# Multinodular Goiter



## macklulu (Nov 8, 2010)

Hi everybody.

I just recently had an ultrasound done due to having a bit of tightness in my throat. All the ultrasound found was two nodules, 9mm x 7mm nodule on right lobe and a 8mm x 7mm nodule on the left lobe. The report described them both as hypoechoic, but did not say any other details about the margins (ill or well defined) or anything else. The lobes were apparently normal at 5.1 x 1.4 x 1.1 cm and the other at 5.0 x 1.1 x 0.7 cm. The texture around the nodules was homogenous in appearance. The radiologist made no recommendations on the report, it was quite basic. She did not write whether the nodules were solid or not, but she said they have the appearance of an adenoma, so think that means they were solid in appearance. The only other mention of the report was a 4mm cystic area with bright margins.

I just have a few questions:

1. Would this be the characteristics of a mulitnodular goiter, even though the report says my thyroid is normal in size? To me the thyroid seems enlarged in length, but too small in width and depth.

2. I'm just curious if nodules means there is something abnormal going on with the thyroid, or is this common and normal?

Thanks again and look forward to meeting everyone!


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## Andros (Aug 26, 2009)

macklulu said:


> Hi everybody.
> 
> I just recently had an ultrasound done due to having a bit of tightness in my throat. All the ultrasound found was two nodules, 9mm x 7mm nodule on right lobe and a 8mm x 7mm nodule on the left lobe. The report described them both as hypoechoic, but did not say any other details about the margins (ill or well defined) or anything else. The lobes were apparently normal at 5.1 x 1.4 x 1.1 cm and the other at 5.0 x 1.1 x 0.7 cm. The texture around the nodules was homogenous in appearance. The radiologist made no recommendations on the report, it was quite basic. She did not write whether the nodules were solid or not, but she said they have the appearance of an adenoma, so think that means they were solid in appearance. The only other mention of the report was a 4mm cystic area with bright margins.
> 
> ...


While not a pathologist, I do believe that bright margins are referring to microcalcifications or rim calcifications. For that reason, I would push for FNA (fine needle aspiration.)

http://onlinelibrary.wiley.com/doi/10.1002/jcu.20625/abstract

In all likelihood, the hypoechoic nodules are probably cysts but that should be looked into as well.

This site is excellent for images and explanation.......

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1665239/

Welcome to the board.

Have you talked to your doc about these results and if so,what has she/he purported as the next logical step for you?


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## macklulu (Nov 8, 2010)

No, I am still waiting to see my doctor as he has not called me back yet.

You mention that the hypoechoic nodules are likely cysts as well. Why do you feel this is? The radiologist said they appeared to be adenoma's, I thought that meant solid. Please let me know as it makes me feel better if they are only cysts and not nodules. You also mentioned an FNA, the bright echo is only on the small 4mm cyst which form I read is way too small to biopsy. Should I push for a biopsy on the largest one even if it doesn't have any calcification? Thanks!!!


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## lainey (Aug 26, 2010)

macklulu said:


> Hi everybody.
> 
> I just recently had an ultrasound done due to having a bit of tightness in my throat. All the ultrasound found was two nodules, 9mm x 7mm nodule on right lobe and a 8mm x 7mm nodule on the left lobe. The report described them both as hypoechoic, but did not say any other details about the margins (ill or well defined) or anything else. The lobes were apparently normal at 5.1 x 1.4 x 1.1 cm and the other at 5.0 x 1.1 x 0.7 cm. The texture around the nodules was homogenous in appearance. The radiologist made no recommendations on the report, it was quite basic. She did not write whether the nodules were solid or not, but she said they have the appearance of an adenoma, so think that means they were solid in appearance. The only other mention of the report was a 4mm cystic area with bright margins.
> 
> ...


A goiter generally implies that the thyroid has become inflamed and is larger than normal in size. If your thyroid is "normal" in size, you probably don't have a goiter.

It seems like a lot of reading, but scroll down to the part called "sonography and the thyroid nodule"

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

Especially: "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."

Thyroid nodules are present in the normal population at a rate of about 40% for the small, non-palpable nodules such as you have. A vast majority of them--95% or so--are benign, especially when they occur in multiples.

The key to a FNA is to achieve a sufficient sample of cells from a nodule to see if it is suspicious. There are diminishing returns here on small nodules, especially those under 1cm. Indeterminate results taken from a small nodule can of course lead to anxiety and unnecessary procedures.

