# Thyroid Nodule - Odd problem



## dantetila (Jul 24, 2010)

Hi all,

I'm not sure if anybody remembers my posts (24 year old male with Celiac Disease), but basically what happened was:

July Ultrasound (Initial Consult with Endo Dr to check Thyroid after Celiac Diagnosis): 8mm hypoechoic nodule found on left lobe, FNA scheduled due to family history of thyroid cancer.

August Ultrasound (Prebiopsy for FNA): 8mm nodule disappeared, new 6mm hypoechoic ill defined nodule of right lobe is found...too small to biopsy.

Sept Ultrasound (This was scheduled by a different doctor, due to palpable lymph nodes in neck): 6mm nodule on right lobe has disappeared as well. No nodules found on either lobes.

Nov Ultrasound (Followup for Lymph nodes): 8mm nodule found on left lobe, 6mm found on right nodule.

These nodules are in same positions as original U/S's. How can this be? How can they disappear and then reappear? I know human error is common, but twice at different labs? I know since they didn't grow, I have nothing to worry about, but I'm just curious if others have experienced this.

Thanks!


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## lainey (Aug 26, 2010)

Yes, it is common for nodules to come and go, and sometimes even those of a larger size.

Yes, human error could be part of the problem with different ultrasounds done by different technicians.

Did each technician have the report from the prior ultrasound to work from? The nodules were quite small, and in each case the old report would be helpful to the new technician, so that they could locate and measure the correct nodule.

When you go for followup in the future, you should have your previous records for comparison.


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## Andros (Aug 26, 2009)

dantetila said:


> Hi all,
> 
> I'm not sure if anybody remembers my posts (24 year old male with Celiac Disease), but basically what happened was:
> 
> ...


Good to hear from you! It's too bad they won't give you a RAIU (radioactive uptake scan.) From my experience, nodules don't disappear and then reappear.

What does your thyroid panel look like now? Have they done any antibodies' tests?


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## GD Women (Mar 5, 2007)

"can thyroid nodules disappear and then reappear"

FYI:

Most solid thyroid nodules generally will not shrink spontaneously and completely disappear. Patients with a hemorrhage into a thyroid nodule may commonly experience reduction in size of the expanded nodule once the hemorrhage resolves. Similarly, patients with a nodular variant of Hashimoto's disease may notice nodules gradually getting bigger or smaller. Nevertheless, the majority of solid nodules remain persistent and detectable for many years.

http://www.mythyroid.com/thyroidnodules.html

Thyroxine suppression is not always effective in preventing further thyroid nodule enlargement. In fact whereas some studies show that 25-50 % of patients taking thyroid hormone will have shrinkage of thyroid nodules, other studies do not show major reduction of nodule size in patients on thyroxine. http://www.mythyroid.com/thyroidnodules.html

Several studies reveal that suppression with thyroid hormone does not decrease the size of thyroid nodules. Therefore, unless a nodule is growing or becoming symptomatic, it is not necessary to suppress the nodule. In addition, suppression of a thyroid nodule would require long-term thyroid-stimulating hormone (TSH) suppression, potentially increasing the risk of osteoporosis in these patients.

http://www.endocrineweb.com/conditions/thyroid/fine-needle-biopsy-thyroid-nodules

Levothyroxine does not seem to benefit most people with thyroid nodules, and can cause serious complications. Complications include heart problems and loss of bone density. http://www.endocrinesurgery.ucla.edu/patient_education_adm_thyroid_nodule.html

For many years, patients with nodules were often advised to take thyroid hormone (thyroxine) indefinitely to shrink or prevent further nodule growth. Indeed, many studies show that most nodules, but not all, will exhibit some degree of size reduction after a year or so on thyroxine. However, the nodules do not usually go away, and the need for follow-up and occasional repeat biopsy remains the same. Furthermore, some studies (Slow growth of benign thyroid nodules after menopause: no need for long-term thyroxine suppressive therapy in post-menopausal women. J Endocrinol Invest. 2004 Jan;27(1):31-6) show that nodules may not increase in size, even in the absence of thyroxine. The advantages and disadvantages of thyroxine therapy for nodules should be discussed with a physician and may vary, depending on nodule size, the TSH, and other factors.

http://www.mythyroid.com/thyroidnodules.html


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## dantetila (Jul 24, 2010)

Good to hear from you too Andros and thanks everybody for the quick responses.

