# Lab results - How do you miss the thyroid and get a lymph node during a biopsy?!?



## skpatel73 (Jan 11, 2011)

So, we've gotten copies of results of bloodwork, RAIU, and ultrasounds I'd like to share, which ultimately led to a biopsy that didn't lead to any useful results.

So, our primary doc noticed my wife losing weight without trying (40 lbs of loss down to 131 lbs over 5-6 months...no diet or exercise). So, he ordered bloodwork, and going through it, these are the out-of-range items in the report:
Leukocyte esterase: 1+
Occult blood: 3+
White blood cells: 10-15 (normal range 0-5)
Red blood cells: >50 (normal range 0-5)
Creatinine: .5 (normal .6-1.3)
TSH: <.01 (normal range 0.3-5.1)
Free T4: 2.54 (expected range .73-1.95)​So, based on the bloodwork, we got referred to an endo, who said definitely hyperthyroid, and ballparked her with Graves based on the bloodwork and slightly bulging eyes, which we hadn't noticed. She ordered an RAIU test, and put her on a beta blocker (propranolol) in the meantime. The beta-blocker really help my wife with racing heart issues she had throught were normal. While waiting for the RAIU appt, my wife's eyes started to get really dry, and our eye doctor put her on restasis drops and lodemax drops.

The RAUI results were:
4 hour uptake: 13% (Normal range 5-15%)
24 hour uptake: 32% (Normal range 15-35%)​
They also found decreased activity in the lower pole of the right lobe, which may indicate a nodule. They recommended an ultrasound.​So, we got the ultrasound done. Those results were:
Findings: Echotexture is heterogenous

Right lobe: Size 7.0 x 1.9 x 2.0 cm. 
Nodules: Small circumscribed hypoechoic inferiorly measuring 9 x 4 x 3 mm

Left Lobe: Size 4.9 x 1.7 x 1.8 cm
Nodules: Circumscribed hypoechoic nodule anteriorly measuring 8 x 7 x 4 mm.
Two hypoechoic nodules in the inferior aspect measuring one 1.1 x 0.6 x 0.5 and 1.3 x 0.7 x 0.5 cm.​
So, based on the ultrasound, our doctor ordered a biopsy of the 1.3cm nodule on the left side, and the small nodule on the right side. The one on the right is the one she was concerned about because she said it didn't have very much activity based on the RAUI, which the nodules on the left were hypo, but were at 80%-ish of normal.

So, the biopsy happened. They took samples from what they thought was the nodule on the left lobe, but it later on turned out they got the lymph node instead. My wife heard them talking about thyroid, thyroid, thyroid during the procedure, so they were definitely trying to get the right thing. And they were using the ultrasound, but they somehow missed? Is that even possible with competent lab people, or is that common?

And for the nodule on the right hand side, they debated it, but said it didn't fit the "parameters" of anything, and that it was too close to the carotid (sp?) artery, so they didn't feel comfortable trying to get it. They recommended monitoring it instead.

So, going back to our endo, she was disappointed that they couldn't get the biopsy on the right side nodule, because that is the one that was really cold, which indicates it could be cancerous. She was surprised they got the lymph node on the left side nodules, but wasn't too concerned about it since that side had decent activity, which would indicate those are not cancer.

Anyway, she prescribed methimazole for her, and we are going to do monthly blood tests for a while until the medication is tuned in right. And we'll redo the ultra-sound in 6 months. And no new try at a biopsy.

So, that's where we are at. We're kind of at a loss with the whole missed-the-thyroid-and-got-a-lymph-node thing. Does this sequence of events sound right to everyone here? Is our doctor missing something? Are the lab guys completely incompetent? Should we be looking for another doctor or a second opinion? Does the treatment sound reasonable?


