# Surgery recommended for Dad's nodule- have questions



## Veronica7 (May 13, 2015)

My dad has been to an ENT and they recommend surgery for his thyroid nodule. He has had this nodule for as long as I can remember, 20+ years, he is 65 now. It is large, I believe at least 4cm, but I don't know for sure the exact size. It is smaller now that is has been in past years however. (I thought in the past they called it a goiter but I could be wrong and was maybe always a nodule.) He had it biopsied years ago and it was benign and after that he just kind of forgot about it and didn't deal with it as he never had good insurance. He now has better insurance and went in for a check-up and the Dr. felt this lump and sent him to an ENT who ordered tests done. He had an ultrasound and needle biopsy done (and then an ultrasound guided needle biopsy as the first biopsy showed nothing). The 2nd biopsy results were- indeterminate, follicular lesion, no focal onocytis changes, negative for papillary architecture, negative cellular atypia. They tested his TSH- results were 4.58 (with normal levels being .35- 4.5).

Can anyone tell me what any of these results mean? He is not good about always asking questions of his Dr.s. Could this possibly be benign? I haven't done much research yet but what about hashimotos, is that a possibility with him as he's had this so long?

He has surgery in a few weeks. They will be removing 1/2 the thyroid and having the biopsy done while he is under and will remove the whole thing depending on results.

Are there things we should be asking? More tests that should be done? He just had his pre-surgery check-up but should he be asking for anything else?

Any help would be greatly appreciated as I know nothing about any of this and would like to make sure he is as informed as possible before he goes ahead with surgery.

Thank you!


----------



## Andros (Aug 26, 2009)

SUGGESTED TESTS
TPO (antimicrosomal antibodies) TBII (thyrotropin-binding inhibitory immunoglobulin), Thyroglobulin and 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/
(Copy and paste into your browser)

TBII
http://www.ncbi.nlm.nih.gov/pubmed/9364248
http://en.wikipedia.org/wiki/Anti-thyroid_autoantibodies
(Copy and paste into your browser)

Blocking TRAbs (also known as Thyrotropin Binding Inhibitory Immunoglobulins (TBII)) competitively block the activity of TSH on the receptor. This can cause hypothyroidism by reducing the thyrotropic effects of TSH. They are found in Hashimoto's thyroiditis and Graves' disease and may be cause of fluctuation of thyroid function in the latter. During treatment of Graves' disease they may also become the predominant antibody, which can cause hypothyroidism.

IMPORTANT!!

Thyroid cancer symptoms
http://www.cityofhope.org/patient_care/treatments/thyroid-cancer/Pages/symptoms.aspx
(Copy and paste into your browser)

TPO and thyroglobulin
http://onlinelibrary.wiley.com/doi/10.1111/j.1699-0463.1994.tb04888.x/abstract
http://www.wikigenes.org/e/gene/e/7173.html
(Copy and paste into your browser)

Understanding Thyroglobulin Ab.
http://www.labtestsonline.org/understanding/analytes/thyroglobulin/test.html
(Copy and paste into your browser)

Thyroglobulin Ab and cancer
http://qjmed.oxfordjournals.org/content/59/2/429.full.pdf
(Copy and paste into your browser)

Hi and welcome.

Yes; there are some important tests that should be done. It would be good to get the Thyroglobulin and Thyroglobulin Ab "before" the surgery.

Your poor dad; he has had to suffer all these years. Please keep us in the loop and continue to be his advocate as he needs that!


----------



## joplin1975 (Jul 21, 2011)

I think the most important thing at this point is insuring that he has a very, very experienced surgeon. The surgeon should be involved in 3-5 thyroid surgeries per week. Ask about complication rates, especially laryngeal nerve and parathryoid damage. Both should be minimal. Ask how they will close the wound (should be stitches or glue...if they say staples, find a new surgeon).

Secondly, ask how they will be monitoring his post-op medication needs. I see he really only has had TSH run. TSH is not sufficient for dialing in on the meds he needs *and* they should not be calling a TSH of 4+ "normal." They need to be testing free t3 and free t4.

You should have the antibodies tested that Andros suggested before surgery. If he does have antibodies, I would strongly suggest removing the whole thyroid. Antibodies infer with thyroid function and the presence of them can make post-op medication regulation really difficult.

Thyroid nodules are very common, but are most common in women under 40. Once you start talking about men who are older, you want to make sure you aren't dealing with some of the more challenging thyroid cancers, like medullary or anaplastic. Has he had this calcitonin tested?


----------



## Veronica7 (May 13, 2015)

Thank you for your replies- I have started to read some of the links you posted.