I have had the ultrasounds done at the same lab on 3/4, except for the prebiopsy which I had to have done at the hospital (no choice). I did bring the CD with the previous images/reports to the hospital though, so they had everything. Other than the prebiopsy, all the U/S's have been done by the same tech and reviewed by the same two radiologists at their lab. That is why I'm so confused about it all.

As for my Thyroid panel, my endocrinologist doesn't feel I have any thyroid issues since nodules are common, so he hasn't retested anything but my TSH since I last spoke to you. My last Free T4 was midrange of normal and my Free T3 was at the high end of normal, 5.3 I think. My TSH was retested a few weeks ago and was 1.6, which is good. My GI doctor wrote down on my medical history chart as having Multinodular Thyroid Disease and noted that I should be followed every 6/12 months to ensure my thyroid levels don't change since Celiac Disease raises my risks. I have never heard of Multinodular Thyroid Disease, but how can he write me down as having this since my levels are normal. Not that it matters since this is just his personal history notes on me, but I was curious.

Thanks again for the info everybody, I'll let you know if I hear anything else.


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## lainey (Aug 26, 2010)

A little more reading for you regarding nodules and ultrasonagraphy. As you can see, there is plenty of error that can be expected of this test on the part of the technician.

From Thyroidmanger.org--spontaneous regression of a thyroid adenoma (nodule) can occur:

http://www.thyroidmanager.org/Chapter18/18-noduletxt.htm

"Thyroid adenomas grow slowly and may remain dormant for years...............Spontaneous regression of adenomas can occur" under "course and symptoms of nodules".

Additionally from Thyroidmanger, this is the chapter regarding ultrasonagraphy of the thyroid. The section about ultrasound and non-palpable thyroid nodule or incidentaloma--scroll down in the article to reach it--is actually quite critical regarding this technique and the resulting need to "manage " these very small nodules similar to what you have:

http://www.thyroidmanager.org/Chapter6a/text6c.html

Also, regarding the treatment of nodules with hormone suppressive therapy:

http://www.cumc.columbia.edu/dept/thyroid/nodules.html

Specifically: "Occasionally, if a fine needle aspiration biopsy is nondiagnostic, we recommend thyroid hormone medication in order to shrink the nodule. This treatment is still controversial because about one third to one half of all thyroid nodules shrink spontaneously without medication."

I have a very nice diamond I received for my 20th anniversary, and it does have a very small flaw in it. Needless to say, more than one "expert" who has looked at it has missed the flaw--maybe I wish it was one of them who wrote the original report on it. My point being, several sets of eyes, or the same set of eyes on a second pass, looking at the same thing, can see things differently, especially in the case of something quite small.

The chapters above should also answer your question of multinodular thyroid disease--yes, you can have multiple nodules and be euthyroid.


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## dantetila (Jul 24, 2010)

Hi all,

I just picked up the CD of images and the report for my latest ultrasound. The report shows 2 solid nodules and a very small cyst. Instead of confusing the situation with my words, here are the reports for my last 4 ultrasounds (newest to oldest). Now they have not grown much in this short time, but it appears they have turned more round shape. I have looked at the images myself and from what I can see, the nodule should say 10mm x 7mm x 5mm as this is the measurements showing at the bottom of the US image, but she wrote 8x7x5, not sure why. I have read the images each time and they usually match up with the report, but not this time. Either way 8 or 10mm, they are not big, I'm just wondering why every month I get more. I want something done, but with my thyroid blood levels ok and negative antibodies, my doctor feels my thyroid is normal. Also, is it normal for my thyroid lobes to change sizes so frequently...if you look from July to now, they have changed a lot. Anyways, any opinions are helpful. Thanks.

