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Update: got my thyroid ultrasound. Should I be worried? Need an FNA

Update: just got my ultrasound report: impression:Left : 1. 3.1 x 1.7x 2cm solid hypoechoic nodule with Doppler flow TR4. Numerous other suncentimeter spongiform nodules have a benign appearance, measuring up to 6 mm,TR1. FNA biopsy is indicated at this size. Right:  numerous subcentimeter spongiform nodules, measuring up to 6mm, benign in appearance TR1.
Should I be concerned?
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Avatar universal
Hi Tiredgirl68,

Most thyroid nodules are benign (90-95%), and many people, especially women, have thyroid nodules and don't know about it.  I was told that 20% of 20 year old women, 30% of 30 year olds, 40% of 40 year olds, etc. have thyroid nodules.  

Because of your nodule size (at or greater than 2 cm) and because it is hypoechoic, it is important to get an FNA because those features put you at a slightly higher risk, but that doesn't mean your nodule is cancerous  At this point we can't say whether it is something to be concerned about or not until you get the FNA, but as long as you get the FNA you are doing what you need to do to take care of the nodule.

I saw your other post that gimel answered - I'm surprised that your antibody tests were negative because numerous subcentimeter spongiform nodules sounds a lot like what I had (chronic untreated Hashimoto's which led to a multinodular goiter, so I had lots of nodules all over my thyroid).  I know other things can cause multinodular goiter, but usually in countries where they use iodized salt, the main causes are usually Hashimoto's or Graves diseases, both autoimmune thyroid diseases, and the terminology used "numerous subcentimeter spongiform nodules" sounds very much like thyroiditis, compared to a normal thyroid tissue which they normally would describe as "Isoechoic" or "homogeneous".  Hashimoto's can cause subclinical hypothyroidism where you have many, many hypo symptoms but your TSH is "in range" because your thyroid goes through fluctuations where it is attacked by the immune system, produces less hormone, and then TSH increases stimulating thyroid growth and production of more hormone.  This can cause fluctuations of TSH and often tests show you have "normal" TSH when you are experiencing a lot of hypo symptoms.  If you have results for your antibody tests, posting them here would be helpful because most of what you've described sounds like Hashimoto's to me (except for the negative antibody tests, but I don't actually know what was tested).

My thoughts are get your thyroid nodule biopsied because that is very important.    If you have the results from your thyroid hormone and antibody tests, posting them would be helpful so we can actually see where your hormone levels are and where your antibody numbers are at (and if your doctor has actually done the correct tests needed to assess thyroid hormone and antibodies).   If you are in the US your doctor is required to give you your actual test results if you request it (like a paper or digital copy).  

I'm sorry you are going through this - this is pretty similar to what I went through a year ago, and I know how frustrating it can be to try to convince the doctors you have a problem when they say everything's fine.

Oh.. and to answer your other question here, you can have totally normal thyroid function and have a goiter or nodule.  A lot of people have nodules and perfectly fine thyroid function, but your symptoms and the fact that you have lots of little nodules makes me think something else is going on in your case.
8 Comments
Thanks! I have almost every symptom of hypothyroidism. TSH was 1.000, thryoid peroxidase 12, thyroglobulin antibody <1.0. I live in a very small town and the ent I’m seeing for this says it’s very difficult to get into an endocrinologist here. But, I’m going to call one myself on Monday and try to make an appointment. I’m feeling like this dr I’m seeing doesn’t really know what to do. I work in the medical field and had the ultrasound in front of me when he called to tell me the result. He mentioned nothing to me at all. He didn’t tell me both sides were effected, he onky mentioned the biopsy needed. He also then went on to talk about false positives and biopsy’s that are inconclusive. He stated if the biopsy is inconclusive, we would wait 6 months and do it again? I’m not waiting 6 months if this is a possible cancer. I’ve read that being over 3cm makes the risk for cancer higher? Idk what to do. Feeling like I’m having to run my own care.
Hmm... inconclusive is one possible result of the biopsy, but I wouldn't jump to worrying about an inconclusive result just yet.

The usual results from a thyroid nodule biopsy are:
1.) benign - nothing to worry about right now.  Monitor every 6-12 months by ultrasound for change in size/texture.
2.) inconclusive - usually this happens when not enough cells are collected for the slide analysis.  This can happen to any size nodule, but I feel like I read about it happening most often in nodules that are partly cystic (part solid, part fluid filled) and nodules that are too small.  At 2 cm they should be able to get plenty of cells out, and my pathologist did two biopsies per nodule (out of two nodules biopsied), so hopefully this won't be a problem for you, but if it is inconclusive see below.
3.)  suspicious for neoplasm.  This means there are some cells that look like they might be cancerous (like lots of Hurthle cells or cells that look like follicular neoplasm).  If this is the result, then there is a higher likelihood of cancer, but still most of these end up being benign.  One of my nodules was suspicious for neoplasm, and my pathologist said that meant 30% chance of cancer.
4.)  malignant - the nodule is cancerous, and usually the next step is a thyroid lobectomy or total thyroidectomy.