Why do you recommend he get those 2 tests before the surgery? Like I said, they will biopsy while he is still open and remove the whole thing if cancer is found, so why test the antibodies beforehand? If it is not cancer but he has these antibodies, would the removal of the whole thyroid still be recommended?

And do the t3 & t4 need to be done before surgery or just for treatment afterwords?

He has not had the calcitonin tested.

I told him to ask his surgeon how many surgeries she has done, I don't believe she gave an exact # but did say she has done lots and lots. There will be 2 surgeons there, her and her partner. I don't know if he has a lot of choice in providers as he is on Medicaid now. He said he trusts her and feels comfortable with her. He told me to make a list of questions and he will call her in a few days- what should I have him ask besides about staples or glue?

He has not seemed to have any symptoms of a thyroid disorder all these years, just the lump.

As I said, he has had this lump for years and years and it has not grown but has gotten smaller (although it is still large)- could it still be a more aggressive cancer in that case?

Should more testing be done before he even considers surgery or should he just go ahead with the surgery ASAP? It is scheduled in about a week from now. If he asks for more tests, I imagine they would have to reschedule the surgery???

What can he expect in the day or two after surgery? Is it a difficult recovery if the whole thyroid is removed?

Sorry for all the questions, I am trying to get a handle on this and there is so much information out there. It is also hard as I don't know what the Dr.s are saying and what information he is getting and if he is asking enough questions. It would be a lot easier if I could talk to the Dr.s myself but as I live in a different state, it is not possible for me to go with him to appointments.

Anyways, please let me know if there are any questions you think he should be asking his Dr. before the surgery and I will pass them on.

Thank you for your time!


----------



## joplin1975 (Jul 21, 2011)

The process of testing one's thyroid during surgery is known as taking a "frozen section." It's a good idea in theory, but unfortunately it is notorious for being incorrect a lot of the times. Meaning a few weeks after the initial surgery, they have to go back in and take out the other half.

There's no one way to be 100% sure about the whole cancer vs no cancer thing, but getting antibodies tested will help...so yes, I would do that before surgery.

The free t4 and free t3 tests are most important after surgery.


----------



## Octavia (Aug 1, 2011)

I would also suggest having your dad's thyroglobulin level tested prior to surgery if possible. This will be helpful in the (hopefully very unlikely) event that he does have thyroid cancer. Here's a link to read about it: http://www.thyca.org/pap-fol/more/thyroglobulin/

More lab tests won't necessarily delay the surgery...well, except for the antibody thing.

Regarding your question above about antibodies...if he has high antibody levels, then his immune system is fighting his thyroid and will continue to fight the remaining half if left in. That makes it hard to get to the correct dose of replacement meds (because of the ups and downs caused by the autoimmune response).

I ended up having two surgeries (like what joplin described above...my "frozen section" during surgery was negative for cancer, but full pathology results ended up being positive for cancer, so I had to go back to get the other half removed a few weeks after the first half was removed). My recovery was fairly easy both times.

That's great that your dad likes and trusts his surgeon.


----------



## Veronica7 (May 13, 2015)

Thanks for the information!

I am still trying to wrap my head around all this info.

In the article it says that "having a high tg level before surgery does not indicate that a tumor is present." So if that is the case, how does it help to know it before? The only way to know for sure if it is cancer is a surgical biopsy because his needle biopsy was indeterminate.

I have a feeling his Dr. will say he doesn't need it or that it doesn't matter since she hasn't ever ordered any further thyroid blood testing beyond the TSH.

Is this correct- Knowing it before hand is good because if it is cancer, you know you can then use the test to detect anything left after?? Can you not still use the test to detect things after surgery if you haven't done it before?

And it says that if your TSH is high, your tg will be increased about 10 times- his TSH is high, so most likely his tg is too. Can a tg NOT be high with a high TSH? If so, what does that mean?

I told him to call his Dr. tomorrow and ask for the tests. How long do the results take? Should I have him ask for the calcitonin test too?

Sorry for all the questions. I just want to make sure I am understanding everything.

Thanks again!


----------



## Veronica7 (May 13, 2015)

Also- do his needle biopsy results point to anything or rule anything out? Is this good, bad or just inconclusive?

Needle biopsy results- follicular lesion- no focal oncocytic changes- negative for papillary architecture-negative cellular atypia.

Thanks!


----------



## joplin1975 (Jul 21, 2011)

Follicular lesions are in a grey area. About 50% of the time (that's generalized number, btw) they are benign and about 50% of the time, they are malignant. So there's not a lot more that can be gleaned from his biopsy result.

