Suspicious Nodule? Ultrasound results...

[Momnipotent1]

**I previously posted this in the Thyroid Disorders community but I realize now this is the right forum.**

I have had a single nodule on my thyroid for the last 4 years that I know of.  At the time it was discovered, an FNA was recommended and it came back indeterminate.  My endo advised me to do nothing and check on it in a year.

Of course I'm a chump and didn't have it checked again until last December (December '12) because I felt (and still feel) a fullness in my throat that feels like there is something stuck in there. My PCP ordered the ultrasound and ultimately told me it's nothing to worry about, no follow up necessary.

I recently switched PCP's and the new guy looked over my charts and past ultrasounds and sent me to an ENT doctor who told me that the nodule on my thyroid appears to have some markers for cancer so he sent me for another ultrasound.

I have another FNA tomorrow but the ENT doc said regardless of the results he would recommend surgery.  The results of my ultrasound are below.  What do you think?  Is this actually suspicious of cancer or am I getting hyped up for no reason?  Is this significant growth in a nodule over a period of 7 months?  Thank you in advance for your time.

FINDINGS:
Right lobe:  Measures 5.0 x 1.8 x 2.1cm and is normal in echotexture and contour.  1 nodule.
1.  Central gland heterogeneous slightly hypoechoic lesion with moderate internal vascularity and scattered coarse calcifications 2.2 x 1.6 x 1.4cm, previously 1.8 x 1.5 x 1.2cm.

Left lobe:  Measures 5.1 x 1.4 x 0.9 cm and is normal in echotexture and contour.  There are no nodules.

Isthmus:  3mm

IMPRESSION:
1. A large dominant right lobe nodule is growing compared to December 2012. Recommend FNA if not previously performed.

I should also mention that all of my thyroid levels are within normal range. :)

[Momnipotent1]

First of all, I just want to say thank you for taking the time to answer these questions.  Not just mine, but everyone's.  If I was in FLA, I would be booking an appointment in your office asap because you obviously care about people and that seems to be rare to find these days.  So THANK YOU!

Now, I had the biopsy as mentioned and am still waiting on results.  The doctor (who I had never met before) ended up trying to extract..  material..  from the nodule 5 different times.  The first 3 times, the needle would not penetrate the nodule, instead it "bounced" off of it and the doctor commented that it was pretty firm. (Thankfully I had been numbed prior to this, but it did actually ache pretty nicely after the lidocaine wore off.)  He had to change the gauge of needle and was successful in getting the samples needed after 2 more tries.

Also, I had mentioned that I have a feeling of something in my throat.  I asked my ENT and he said it was likely not the thyroid as the nodule (2.2cm) would be too small to feel.  However, when the FNA was being done, I could feel the pressure right where the nodule is and it intensified in the exact same spot as I have been feeling a "lump" in since December.  The soreness I felt in my neck for the next day or so was centralized right over the "lump" in my throat.  This can't be my imagination, can it?

I am supposed to find out the results of the FNAB tomorrow.  I will post when I know more.

Thanks again!

[Mark Lupo, M.D.]

The calcification and internal vascularity are sometimes higher risk features.  At minimum a repeat FNA is warranted (as planned) - but an indeterminate result carries about a 25% chance of cancer - if it is clearly growing or causing symptoms, then surgery is often recommended to make a definite diagnosis. This may be a case, however, where molecular markers would help guide the extent (if any) of surgery.  This is rapidly evolving field that is contraversial, but in general if at least a lobectomy is planned then doing a mutation panel (Asuragen and Quest offer this on FNA samples) can identify high-risk mutations that would suggest a total thyroidectomy.  If otherwise clinically benign and the desire is observation, then the Afirma test may be helpful to further risk stratify the nodule.  

Also - thyroid blood tests are usually normal w/ nodules and a normal TSH does not predict for/against cancer - while a higher TSH may increase the risk of a nodule being cancer.