# Suspicious nodule on ultrasound, need some help?



## psychopika (Mar 1, 2015)

Hi everybody,

I'm new here and so glad I found this forum. I am a 29-year old woman suffering from long-term intense anxiety and hypochondria. Last week I incidentally discovered I have a small nodule on my thyroid, on an ultrasound recommended for my anxiety and IBS issues.

I had a second ultrasound a couple of days ago to better evaluate the nodule. It's 4.5mm (that's MM, not CM) in size, round-oval in shape with a smooth margin. It's hypoechoic so it appears a bit darker. It's solid and the doctor says she could see a few microcalcifications, although on the first ultrasound I wasn't told that. There is also slight vascularity inside the nodule.

After asking her about it, she said she wasn't 100% sure that there were microcalcifications and that it could have been other stuff appearing as such. But she did write microcalcifications on the report.

The endocrinologist is not very concerned, told me even if it is cancer I can wait on it and check it every year because thyroid cancers are indolent. However I've read that some thyroid cancers like medullary and a small portion of papillary and follicular are more aggressive.

I also read that hypoechogenity, vascularity and especially microcalcifications are highly suggestive of malignancy! So I'm very reluctant to wait a year before checking on this again!

My (only) TSH test was 1 year ago and it was 4. T3 and T4 were normal, so my doctor back then just told me I was absolutely fine and sent me home.

This week I'm also doing the calcitonin test (at my request) to check for possible medullary cancer. And also testing for autoimmune thyroiditis and such.

Does anyone have experience with nodules? Is anyone here who had microcalcifications and the nodules were benign? What should I do? Have another ultrasound with a different doctor to see if these features will be confirmed?

I'm just in a bit of shock as I wasn't expecting any of this. Thank you for any help.


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## Lovlkn (Dec 20, 2009)

> My (only) TSH test was 1 year ago and it was 4. T3 and T4 were normal,


You need to post the actual results with ranges.

A TSH of 4 is NOT normal, in range, yes but not normal. Most feel well with a TSH around 1.

I would also insist on a FNA of the nodule to rule out cancer.


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## psychopika (Mar 1, 2015)

Lovlkn said:


> You need to post the actual results with ranges.
> 
> A TSH of 4 is NOT normal, in range, yes but not normal. Most feel well with a TSH around 1.
> 
> I would also insist on a FNA of the nodule to rule out cancer.


TSH 4.06 [0.27 - 4.20]

FT4 16.9 [12 - 22]

T3 1.26 [1.3 - 3.1]

Those were a year ago.

My endo said that the nodule is too small to do a FNA and I should wait to see if it grows and come back in 6 months to 1 year.

Also I'm very reluctant about doing a FNA and inserting a needle in the nodule, because I'm afraid of the possibility of spreading the cancer by breaking its capsule and seeding cells along the tract of the needle. Especially if perhaps there's a medullary cancer in there which is more aggressive.

I'll wait for the calcitonin results first and then decide if I will do the FNA or wait or maybe go directly for surgery, what do you think?

If the calcitonin levels are negative (< 5), medullary cancer should be highly unlikely, right?


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## Lovlkn (Dec 20, 2009)

My bad mm vs cm.

How many times have you had your thyroid labs run?

17.5 is 3/4 of range for your FT-4. Total 3 is harder to gauge and if you re-test insist they run a FT-3 which should also be 3/4 of range.

You can get them run by ordering a lab slip if you are in the USA. This panel has the Free tests plus TSH and a few others for only $59

http://www.healthonelabs.com/pub/tests/test/pid/167


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## psychopika (Mar 1, 2015)

Lovlkn said:


> My bad mm vs cm.
> 
> How many times have you had your thyroid labs run?
> 
> ...


I've only had them done once, a year ago, because I was feeling very tired and foggy. Since then the symptoms disappeared after lasting for 1-2 months so I'm assuming they weren't thyroid-related.

What do you mean, your bad - cm vs. mm. Did you read that the nodule was 4.5cm instead of 4.5mm? Do you also think I should wait and see if it's smaller than 10mm?

I was just a bit surprised that the doctor was so relaxed about it, only because it was small, even if there are probable microcalcifications inside (she said she wasn't 100% sure) and slight vascularisation.