Everyone (with a thyroid, that is) has a little bit of Tg in their systems. It's produced by the thyroid gland. But any time that number get above the 40 ng/mL mark, it gets really suspicious because tumors tend to produce Tg at a higher rate than "normal" thyroid cells. His TSH is elevated slightly, but it's not SO high that it would make a Tg/TgAB test that out of whack.

My opinion is that you want your surgeon as well informed as possible before surgery. I think what I was trying to say is that relying only on the frozen section is considered meeting minimal standards of care, BUT who wants to be treated with minimal standards of care? Not me. I want as much information as possible. Thyroid surgery isn't "clean." Even the best surgeon performing a total thyroidectomy will leave bits and pieces of thyroid tissue behind. But if you surgeon know ahead of time that s/he needs to exercise as much caution as possible to remove as much tissue as possible, I think it's a good thing. More over, if additional testing points to cancer, the surgeon will also know to more closely examine lymph nodes and other structures surrounding the tissue and make the decision do the proper level of neck dissection, if needed.

I meant to answer your earlier question and neglected to do it: there's very little difference in terms of recovery from a partial thyroidectomy and a total. Relative to other surgeries, this one is pretty easy to recover from and the pain is minimal.


----------



## Octavia (Aug 1, 2011)

I was just thinking the thyroglobulin test would be helpful just in case your dad has thyroid cancer. Later on, it can be used as a tumor marker to see if the cancer has come back. But the test is most helpful if you know the thyroglobulin level before surgery.


----------



## Veronica7 (May 13, 2015)

Thanks for the help! I have passed on all the info to my dad.

As his surgery was coming up so quickly, he didn't have any further testing done. His surgery is tomorrow and he just wanted to get it done and removed and didn't want to wait for further testing. Hopefully all will go well and they know enough to give him the care he needs and deserves! I am very nervous and hope that his Dr. is competent considering this testing wasn't done beforehand.

He will be coming to my house to recuperate after the surgery.

Again, thank you for the help and wish us luck tomorrow!


----------



## Octavia (Aug 1, 2011)

Understandable.

Best wishes for a successful surgery. Please keep us posted.


----------



## Veronica7 (May 13, 2015)

They just finished the surgery and the surgeon said all went well. They removed the left lobe, she said it was very calcified. The pathologist saw nothing to be concerned about but they will be sending it out for further testing and will do a certain stain because it was so calcified. He has a drain now.

I guess now we just wait and see what the final pathology says.

And hope he doesn't have to go back in. I wish they would have ordered further testing beforehand but there is nothing we can do about it now. The surgeon said there was no way to know for sure what it is until they got it out and that she prefers to be conservative now and go back in later if they have to.

Anything I should ask the surgeon? I think now he needs to speak to an endocrinologist, right?

Thanks!


----------



## Veronica7 (May 13, 2015)

I have just been reading that calcification may mean a higher chance of malignancy. I was so hopeful after the pathologist said he saw nothing to be concerned about but I guess we just have to wait and see.


----------



## joplin1975 (Jul 21, 2011)

I think at this point, you'll want to know how long the drain stays in and if his calcium is stable. Beyond that, you'll just have to wait for the final pathology to come back.

Your surgeon should clarify a follow up plan for your father *before* he leaves the hospital. That should include a plan for TSH, free t4, and free t3 testing six to eight weeks after surgery.

Some surgeons will do it (mine was more than happy to run the tests), while others prefer to discharge the patient to the care of an endo, pcp, etc. There's no right doctor to treat him, long term. Usually, the right doctor isn't defined by a specialty, but rather willingness to be a good partner with the patient to find the right meds/dose.

I'm glad your father made it through surgery without any major complications.


----------



## Andros (Aug 26, 2009)

Hope your dad is doing well. Calcified does "suggest" malignancy. Let us hope it is not definitive.

Best you can do now is what you are already doing and that is standing by your dad. What a wonderful daughter you are!

Keep us informed and I hope your father is comfortable and w/o pain.

Hugs,


----------



## Veronica7 (May 13, 2015)

My dad is having a lot of stomach and gas pain. Is it normal to have gas/ stomach pain after surgery? We called his Dr. who said that the anesthesia and pain meds can cause that and to just ride it out, but he is in a lot of pain now. Has anyone else experienced this after surgery?

His incision is not paining him as much as this stomach and gas pain. They recommended Milk of Magnesia once a day.

When can we expect this to improve? I hate seeing him in so much pain.

I don't know what to do for him- he doesn't want to take any more hydrocodone because of it causing this gas pain. He took some ibuprofen. But I don't know what else to do for him.