----------



## Andros (Aug 26, 2009)

skpatel73 said:


> So, we've gotten copies of results of bloodwork, RAIU, and ultrasounds I'd like to share, which ultimately led to a biopsy that didn't lead to any useful results.
> 
> So, our primary doc noticed my wife losing weight without trying (40 lbs of loss down to 131 lbs over 5-6 months...no diet or exercise). So, he ordered bloodwork, and going through it, these are the out-of-range items in the report:
> Leukocyte esterase: 1+
> ...


Good grief! Let me ask you this? Did they in fact get a sample from the lymph node and did they send that to pathology?

I don't know what to say to you. I do know that a cold nodule is highly suspicious for cancer. I also know that cancer and Graves'/Hyperthyroid are bedfellows.

Graves' and Hashi's cancer
http://www.thyroidmanager.org/Chapter18/18-cancothr.htm

Given what I know to be true; I would definitely be concerned about "trying" to get another FNA done in the near future.

By the way; on the results of the RAIU, did not the radiologist make a recommendation?


----------



## skpatel73 (Jan 11, 2011)

They thought they got thyroid cells and sent them off to pathology. The report came back and said they got lymph node cells. Our doctor tried to play that off as something that is easy to mess up.

The RAIU findings were:
1. Questionable nodule in the lower pole of the right lobe. Thyroid ultrasound recommended to further characterize this finding.
2. Thyroid uptake is in the upper normal range.​Basically, the endo was saying that the nodules on the left were operating at about 80% functionality...so cold, but not really cold. She said for cancer it had to be really cold...closer to 0%. According to her, the small nodule on the right is the one that is really cold and is the real cancer risk.

The RAIU recommended a thyroid ultrasound. The ultrasound findings were:
Prominent, heterogeneous appearing thyroid glnd with 4 discrete nodules identified, measuring up to 1.3 cm. Recommend follow-up ultrasound in approximately 6 months to ensure stability, if clinically warranted.​
We're going to go back to our primary doc with these lab results and ask him if there is another endo he can recommend for us. On the one hand, the RAUI/ultrasound results didn't recommend biopsy, but on the other hand, its kind of disturbing that having gotten a biopsy, it got so screwed up.


----------



## Andros (Aug 26, 2009)

skpatel73 said:


> They thought they got thyroid cells and sent them off to pathology. The report came back and said they got lymph node cells. Our doctor tried to play that off as something that is easy to mess up.
> 
> The RAIU findings were:
> 1. Questionable nodule in the lower pole of the right lobe. Thyroid ultrasound recommended to further characterize this finding.
> ...


That is what I wondered. (RAIU recommending FNA) Hmmmmmmmmmm!! Strange because they should have.

I do believe you have run across some incompetence here. Not exactly reassuring and comforting.

And to think we have to pay the bill anyway! This really irks me no end.

I agree about getting fresh eyes and fresh opinion. Please let us know.

What is your wife's Thyroglobulin Ab level?

Thyroglobulin Ab and cancer
http://qjmed.oxfordjournals.org/content/59/2/429.full.pdf

Another Thyroglobulin and cancer
http://www.mdlinx.com/endocrinology...963/?news_id=811&newsdt=092010&subspec_id=419


----------



## midgetmaid (Jul 22, 2010)

I'd get a second opinion.

Renee


----------



## lainey (Aug 26, 2010)

There are about 600 lymph nodes in the neck--did anyone ever suggest that perhaps one of the "nodules" was in fact an enlarged lymph node? In that case, perhaps they didn't really miss it on the biopsy, but misread it on the sonogram?

All of the nodules are quite small, which lends itself unfortuantely to the situation that you have, which is a biopsy with indeterminate results.

Small comfort, but with multiple nodules, cancer risk is really pretty low to start with. Your wife's more immediate danger is that her hyperthyroidism come under control with medication quickly.

I think the end result is at some point in the future, you will be asked to consider what you want to "do" about her thryoid itself, simply because antithyroid drugs are not to be taken forever, and unless she goes into remission, you will likely need to explore options for ablating the gland. The situation with the nodules may hasten that decision.


----------