Does having 'slight vascularization' mean the same thing as 'vascular node'? I've read that a vascular node has its own blood supply. Not sure if that's the same thing?

Thank you so much for helping me out.

I'm not in the US, I'm in Europe.


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## joplin1975 (Jul 21, 2011)

Very, very, very few thyroid cancers are like medullary. And the vast majority of MTC cases are genetic. If you don't have a strong family history of MTC, the chances of you having it are exceptionally small.

"Seeding" of cancer cells really doesn't happen. The NIH ha published some nice articles that debunk that idea - you might want to google it.

That said, it's pretty hard to biospy a nodule that small. So, as far as I see it, your only options are to attempt to find someone who is willing to poke around you neck to see if they can hit it, or wait a bit (six months might be better) to see if the nodule ever grows enought hits the 1cm threshold for an FNA.

Those characteristics do raise red flags...but it's in no way meant to be a means for a diagnosis of thyroid cancer. Many people have thyroid nodules with suspicious characteristics and many of those cases are benign.

I agree that getting a thyroglobulin and thyroglobulin AB blood draw is a good move and think it will be much more informative than a calcitron test.


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## 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)

Trab
http://www.ncbi.nlm.nih.gov/pubmed/17684583
(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.

TSI
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://labtestsonline.org/understanding/analytes/thyroid-antibodies/tab/test
(Copy and paste into your browser)

Welcome!

Please insist on a biopsy. That nodule is highly suspicious and vascularity means it may have it's own blood supply.

Why wait a year? You will lose sleep over this and this may be the reason you have anxiety. Many of these nodules cause hyperactivity.

Listing some tests that would be good.


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## psychopika (Mar 1, 2015)

Thank you for your help!

I've seen another endo today and she was rather optimistic. She said 'slight vascularization' is actually a good thing and suggests non- or low-aggressiveness. The microcalcifications she says could be from other more benign causes as well (something to do with possible broken blood vessels?), but of course it's a red flag and we must keep an eye on the nodule in the next weeks / months.

Apparently calcifications are specific to papillary and medullary cancers so because of this and the size & vascualrization, anaplastic cancer is hugely unlikely and also follicular is less likely.

She gave me these tests to do - TSH, Free T4, ATPO, Thyroglobulin Antibodies, Blood calcium, Parathormone, Prolactin and of course the dreaded Calcitonin (to evaluate the possibility of medullary which she says exists but is less likely). Unfortunately with the basal calcitonin, even with results in the normal range, the possibility of medullary cancer still exists. I've read that 25% of small medullary cancers have basal calcitonin <10.

This week I will have all the results and I guess I'll go from there.

I wish I could do the pentagastrin stimulated test because that one is very accurate with respect to medullary cancer risk. It might not be available in my country, but I might just take a trip to a place where they do it (Austria, I hear).

They can't biopsy the nodule because it's too small and will have a high false negative rate. More than that I don't want to poke needles into it. If the calcitonin is off I will take it out. If it grows within 3 months I will take it out. I will check it every damn week if I need to.


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## psychopika (Mar 1, 2015)

OK, so first results are in.

Here they are:

Calcium 9.4 [8.4 - 10.2]

Ionized calcium 4.06 [4.0 - 5.2]

FT4 1.09 [0.7 - 1.48]

TSH 1.50 [0.35 - 4.94] so this got better on its own for some reason

Anti TPO antibodies 115 [ <5.6 ] these are highly elevated. Are they suggestive of thyroid cancer or Hashimoto's?


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## joplin1975 (Jul 21, 2011)

psychopika said:


> Anti TPO antibodies 115 [ <5.6 ] these are highly elevated. Are they suggestive of thyroid cancer or Hashimoto's?


Could be either. TPO is not meant to be used as a diagnosis, just as an indication that your thyroid is "under attack." Speaking very, very, very, very generally, while that result is elevated, most folks with cancer have a much higher number (mine was 720-something).

Make sure they run both thyroglobulin and thryoglobulin AB. The TgAB is really just another marker indicative of Hashi's or another autoimmune process...red flags for cancer go up with an elevated Tg *without* the presence of an elevated TgAB test.


