# Question about Following-Up Thyroid Nodules



## Tharmas (May 7, 2011)

Is there anyone here who follow-ups their thyroid nodules on a multinodular goiter? I just had a chance to look at my ultrasound from November 2011 for the first time, and found it strange that there seemed to be two nodules that had gotten larger than 1 cm but were not biopsied. I called my doctor in Atlanta, but haven't heard anything yet.

When I got the ultrasound, my doctor had determined that no significant change had occurred. And the two ultrasounds are from two different machines, so I'm guessing part of the problem is that there are small differences (probably) in how they measure things.

Here's the first report findings from 5/06/11:

"Right lobe measures 5.3 x 1.7 x 1.6 cm. The right lobe is heterogeneous in echogenicity. There is a solid nodule situation inferiorly which contains calcification. This measures 2.3 x 1.3 x 2.3 cm. There is a smaller solid nodule in the interpolar region measuring 9 x 5 x 9 mm. There is a complex nodule superiorly measuring 6 x 6 x 4 mm. Doppler of the right lobe is normal.

Left lobe measures 5 x 1.9 x 1.7 cm. Again echogenicity is heterogeneous. There is a single complex nodule measuring 1.4 x 1.2 x 2.1 cm. No other nodule is present on the left. Doppler on the left is normal. Isthmus is unremarkable measuring 3 mm.

Impressions: Bilateral nodules as described."

And here are the report findings from 6 months later - 11/3/11:

"Findings: The thyroid gland is heterogeneous in echotexture. The isthmus measures .4 cm in thickness.

The right thyroid lobe measures 4.6 x 1.8 x 2.2 cm. A solid nodule in the superior, mid portion of the right-sided lobe measures 1.0 x .9 x .5 cm. A hypoechoic, solid and cystic nodule in the mid right thyroid lobe with a coarse calcification measures 2.2 x 1.6 x 1.2 cm.

The left thyroid lobe measures 5.1 x. 1.6 x 2.2 cm. A solid nodule in the superior mid left thyroid lobe measures 1.5 x 1.0 x 1.4 cm. Immediately inferior to this, a solid lobe measures 2.0 x 1.2 x 1.4 cm and contains a coarse calcification.

Impression: Solid nodules with coarse calcifications in both lobes of the thyroid gland. Recommend correlation with any previous biopsy history, as both nodules meet size criteria for FNA biopsy."

I'm not concerned about the two 2.0 cm nodules, since those are the ones we biopsied back in May 2011 (they came back benign), and they seem roughly the same size. But the 1.5 x 1.0 x 1.4 and the 1.0 x .9 x .5 both seem to qualify for biopsy, right? I thought that any solid nodule above 1.0 cm should be biopsied.

Any thoughts on what might have happened here to make the endo think I didn't need a biopsy in November?


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## joplin1975 (Jul 21, 2011)

Yeah, I would think they would want another FNA...I'd be less concerned about the new measurements, as those aren't always perfect, but more interested in all the new calcifications.


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## Tharmas (May 7, 2011)

Well, I already had the calcifications. These were confirmed by my endo when she did the original FNA. She said both of them were coarse calcifications, which are less concerning than microcalcifications. Both of the nodules w/ calcifications were already biopsied and found benign.

The person who did the original ultrasound wasn't very good, so I think I should take what it says with a grain of salt.


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## Tharmas (May 7, 2011)

Yeah, in the letter the endo wrote to my doctor after the original biopsy, she notes macrocalcification in both of the nodules.

Right lobe: "has a well-defined wall it has an area of macro calcification along the superior margin. No microcalcification and on color flow Doppler it shows predominantely vascular flow. No central vascularity."

Left lobe: "Within the left lobe, a large heterogeneous nodule was also noted. It is difficult to ascertain whether it is a single nodule or a combination of two adjacent nodules. One nodule is more solid and the other nodule is more cystic. There is an area of macrocalcification in the lower cystic portion of the nodule; however, no microcalcification. On color flow Doppler, this nodule also has predominantly peripheral vascular flow. No central vascularity."

Maybe I'm freaking out about this heterogeneous nodule, unduly. Though I don't know why it is noted as "solid" when the macrocalcification in this letter is associated with the cystic nodule.


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## Tharmas (May 7, 2011)

The other problem is that neither of the other two nodules w/out calcification were above 1.0 cm originally, and so the endo did not biopsy them.

I've read that in multinodular goiters, they tend to biopsy only the dominant nodules - is this correct? Or do they biopsy all nodules above 1.0 cm?


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## joplin1975 (Jul 21, 2011)

Sorry, I misspoke. I did not mean new calcifications, but rather that the previously complex nodule has become solid and that there's a new solid "lobe" there also.

Regardless, I think you need a FNA again, just to be sure.


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## Tharmas (May 7, 2011)

Good lord, this is frustrating. I was under the care of someone at Emory University Hospital and thought they would be thorough. The last ultrasound was taken almost a year ago (meaning, I haven't had an ultrasound since last November). I called her, and hopefully she'll have a good answer for me. I'm assuming that there was some problem with correlating the two, since the first ultrasound was taken at another clinic. She said she wanted this ultrasound to establish a baseline, so it's entirely possible she didn't compare the two - thinking that there would be too many differences.

At one point, I almost thought that the new ultrasound switched the left and right lobes - since (as you say) the complex is now on the left lobe instead of the right. But that still doesn't account for the appearance of the 1.5 cm nodule.


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