Blood work with antibodies testing can be done to see if there are any abnormalities there.

Nodules generally do not require much more than a watch and wait approach--ie, in the presence of normal blood work, monitoring of the nodules is usually done by performing a new ultrasound a few months later. Changes are noted, if any.


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## Andros (Aug 26, 2009)

macklulu said:


> No, I am still waiting to see my doctor as he has not called me back yet.
> 
> You mention that the hypoechoic nodules are likely cysts as well. Why do you feel this is? The radiologist said they appeared to be adenoma's, I thought that meant solid. Please let me know as it makes me feel better if they are only cysts and not nodules. You also mentioned an FNA, the bright echo is only on the small 4mm cyst which form I read is way too small to biopsy. Should I push for a biopsy on the largest one even if it doesn't have any calcification? Thanks!!!


A hypoechoic nodule is a fluid-filled or solid mass that casts limited, weakened echoes than surrounding tissue during the administration of an ultrasound, or sonogram. Though this type of mass may be found in any part of the body, it is most frequently detected in the thyroid. Due to the characteristics of its composition, suspicion of malignancy may arise upon the discovery of a hypoechoic nodule prompting additional testing and biopsy. Treatment for a hypoechoic thyroid nodule is dependent on its type, composition, and the overall health of the individual.

http://www.wisegeek.com/what-is-a-hypoechoic-nodule.htm

Adenomas are usually benign and they do appear solid. The word appears is important here.

http://www.ncbi.nlm.nih.gov/pubmed/11788674

I am not a doctor so I think it is best to get your own doctor's input but I am really big on ruling out cancer. So many have been fluffed off with the comment, "You can't possibly have cancer of the thyroid" only to find out at a later date that they sure did.

Please do let us know what your doctor has to say and I hope all of us here can be of a help to you in sorting this out.


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## macklulu (Nov 8, 2010)

To Lainey/Andros:

Thanks for the info on Adenoma's & the article! I read the article, very interesting. I looked at the normal thyroid size, "Each lobe has a smooth globular-shaped contour and is no more than 3 - 4 centimeters in height, 1 - 1.5 cm in width, and 1 centimeter in depth." Based on this and reading other posts I've seen where people U/S reports said goiter with height like mine, I don't understand why the radiologist said my thyroid was normal size. It seems 5cm+ would be enlarged for height and 0.6cm depth would be too small. Especially since 4 months ago my left thyroid lobe was 3.6cm high, it has grown a nodule and 1.5cm (the lab new this as they did previous U/S).

From what I can see nodules are quite common. It says with age it increases and being female. Since I am male and 23, and the fact that I have 2 nodules close to 1cm, should this seem a bit less normal and be checked out?

Sorry if I seem worried, I am just new to this. Thyroid issues run in my family and I already have Type1 Diabetes, so I know autoimmune disease come in bunches. Just don't want to ignore anything because I know my Dr. wont likely care unless I am on top of it! 

As far as blood work, TSH was 1.4, Free T4 was middle of ref range, Free T3 was right at top of ref range borderline high, all antibodies negative.


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## lainey (Aug 26, 2010)

In the literature, adenoma is used interchangeably with "nodule" when referring to the thyroid. Technically, an adenoma is a benign tumor that can occur anywhere in the body, but people get a little excited when they see the suffix "oma" or hear the word "tumor", because they mistake them for cancer.

Please keep in mind that ultrasound, especially the measurement, can be less precise than you think, and varies greatly with the equipment and the skill of the technician, as well as the skill and experience of the radiologist reading the images.

By checked out .... you can:

Have a radioactive uptake stan. This will show the nodules in more definition, and determine if they are functional (producing thyroid hormone) or not.

Find a surgeon to do an ultrasound guided FNA. Your age and sex will be helpful in pushing for this, yes, because it makes your risk slightly higher. Many will not do these on nodules less than 1 cm because the chance of getting indeterminate results is very high in nodules of this size. Keep this in mind, because it can lead to further procedures that may not be necessary.

The thyroid gland can vary in size with season and diet, as well as other inflammation in the body. Goiters alone are generally not treated unless they are of a size to interfere with neck structures, or there is supporting blood work to indicate that the thyroid is dysfunctional. Treatment with thyroid hormone for a goiter or nodules is considered controversial and generally not effective in reducing the size of either.