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## psychopika (Mar 1, 2015)

joplin1975 said:


> Could be either. TPO is not meant to be used as a diagnosis, just as an indication that your thyroid is "under attack." Speaking very, very, very, very generally, while that result is elevated, most folks with cancer have a much higher number (mine was 720-something).
> 
> Make sure they run both thyroglobulin and thryoglobulin AB. The TgAB is really just another marker indicative of Hashi's or another autoimmune process...red flags for cancer go up with an elevated Tg *without* the presence of an elevated TgAB test.


So I guess that's not so good news.

Is a high TPO antibody level more related to papillary or medullary cancer, do you know?

I am also waiting for thyroglobulin AB. The doctor didn't want to do thyroglobulin because it's normally secreted by the gland and it's not specific.


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## joplin1975 (Jul 21, 2011)

Based on the good calcitron test, you should feel confident you do not have MTC.

An elevated TPO is most commonly associated with Hashi's first and in cases when it is very high (which to be clear, yours is not...many here would be thrilled with a TPO that low!), it is associated with both papillary and follicular cancers.

Your doctor is misinformed. Tg is normally secreted by the gland, but thyroid cancer cells often produce it at higher rates. That said, TgAB skews the results of Tg. So, TgAB without Tg or Tg without TgAB is useless. See: http://labtestsonline.org/understanding/analytes/thyroglobulin/tab/test/


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## psychopika (Mar 1, 2015)

joplin1975 said:


> Based on the good calcitron test, you should feel confident you do not have MTC.
> 
> An elevated TPO is most commonly associated with Hashi's first and in cases when it is very high (which to be clear, yours is not...many here would be thrilled with a TPO that low!), it is associated with both papillary and follicular cancers.
> 
> Your doctor is misinformed. Tg is normally secreted by the gland, but thyroid cancer cells often produce it at higher rates. That said, TgAB skews the results of Tg. So, TgAB without Tg or Tg without TgAB is useless. See: http://labtestsonline.org/understanding/analytes/thyroglobulin/tab/test/


Oh, I understand.

But I haven't yet received my calcitonin results. Those are just calcium, I don't know why she gave me those tests but whatever.

With so many signs I think I should prepare for surgery and have a talk with a surgeon. It's just too many signs, it would be stupid of my part to ignore them.

Even if by chance it's benign I will lose half of the thyroid. But if it's malign and there are so many things that point to that.... I don't know, isn't it better to get rid of it?


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## psychopika (Mar 1, 2015)

Just now I received the calcitonin result on my email.

It's 0.87 so it's clearly <5. I guess medullary cancer is now very unlikely.

Which leaves me with most likely papillary cancer... or a very evil benign nodule trying to drive me nuts.


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## joplin1975 (Jul 21, 2011)

Whoops, sorry I jumped the gun with the calcitonin.

I'm generally very pro-surgery wen it comes to thyroids, but in this case, with an incidental finding, I'd be hesitant to jump to surgery. I would be more inclined to try meds and put that nodule on a wait and watch routine.


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## psychopika (Mar 1, 2015)

joplin1975 said:


> Whoops, sorry I jumped the gun with the calcitonin.
> 
> I'm generally very pro-surgery wen it comes to thyroids, but in this case, with an incidental finding, I'd be hesitant to jump to surgery. I would be more inclined to try meds and put that nodule on a wait and watch routine.


Lol well you were right after all, the calcitonin did come up low enough to make medullary quite unlikely -> 0.87.

Maybe the doc thinks I should first do the thyroglobulin antibodies first and then the thyroglobulin? I will ask her about it when I see her.


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## jenny v (May 6, 2012)

To put things in perspective a little, I had many nodules, most of which were bigger than yours (although all under 1cm, thank goodness) and a higher TPO Ab than yours and I did not have cancer. I had Hashi's and a thyroid that had lost its mind and was trying to grow back into my neck.


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## psychopika (Mar 1, 2015)

jenny v said:


> To put things in perspective a little, I had many nodules, most of which were bigger than yours (although all under 1cm, thank goodness) and a higher TPO Ab than yours and I did not have cancer. I had Hashi's and a thyroid that had lost its mind and was trying to grow back into my neck.


