varies from hospital to hospital.  (Usually the nodule has to be at least 1.5-2cm unless there are more suspicious factors like hypoechoic, then some hospitals will do a biopsy at 1 cm.)

I had a biopsy, the hypoechoic one came back still suspicious, we did Afirma genetic testing on it, it was still suspicious, so I had a lobectomy, turns out 3 nodules were cancerous so I had the other half of my thyroid removed, but I'm lucky that the cancer hadn't left the thyroid, I didn't need radioactive iodine, and the cancer was gone after that first surgery.

Just because my hypoechoic turned out to be cancer doesn't mean yours is.  My whole thyroid was full of nodules, so my experience is going to be different than someone who has just a few. My aunt has thyroid nodules (not as many as I had, she has had some since she was 15, she's 60 now).  She has some with calcifications, internal vascularity, irregular margins, hypoechoic, above 2 cm in size, all of which make it higher in the "chance of cancer" ratings, but every biopsy she has had comes back as benign, so just having those risk factors doesn't mean it is cancer.  But they do mean getting a biopsy is a good idea, to make sure that it is benign, and if not, decide what the next step is.

Good luck - and I hope the biopsy goes well for you.  I know the waiting for the biopsy and results from the biopsy can be very stressful - it was for me.  Until they do the biopsy and give you results, I would not assume anything about the nodule, even certain factors put it in a higher risk category.  I know sometimes that can be easier said than done though.

Thank you hun.  I am kinda scared of fact that I also had hypotrophy ( I think that's what they called it) of my left adrenal gland and I have lymphadenapathy for years now that has had doctors baffled.  So I can't help but wonder if this has been cause all along
I don't know too much about hypotrophy in the adrenal glands, so I'm not sure if there is a thyroid connection or not.

Is your lymphadenopathy located in the neck?  I can only speak from my own swollen lymph node experience.  When they pulled out my thyroid (the first half) there were three swollen lymph nodes they also took out, all three negative for cancer.  When they took out the other half of the thyroid 2 months later, they pulled out another 11 lymph nodes, three stuck to the thyroid itself and 8 in a massive clump.  All negative for cancer.  This is apparently common in people with Hashimoto's (or people with  chronic, untreated Hashimoto's as mine was), my immune system was destroying my thyroid and this caused a lot of neck inflammation and a lot of swollen lymph nodes.  When I had the second half of my thyroid removed (and lots of lymph nodes) I felt the tightness and inflammation that I hadn't noticed was there but apparently was, was gone.  My healing after the second surgery was much faster, I stayed on pain meds for a shorter period of time, I didn't have the same pouchiness at the base of my throat that I had from the first surgery.    My immune system really, really did not want my thyroid to be there.

I am very thankful that my mom "forgot" to tell me after the first surgery that lymph nodes were also removed, because I would have been terrified for that week before I got my pathology back that the lymph nodes were cancerous and that I had thyroid cancer that had spread.(I didn't know that it was cancer until about 2 weeks after the surgery, there was so much inflammation in my thyroid that they had to send the pathology to a  different hospital for a second/expert opinion). I did not worry at all about the second batch of lymph nodes because I knew there would be some swollen ones and odds were low that they'd contain cancer cells.

I'm not a medical professional and I'm sure your doctors are doing everything they can to investigate your lymphadenopathy, but have they ruled out autoimmune diseases?  Doctors seem to be reluctant to test for Graves or Hashimoto's unless you have abnormal thyroid hormone levels, and I had to ask to get my doctor to reluctantly test for Hashimoto's, despite having a multinodular goiter, which is a giant red flag that something is wrong with my thyroid.  If you haven't yet been tested, since your TSH is a little low, your doctor might be willing to test for Graves (or both Graves and Hashi's).  It is an antibody blood test.  There are also many other autoimmune disorders that can cause lymph nodes to swell and stay swollen.