Type 1 diabetes is a risk factor for thyroid problems. Thyroid testing should become part of your overall well check.

I am not a doctor, but as for the nodules, barring the other tests, based on their size, watch and wait is the most likely course--repeat ultrasound in 3 to 6 months.


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## macklulu (Nov 8, 2010)

Thanks Lainey. You may not be a doctor, but you are very helpful.

I agree exactly with what you're saying. I do think followup ultrasound makes the most sense, since even if it was cancer (not likely), nothing worse is going to happen between now and 6 months at these sizes. I just was afraid because they're common, Dr's were likely to just tell patients to ignore it.

Thanks for the help!! Also thanks to Andros for the help as well!!


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## Andros (Aug 26, 2009)

macklulu said:


> To Lainey/Andros:
> 
> Thanks for the info on Adenoma's & the article! I read the article, very interesting. I looked at the normal thyroid size, "Each lobe has a smooth globular-shaped contour and is no more than 3 - 4 centimeters in height, 1 - 1.5 cm in width, and 1 centimeter in depth." Based on this and reading other posts I've seen where people U/S reports said goiter with height like mine, I don't understand why the radiologist said my thyroid was normal size. It seems 5cm+ would be enlarged for height and 0.6cm depth would be too small. Especially since 4 months ago my left thyroid lobe was 3.6cm high, it has grown a nodule and 1.5cm (the lab new this as they did previous U/S).
> 
> ...


I did not realize you were male. It just so happens that w/ the male gender, suspicious nodules most certainly need to be checked out for the likelihood of cancer is increased.

Quote.....

Did you know...
...a nodule found in a man's thyroid is more likely to be cancer than when found in a woman?

Source......
http://www.umm.edu/endocrin/thytum.htm

I have read this in other places as well.

What antibodies' were done? Would you mind elaborating? And would you have the results and ranges in your possession to share w/us?

These are the antibodies' tests I personally recommend.

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


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## macklulu (Nov 8, 2010)

Hi Andros,

I had antibody tests for TPO, TSI, Thyroglobulin Ab. The lab said "Negative" for all of them specifiying no values. As for the other labs:

TSH - 1.4 (range 0.3 - 3.0)
Free T3 - 5.2 (range 2.8 - 5.4)
Free T4 - 18 (range 12 - 24)

Thanks for the article, I thought being young and male was a factor. The US also said i have 10 cervical lymph nodes mildly enlarged between 1cm & 1.7cm but appear benign. I doubt this has any issues because they look benign, but does this matter?

Thanks.


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## Andros (Aug 26, 2009)

macklulu said:


> Hi Andros,
> 
> I had antibody tests for TPO, TSI, Thyroglobulin Ab. The lab said "Negative" for all of them specifiying no values. As for the other labs:
> 
> ...


Oh, dear. Appearing benign is not good enough in my book. That is also very suspicious to have 10 cervical enlarged lymph nodes.

Do you know what the number was for TSI? I ask because you should have none, zilch, zero. They do have a range but that is only to detect movement. If you have any at all, that points to hyperthyroid. And cancer and hyper are known bedfellows.

TSI

Results and Values
What do the test results mean?
Normally, there is no TSI in the blood. If TSI is found in the blood, this indicates that the thyroid stimulating immunoglobulin is the cause of the of a person's hyperthyroidism. 
http://www.medicineonline.com/topics/t/2/Thyroid-Stimulating-Immunoglobulin/TSI.html

We are here for you and I am not out to scare you. I am a real straight-shooter when it comes to cancer of the thyroid. I have seen too many go undiagnosed.

Lymph node involvement suggests Papillary thyroid cancer.

http://atlasgeneticsoncology.org/Tumors/PapilThyroidCarID5053.html


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## lainey (Aug 26, 2010)

There are over 600 lymph nodes in your neck, and a large number of reasons why any one or several of them may be enlarged--inflammation in many areas of the body show as enlarged lymph nodes, as that is their job.

There is a certain type of thyroid cancer that is common in families, in men, that is due to a genetic defect. If this is in your family history, you would know it--it is a rapidly moving disease and strikes at a young age.

After that, the primary risk factors for thyroid cancer from a nodule consist of being female and between 20 and 55 years of age.

http://www.endocrineweb.com/conditions/thyroid/thyroid-nodules

Women have a rate of occurrence of nodules that is almost 3 times that of a man, and a corresponding rate of thyroid cancer. Because nodules are less frequent in men, the common perversion of the math is that the cancer is more likely, simply because fewer men get nodules.