----------



## Andros (Aug 26, 2009)

Can you get your father to walk a little? That would help expel the gas; move things along.

That can be painful for an elderly person for as we age, all derma gets thinner and thinner.

Hopefully today will be a better day for the both of you!


----------



## joplin1975 (Jul 21, 2011)

Hydrocodone is really hard on your belly. Is he in that much pain? Has he been icing his neck?

MoM is probably a good idea, along with bland foods.

I don't think belly pain is exceptionally common with thyroid surgery, but it common with narcotic use.


----------



## jenny v (May 6, 2012)

I had stomach issues after my surgery thanks to the anesthesia. Definitely get him up and mobile and make sure he stops the pain meds (if he can). I switched to Tylenol about 4-5 hours after my surgery was over and it was fine.


----------



## Veronica7 (May 13, 2015)

We took him back to the hospital this morning as he wasn't doing well. Turns out he has a bowel obstruction and perforation. He is in surgery now. I am very worried. How did this happen? I feel so awful, his doctor had assumed and told us gas and constipation after the thyroid surgery, when in fact it was something serious.

I actually can't believe this is happening, it was enough with the thyroid surgery and waiting for that pathology, now this. I hope he makes it through all this ok.

Please pray for him if you can.

Thank you!


----------



## joplin1975 (Jul 21, 2011)

Oh no! I'm so, so sorry.

Bowel obstructions can happen after surgery, but they are usually much more related to abdominal surgery. Did he have any previous digestive issues?

Please let us know how he is doing, ok?


----------



## Veronica7 (May 13, 2015)

Well what a time this has been! He will get out of the hospital in a few days & is doing well. The surgeon said that his bowel issues were completely unrelated to his thyroid surgery and just an awful coincidence. It seems he has diverticulitis and must have had this for awhile so it had abscessed.

If this hadn't happened, the thyroid surgery would have been a breeze- he never had pain or any issues with that surgery at all!

My question now is- I just saw his chart and it said the thyroid path results were "Hurthle Cell Adenoma"- what does that mean? His ent will be calling him with the official results soon I imagine. What is a Hurthle Cell Adenoma? Is that bad or good? If it were cancer, would it say Hurthle Cell Carcinoma?

What causes a Hurthle Cell Adenoma? Should he be tested for auto-immune conditions?

He has an appointment with an endocrinologist the end of the month I believe.

Thanks!


----------



## joplin1975 (Jul 21, 2011)

There's hurhtle cell carcinoma and hurhtle cell abnormalities due to autoimmune comditoins. An adenoma means that it's a benign nodule and that is usually related to autoimmune conditions. So yeah!

I am so, so glad he is doing better!


----------



## Veronica7 (May 13, 2015)

My dad just went in for blood tests, he has an appointment with an endo. in a few days. Yet again, they didn't test t3 or t4, just TSH. I told him to talk to the endo about that at his appointment, but they should be ordering those tests also, right?

These are the results of what they tested-

TSH -4.4 (it was 4.58 before surgery)

Calcium- 9.2 mg

Albumin- 3.4

What does this mean? Why did the test these things and what else should he get tested?

He said he had tingling in his fingertips and his wrist is swollen (he thinks it is gout as he has had that before). He also is a bit tired. As he had the diverticulitis surgery too, I don't know what symptoms are from that and what he should be looking for with his thyroid.

Anything he should be asking or telling his endo in a few days?

Thanks for any help or advice.


----------



## joplin1975 (Jul 21, 2011)

Do you have the ranges for those tests - especially the calcium?

Sometimes the parathyroids can get damaged during surgery. They play an important role in regulating the body's calcium levels. Signs of low calcium include tingling in extremities.

If he gets more tingling, he should take some Tums with calcium and symptoms should get better.

Was he started on any thyroid meds?


----------



## Veronica7 (May 13, 2015)

TSH- 4.4 (normal low 0.35- normal high 4.50)

Calcium 9.2 (normal low- 8.2- normal high 10.0)

Albumin 3.4 (normal low 3.3- normal high 5.0)

His calcium has stayed in those ranges, it did get a bit lower- 8.8, the day of, and the day after surgery, but has always been in range.

He was not started on any thyroid meds. He had this emergency bowel surgery so he was not able to see the endo as soon as was first scheduled, as he was in the hospital for over a week with the bowel surgery.

He stayed with me for over a week after he was released from the hospital and seemed to be doing well but now he has gone back home (in a different state) and when I talked to him on the phone, he sounded tired and down. Like I said, it's hard to know, as he has had all these different issues, what is causing what. I just want to make sure he goes in to his endo appt. in a few days with the right questions and information.

Thanks!


----------