I'm so sorry you're going through this now... I was more stressed out about my thyroid and the possibility of surgery during the early stages (ultrasound, biopsy, genetic testing), once the surgery was scheduled, even though I didn't really like that I needed surgery or the idea that I might have cancer, I had a plan and knew what was going to happen next and felt less anxious.
Yesterday I saw specialist which was suppose to be consultation but after he viewed it on ultrasound he decided that it would be best to remove it all. Turns out there were alot on the left where only two were noted. He went ahead and did biopsy on the large one on the right. They have me scheduled for surgery on next Friday the 8th unless get bad results on biopsy . Then they will do it before then. I was a bit shocked yesterday that things went so fast I think it might be why I almost passed out and became extremely nausea midway into the FNA. It wasn't really painful I think my bp dropped drastically idk. They say it happens alot
I'm so sorry to hear you need surgery!  My first surgery was scheduled for 2 months after the biopsy, so even if it is thyroid cancer (which they don't know yet, and might not know until after the surgery), it is usually very slow growing.

FNA biopsy experience ... I had at least two nodules tested with two biopsies on each nodule (and then the suspicious one we did another biopsy to send for genetic testing after I got the results back, and I thought I was all done with needles - my biopsy doctor did the pathology himself right away and could give me the results and send it off to Afirma at one appointment - I do not think this is common though).  We were supposed to go out to eat after the biopsy and I was in tears in the car with my mom driving me home so we did not go out to eat.  The local anesthesia I was given for the biopsy was quite painful, and one of my nodules was off to the side of my neck so he had to go through muscle to do the biopsy - holy cow that one was very, very painful.  I've had a bunch of blood draws and intramuscular injections since then that I barely feel at all, and I have to say jabbing needles repeatedly into my neck was not my favorite part of the whole experience.  The IV for surgery has been done in my hand at my thumb/wrist - and that is also "very painful" for me.  I screamed out loud last surgery (July 2020 - 2nd fibroid surgery of the year) and ended up apologizing profusely to the person who did the IV.  My bp is always high at any doctor's office or dentist (I check it at home sometimes and it is fine) -- I think part of me is scared of doctors, part of me is scared of failing tests, and I 100% always fail the "have a normal blood pressure test at the doctor's office" test.  

The time between my biopsies and actually being scheduled for surgery, I was so anxious because I did not know if I would need surgery or not.  I found out my Afirma results (genetic testing) were back when my ENT (surgeon)'s office called to schedule my surgery, while I was shopping in Target, and did not know if it came back as suspicious or malignant, just that I needed surgery.  It was suspicious, so I went in to surgery mostly convinced that it was not cancerous but we just needed to remove it to make sure (so I was surprised that it came back as cancer, but it was also removed at that point - so it was a very odd "I had cancer but now that I know it is already gone" feeling for me).

As for being worried about lots of nodules... everyone is different and I do not know what your experience will be, but I can share my experience.  I had a multinodular goiter with many, many nodules.  My biopsy doctor described it as "lots of nodules growing into eachother".  My right lobe (which was removed first, the one with the cancerous nodules) had at least 8 nodules, all about 1 cm diameter.  3 of those were "cancerous", but none had spread outside the thyroid.  We didn't learn that it was cancer until about 2 weeks after the surgery, and my ENT had tried to save my remaining thyroid tissue so I wouldn't be fully dependent on thyroid hormone.  Once we learned it was three nodules and not just one, we removed the rest (2 months later).  Biopsy was in April, surgery 1 in June, surgery 2 in August (2018).  

The left lobe did not contain any cancerous nodules (also was full of nodules though, the largest one was ab0ut 2cm).  I have Hashimoto's and there was significant inflammation and a lot of lymph nodes removed, but no cancer had spread!  My ENT thought I would need radioactive iodine, since I had three cancerous nodules, but my endocrinologist decided to just do "cancer monitoring" since pathology showed no evidence it had spread.  So far 2 years later my thyroglobulin levels continue to be very low (indicating no thyroid tissue is growing in my body).  Having a lot of nodules does not necessarily mean any of them are cancerous.

Good luck with your surgery, I hope it goes well for you!  I know this was probably not the news you were hoping for, but as someone on the other side, I can tell you I am a lot stronger than I thought I was in April 2018,

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