Apparently from a study I read, when high TPO Ab are associated with multiple nodules it is less likely that it's cancer. When it's a single nodule it's more likely.

In any case, I will try to keep calm and optimistic, whatever it is it's small and IF it even moves 1-2mm in size I'll take it out and end it. The calcitonin test is also encouraging that it's probably not medullary. And anaplastic... I think that's super unlikely at this size and super unlikely in general as well.

I will let you know what the rest of my test results will be (Tg Ab, PTH, Prolactin). And what the doctor will say.

Thank you for your help and support it really means a lot to me because I'm so new to thyroid issues and I'm thrown directly into a probable high-risk issue. I'm a bit in shock.


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## joplin1975 (Jul 21, 2011)

You are very, very far from the high risk category. Very far.  Which is a good thing. Hang in there...you'll get your answers soon enough.


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## psychopika (Mar 1, 2015)

joplin1975 said:


> You are very, very far from the high risk category. Very far.  Which is a good thing. Hang in there...you'll get your answers soon enough.


I will, joplin.

Thank you for reassuring me, I hope indeed I'm not in (big) danger with this thing.

If I decide to wait and watch, I'll probably have an US every month. I'm a huge hypochondriac and cancer has been my greatest fear for years.


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## psychopika (Mar 1, 2015)

I've just received another test result.

Anti-Thyroglobulin Ab are 33 and range is [<4.5]. So they're elevated too.

That makes cancer more likely from my understanding.


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## joplin1975 (Jul 21, 2011)

psychopika said:


> That makes cancer more likely from my understanding.


Nope, again, read the previous link. TgAB without Tg is pretty much useless. It does tell you that you've got something going on, but without TG...you have no idea what that something is.


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## psychopika (Mar 1, 2015)

joplin1975 said:


> Nope, again, read the previous link. TgAB without Tg is pretty much useless. It does tell you that you've got something going on, but without TG...you have no idea what that something is.


But doesn't a high TgAb mess with the Tg results?

"A thyroglobulin antibody (TgAb) test is typically ordered along with the thyroglobulin test. Thyroglobulin antibodies (also called thyroglobulin autoantibodies) are proteins produced by the body's immune system that attack thyroglobulin. These antibodies can develop at any time. *When they are present, they bind to any thyroglobulin that may be present in the blood and interfere with the interpretation of the thyroglobulin test. Once they have developed, they will not go away and from that point forward will affect the usefulness of the thyroglobulin tes*t."


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## joplin1975 (Jul 21, 2011)

Exactly. So you are no closer to cancer vs. no cancer as before.

FWIW, I had TgAB, but once my thyroid was removed, those antibodies disappeared so my TG test is accurate.


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## psychopika (Mar 1, 2015)

joplin1975 said:


> Exactly. So you are no closer to cancer vs. no cancer as before.
> 
> FWIW, I had TgAB, but once my thyroid was removed, those antibodies disappeared so my TG test is accurate.


How high were your Tg Ab, do you remember?


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## joplin1975 (Jul 21, 2011)

Not off the top of my head, but I do know everything was in the hundreds/three digits.


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## psychopika (Mar 1, 2015)

OK, so for those who are following this...

I went to the doctor an hour ago. She confirmed me having autoimmune thyroiditis. The ultrasound showed that the nodule didn't grow in these 2 weeks so it's clearly not anaplastic . She didn't see microcalcifications so that's a feature that's not confirmed for now, because 2 technicians didn't see any and only one did, but vaguely. Also, she said the vascularisation is the same as the surrounding thyroid tissue. So this is more or less good news. Also the thyroid gland is a bit on the bigger side of normal, but she said I was ok anyway (probably because of the Hashimoto's?)

I will have my nodule checked every 6 months (I will probably do 3 months at first because I'm a sick f*ck and I want to keep as safe as possible). Same with TSH and FT4. And what's best is that she said in the meantime I can continue to try for a baby!

So I'll go on with my life and keep an eye on this little f*cker in the meantime. Also supplementing on Selenium, Vitamin C, D3, B12, Aloe Vera extract and drinking a lot of fruit juices and vegetables.


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