As for if you get an inconclusive result should you worry about that --- most hospitals now use around 2 cm as the lower limit for deciding to do a fine needle biopsy for a few reasons.  
1.) To avoid unnecessary thyroid surgeries.  Tons of people have nodules, most are not cancerous and most thyroid cancers are very slow growing that even if you miss some, chances are the person is going to be completely fine.  (I'm not going to say if I agree with that or not, but I think that is what their logic is)  
2.)  At 2 cm, the chance of a nodule being cancerous increases from around 10% for nodules under 2 cm to 15% for nodules 2 cm and above.  There is not an increase as the nodule grows in size larger than the 2 cm (Kamran SC et al. Thyroid nodule size and prediction of cancer. J Clin Endocrinol Metab 2013;98:564-70. Epub December 28, 2012; doi: 10.1210/jc.2012-2968.) (except an increased risk in rarer types of thyroid cancer as the nodule size increases).
If you get inconclusive, most nodules grow so slow that waiting 6 months is probably not going to be harmful, but I wouldn't immediately worry about an inconclusive result until you are actually at that point.

As for suspicious for neoplasm - a 30% risk of cancer is a lot higher than the 10 to 15% we've discussed so far.  Usually the choice for this is "wait and see" or "thyroid lobectomy".  I was lucky that my pathologist did my biopsy himself and immediately told me the results, and we decided right at the FNA to do Afirma genetic testing on the suspicious nodule.  Normally, if you get a suspicious for neoplasm result on FNA, there is no way of telling whether it is cancer or not without doing a lobectomy and looking at pathology of the nodule.  A lot of those nodules end up being benign (over 60%), and now you have someone with half a thyroid or no thyroid when there was no cancer.  So in my case, we did another FNA, took those cells and sent them to Afirma where they look for mutated genes and determine whether it is a.) benign, b.) still suspicious for cancer 50% risk, or c.) malignant greater than 99% risk.  If my Afirma testing came back benign, we'd just monitor by ultrasound and FNA.  Unfortunately mine came back still suspicious, so I had a thyroid lobectomy.  (My suspicious nodule actually did end up being cancer, but I was lucky that I caught that and two additional cancerous nodules before they spread outside the thyroid so I didn't need any radioactive iodine).

After going through all of this, I can tell you the worst part for me was waiting to get results from the FNA and then waiting to get the Afirma results.  After that, I knew what my treatment plan was going to be (even if it was surgery and an eventual cancer diagnosis, I knew what the next steps were).  I actually ended up waiting 2 months after my Afirma result for the first surgery (thyroid lobectomy) and then another 2 months to get the rest removed after that came back as cancerous, but I was not worried about it spreading during that time period because most thyroid cancers are very slow growing.

Thyroid cancer is usually very treatable and has an excellent survival rate, but again, right now your risk is still right around 15% until you get a fine needle aspiration and find out more, and I wouldn't assume yours is cancerous at all.  I had an aunt who was going through biopsies at the same time as mine, she had nodules that were more "suspicious" than mine in terms of blood vessels, calcifications, partly cystic, and hers were benign on FNA.  85% chance of being benign is pretty high.

Anyway - I hope this helps.  I know I mentioned some possibilities that are not desirable, but right now the risk for cancer is quite low.  I think once you have FNA results you will feel more comfortable with deciding what the next step is going to be, but at this moment not knowing can be very frustrating and scary.

If you do end up needing thyroid surgery (which right now I don't think is likely, but I also didn't see mine coming), please make sure your surgeon does many thyroid surgeries per year and has a low complication rate.  My ENT was my thyroid surgeon, and she performs hundreds a year and I'm very thankful for that because I ended up having a lot of swollen lymph nodes due to my Hashimoto's which were removed and biopsied (and were benign), and your risk of complication (damage to parathyroid glands and laryngeal nerves) is so much higher if the surgeon only does a couple a year.
Thank you so much, this information is very helpful to me. Very helpful. The suspicious nodule is over 3 cm. Why would my ent go into talking about “inconclusive “ biopsies at this stage? He also didn’t relay the whole report to me. That was what got me thinking I wanted to see an endocrinologist. All the information you provided does ease my mind on many things. Thanks so much. I feel right now like I’m on my own in figuring out my care. I’m going to call one tomorrow and see what I have to do to get an appointment. Even if it’s months away, at least I will eventually see a more specialized dr. If it does end up that I need surgery, what kind of dr does the surgery? An ent or general surgeon or do endocrinologist’s do surgery?
My ENT did my surgery, so I lucked out there.  My endocrinologist did the "follow-up" cancer care, which was basically looking at thyroglobulin levels and deciding not to do radioactive iodine.  It looks like general surgeons also do thyroid surgery, I think the main thing to look for is someone who does more than a couple thyroid surgeries a year.  