Unless you have a direct history of thyroid cancer in men in your family, we're going to come back to, because of their size and number the percentages are still vastly in your favor that these are benign.

Don't misunderstand me--of course they should be monitored, and if you are anxious, you should proceed with further testing.

If you are really curious, go to the thyroidmanager.org website (this is a physician-run website for professionals, btw) and read the section on thyroid cancer, particularly the statistics on rates of thyroid cancer found at autopsy of people who died from other causes. Fascinating. From there you can link to endotext.org and learn everything you never wanted to know about other endocrine disorders, including diabetes


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## macklulu (Nov 8, 2010)

In regards to TSI, all the paper said was negative unfortunately. I wish I had more information, but this is all it says. As far as my TSH, at least that appears to be good at 1.4. My Free T3 was on the high end, but I read that high end is good.

I understand where both of you are coming from. You want to be on top of things and not let them go unconcerned, then to find out it was a real issue. But you also don't want to worry yourself sick over something that is likely not a big deal. The only reason I ask all these questions is due to the fact that I know sometimes doctors just dismiss everything until something worse happens. I've had it happen in my past as I'm sure many others have had happen. That is why I wanted to come here and speak to you (people who have experience with Thyroid issues) before I go to my doctor, since Thyroid issues are new to me.

I appreciate your feedback and support very much, and I appreciate the way you both covered a different viewpoint on the subject. I am sure it will be nothing, but as you both have said, I will definately not let it go unmonitored as I feel it is concern enough to have regular checkups.

Thanks again for all the help and references.


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## Andros (Aug 26, 2009)

macklulu said:


> In regards to TSI, all the paper said was negative unfortunately. I wish I had more information, but this is all it says. As far as my TSH, at least that appears to be good at 1.4. My Free T3 was on the high end, but I read that high end is good.
> 
> I understand where both of you are coming from. You want to be on top of things and not let them go unconcerned, then to find out it was a real issue. But you also don't want to worry yourself sick over something that is likely not a big deal. The only reason I ask all these questions is due to the fact that I know sometimes doctors just dismiss everything until something worse happens. I've had it happen in my past as I'm sure many others have had happen. That is why I wanted to come here and speak to you (people who have experience with Thyroid issues) before I go to my doctor, since Thyroid issues are new to me.
> 
> ...


We love different viewpoints here and the best part is we definitely respect that. A narrow mind is a very sad mind. Thinking outside the box is essential.

And we sure do appreciate you having joined our board. Already you have brought much knowledge and things to think about for our posters.


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## macklulu (Nov 8, 2010)

Hi all,

I just got back from my endo`s office now. Turns out he doesn`t trust other labs and would rather wait. When I first walked in, he said well we will try another FNA on the 9mm nodule since you have a rather odd history of health. Then he went and changed his mind at then end of the meeting because he feels that he doesn`t trust the CML lab I`m going to. He said since the hospital US a few months ago didn`t show it as big and only showed one nodule, so he doesn`t know whether the CML made a mistake or not. He said he`d rather wait until March and do another US at the hospital since they are only 9mm and wont pose a risk if we wait.

He also said the hypoechoic and spherical shape doesn`t bother him, but from what I read they are signs pointing away from benign. I know it is still very unlikely, but I don`t agree with his comment.

Anyways, I guess there is no harm in waiting if they don`t grow much. it is just much nicer to know now vs waiting lol

Thanks for the comments and help!


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## Andros (Aug 26, 2009)

macklulu said:


> Hi all,
> 
> I just got back from my endo`s office now. Turns out he doesn`t trust other labs and would rather wait. When I first walked in, he said well we will try another FNA on the 9mm nodule since you have a rather odd history of health. Then he went and changed his mind at then end of the meeting because he feels that he doesn`t trust the CML lab I`m going to. He said since the hospital US a few months ago didn`t show it as big and only showed one nodule, so he doesn`t know whether the CML made a mistake or not. He said he`d rather wait until March and do another US at the hospital since they are only 9mm and wont pose a risk if we wait.
> 
> ...


I wish your doc would bite the bullet and just order RAIU (radioactive uptake scan) as they are so much more reliable than US. US has it's limitations both technology and human wise.

With you all the way; this needs to be checked into further.

Keep us in the loop here.


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