Nov
------
Both thyroid lobes are normal in size. The right lobe measures 5.0 x 1.2 x 1.1cm. The left lobe measures 4.8 x 1.3 x 0.7cm. There is a subtle hypoechoic solid nodule in mid right lobe measuring 7 x 6 x 5mm, and a 2mm cyst with a bright marginal echo (calcification) is seen at right lower pole. There is a hypoechoic solid nodule in mid third of the left lobe measuring 8 x 7 x 5mm. The intervening thyroid parenchyma is homogeneous in character. Compared with previous study, two nodules consistent with adenomas and a small cyst are now seen in thyroid gland.

Sept
-----
Both thyroid lobes are normal in size. The right lobe measures 5.1 x 1.7 x 1.5cm. The left lobe measures 4.4 x 1.6 x 1.0cm. The nodule demonstrated in left lobe during July ultrasound is not demonstrated today. There are no nodules or masses seen on either lobe.

Aug
-----
Right lobe of thyroid measures 4.4 x 1.7 x 2.0 cm in size. There is an ill-defined hypoechoic area in the lower pole measuring 6 x 5 x 5 
mm. It does not have clear margins. This may be an early and developing 
nodule but it has not become well enough defined at this point to be biopsied. Left lobe of thyroid measures 3.9 x 1.1 x 1.0 cm. It is homogeneously echogenic without evidence of any obvious nodule.

July
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Right thyroid lobe is 5.0 x 1.4 x 1.5cm, left lobe is 3.7 x 1.6 x 1.0cm and isthmus is 0.3cm. The left lobe in the middle portion shows a 0.8 x 0.5cm well defined slightly hypoechoic nodule and the echo features suggest an adenoma. There are no nodules or cysts seen on the right lobe. The parenchyma elsewhere is slightly coarse.


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## Andros (Aug 26, 2009)

dantetila said:


> Hi all,
> 
> I just picked up the CD of images and the report for my latest ultrasound. The report shows 2 solid nodules and a very small cyst. Instead of confusing the situation with my words, here are the reports for my last 4 ultrasounds (newest to oldest). Now they have not grown much in this short time, but it appears they have turned more round shape. I have looked at the images myself and from what I can see, the nodule should say 10mm x 7mm x 5mm as this is the measurements showing at the bottom of the US image, but she wrote 8x7x5, not sure why. I have read the images each time and they usually match up with the report, but not this time. Either way 8 or 10mm, they are not big, I'm just wondering why every month I get more. I want something done, but with my thyroid blood levels ok and negative antibodies, my doctor feels my thyroid is normal. Also, is it normal for my thyroid lobes to change sizes so frequently...if you look from July to now, they have changed a lot. Anyways, any opinions are helpful. Thanks.
> 
> ...


Of course you know that solid and calcification is not a good thing so what does your doctor plan as the next step here? I personally recommend FNA (fine needle aspiration.)

What antibodies' tests have you had? Any of these?

TSI (thyroid stimulating immunoglobulin),TPO (antimicrosomal antibodies) TBII (thyrotropin-binding inhibitory immunoglobulin), Thyroglobulin Ab, ANA (antinuclear antibodies), (thyroid hormone panel) TSH, Free T3, Free T4.

You can look this stuff up here and more.........
http://www.labtestsonline.org/unders...s/thyroid.html

Here is info on nodules.

Nodules http://www.aafp.org/afp/2003/0201/p559.html


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## lainey (Aug 26, 2010)

Okay, I looked a bit, and this was very, very old, but interesting:

http://ajplegacy.physiology.org/cgi/pdf_extract/72/3/464

I'll extrapolate a bit for you and suggest that the minor changes in size to your thyroid can be due to diet and other activity, as well as the always suspect human technician. Your body is dynamic, not static.

Ditto for the nodules.

For your reference:

>>The ultrasonic appearance of a thyroid nodule does not reliably differentiate a benign thyroid lesion and cancer. [1,4] However, there are distinctions in echo-density, calcifications, and a rim that favor one diagnosis or another. But, they are statistical probabilities and not dependable criteria.