Surprisingly, something like 51% of doctors who perform thyroid surgeries only do them once a year, and the risk of complications in that situation is a lot higher (87% higher).  Doctors who do 2-5 per year have a 68% increased risk, and those who do 11 to 15 have a 22% increased risk, and those who do 16 to 20 have a 10% increased risk.  The risk seems to even out once the surgeon gets to around 25 surgeries per year.  My ENT performs "hundreds" a year, according to her.  I didn't believe that until I was waiting for a calcium test after my second surgery and she wheeled in the thyroid patient who was after me... I think she just bangs out 5 -6 surgeries one a day a week, and a lot of those are on thyroids.  I asked what my surgeon's complication rate, and she said it was below the national average, but I can't remember the numbers right now.  The overall risk for serious complications with thyroid surgery is less than 2%, but that depends on the surgeon.  (Also, hemithyroidectomy or thyroid lobectomy is a much safer surgery than a total thyroidectomy because chance of permanent nerve damage or loss of parathyroids is a lot lower).

I would say thyroid surgery is probably lower risk than a lot of other types of surgeries, but there is a possibility of parathyroid gland damage or loss (which could cause inability to regulate calcium levels), and laryngeal nerve damage which can cause temporary or in some cases permanent voice changes or loss of voice.

I hope you don't actually need thyroid surgery, and definitely don't think you are at the point of needing to track a surgeon down right now, but one thing to consider is if you are having problems swallowing and a tight throat feeling, it is possible your thyroid is interfering with your other "throat structures" like your esophagus and trachea, and even if you don't have thyroid cancer, the obstruction of those things might indicate you need surgery.  I wouldn't immediately jump to that conclusion, but sometimes nodules protrude and push in to other structures, and that would be something to talk to a doctor about.  Especially if your thyroid continues to grow, this could become more of a problem - not something to jump right in and remove your thyroid for now, but something to consider when monitoring the thyroid growth. If your ENT is already dismissive about your goiter and nodules, maybe talking to a different doctor, especially if you get a hold of an endocrinologist, would be helpful.  
Yep. I called an endocrinologist this morning and asked my ent to send them a referral . One of the problems is that I live in a tiny town. It will take about 1 month just to get in for the biopsy and maybe 6 months to get in with the endocrinologist. Hopefully the biopsy will be benign. Unfortunately, my state has an above national average for thryoid cancer diagnosis. High desert ? Radon? Idk. Thank you for so much helpful information to think about. I truly feel like I’m on my own here. My ent won’t do a T3 or T4 testing or other labs and didn’t even tell me the whole results of the ultrasound.
Why do you think there was such a big difference in the main nodule’s size on CT and then on ultrasound? On ct it was measured at 1.8 x 1.7. When I was able to get in for the ultrasound a month later it measured 3.1 x 1.7 x 2cm? Is that a result of the modalities being so different?
I am not an expert, but I suspect you are right - CT vs. ultrasound may result in  different dimensions, also it could just be the person doing the reading is making different decisions on what constitutes the nodule and what is "normal" thyroid tissue, and that differs from what the CT radiologist was deciding.

I just googled thyroid nodule size CT vs ultrasound, and found an article in Clinical Thyroidology for the Public published in August, 2017, titled: Incidental thyroid nodules detected on CT, MRI, or PET-CT scans correlate well with subsequent ultrasound evaluation.  The summary of this article states that CT, MRI, or  PET-CT underestimate size compared to ultrasound. The average size thyroid nodule from CT, MRI, PET-CT was 1.56cm, when same nodules were measured on ultrasound the average was 1.75cm.  That's not a significant difference, but does indicate a trend of CT underestimating the size.

Does the CT result have a third dimension?  

3.1 cm vs. 1.8 cm is quite a big change (since the article suggests around a 0.2cm difference).  I wouldn't read too much into the CT vs ultrasound difference at this point though.  Do they have the full dimensions (all 3?) for it or just recommended ultrasound based on the dimensions they had (1.8cm x 1.7 cm, which aren't too far off of the smaller dimensions on the ultrasound).   Maybe they are missing that larger dimension if they weren't specifically looking for thyroid nodules and it showed up incidentally.

Regardless of the size discrepancy in CT vs ultrasound, the next step is fine needle biopsy and hopefully that will give you an idea of what the next step will be for you.  There is still a good chance your nodule is benign, but I can sympathize with how anxious this part of the diagnosis can be.  (Waiting to have the fine needle biopsy (and then Afirma testing) was the worst part of my diagnosis for me, that was when I was learning way too much about thyroid cancer and nodules.  The uncertainty of whether I needed surgery or not was worse for me then actually learning I needed surgery and then being able to move on and deal with that).
Thanks! I’m going to assume it is benign. I’m seeing an endocrinologist on Thursday and hopefully he will be able to do a thorough work up. I wish I could get in sooner for the biopsy, so I can put this all in the past etc.
Avatar universal
AS I mentioned and explained in my reply on your other thread, you should not automatically expect that an Endo will be a good thyroid doctor like you need.   The probability is very low.    I understand that you are focused right now on the biopsy, but that is only part of your thyroid issues.   You seriously should not just wait for 6 months, while assuming that the Endo you mention is going to be the good thyroid doctor you need.   That is why I mentioned that we might be able to help locate a good thyroid doctor if you are interested and will give us your location.  
1 Comments
I was able to get an endo appointment for next week...
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