Thyroid malignancies tend to be hypoechoic when compared with the rest of the thyroid. .[28,29,30,31,32] Since most benign thyroid nodules, which are far more common than malignancies, are also hypoechoic, this finding is not particularly useful except that it is reasonably safe to conclude that hyperdense nodules are probably not cancerous.
The presence of calcification is also not a straight forward diagnostic aid. Micro calcifications are relatively more common in malignant lesions than benign and may represent psammoma bodies. Micro calcifications have been reported as demonstrating a 95.2% specificity for thyroid cancer, but a low sensitivity of 59.3 % and a diagnostic accuracy of 83.8%. [31] However, large coarse calcifications and calcifications along the rim of nodule are common in all types of nodules and reflect previous hemorrhage and degenerative changes. Thus, thyroid calcifications as detected by sonography provide little practical help in identifying cancer in the individual case. In one study, the highest incidence of calcification was found in thyroid cancer (54%), followed by multinodular goiter (40%), solitary nodular goiter (14%), and follicular adenomas (12%). The authors reported that calcifications in a "solitary" nodule in a person younger than 40 years person should raise a strong suspicion of malignancy because of a relative cancer risk of 3.8 versus 2.5 in patients older than 40 years with calcified nodules. [33] It is useful to note that large calcifications are seen with increased frequency in medullary thyroid carcinoma. [34]<<

from http://www.thyroidmanager.org/Chapter6a/text6c.html

>>Either way 8 or 10mm, they are not big, I'm just wondering why every month I get more. I want something done, but with my thyroid blood levels ok and negative antibodies, my doctor feels my thyroid is normal.<<

If your labs are good, and you have no antibodies, what would you like done besides watch and wait? That is basically all that is indicated at this time.

When is the next ultrasound scheduled? About 6 months would be logical.


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## dantetila (Jul 24, 2010)

Hi,

Thanks for the quick response.

In response to Lainey on what I'd like done, I guess I'd like to have an FNA since my grandfather had thyroid cancer, but I know they are small, so 6 months is ok to wait.

In response to Andros, yes I don't like those signs either. I have been tested and came back negative for all antibodies you mentioned except was never tested for ANA. My TSH was 1.6 (range 0.3 - 5.0), Free T4 was 17 (range 12 - 24) and Free T3 was 5.3 (range 3.5 - 5.5).

Thanks!


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## Andros (Aug 26, 2009)

dantetila said:


> Hi,
> 
> Thanks for the quick response.
> 
> ...


Do you have the read out for the antibodies or did they just tell you negative? The reason I ask is that if they are within the recommended range, the patient is often told negative whereas there are antibodies that you should not have at all so if they are in range, that means you have them.

Nag, nag.................that is what I do best of all.


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## lainey (Aug 26, 2010)

Common definition of "family history" is a first degree relative such as parent or sibling. Farther out in the family tree, and you would want several events to raise a very heightened concern.

For a nodules of that size, you would be looking for an endocrinologist or surgeon that specializes in ultrasound guided biopsies to do an FNA.

With the FNA, getting a good sample of cells to study is key. This is why it is usually not recommended to do until nodules are of a certain size.

Keep in mind that having an FNA may not be definitive, in fact in nodules that are very small (and the converse, very large, surprisingly) it is more likely that they will not get enough of a sample of cells to give a good diagnosis, if any.


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## dantetila (Jul 24, 2010)

To Andros, I always try and make sure to pick up a copy of the lab results myself. The tests each just had the word `negative`beside them, so I`m assuming that means zero. It`s not nagging, it`s helping 

To Lainey, yeah I see the point of it being hard to biopsy smaller nodules. The thing that does bother me, as I mentioned above, I checked the US images and all the measurements were correct (thyroid lobes, other nodule, cyst) except for the 8mm nodule. In the images it said 1cm, not 8mm. I think I will bring the images to my endocrinologist to show him with the report. Most places say 1cm is the cutoff. My endo already tried to US guided FNA on my 8mm nodule because it was hypoechoic, I`m male, I`m young (24), my swollen cervical lymph nodes (10 node swollen between 1cm & 2cm in size each) and my grandfather, but the nodule disappeared (according to the radiologist anyways). He may do it again, but as you have mentioned, it may be a waste of time if they can`t obtain enough.

Either way, no point in stressing about it, I will have to follow the doc`s advice in the end anyways. I appreciate all the insight and help from the both of you!!!


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