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Wondering if I wait for 6 month follow up or push for further testing?




HISTORY: Left thyroid nodule seen on head CT study.



COMPARISON: No prior images available for review.



FINDINGS:
Right thyroid: Measures 1.5 x 4.5 x 1.5 cm. Homogeneous echogenicity.
There is a 0.4 x 0.2 x 0.4 cm hypoechoic lesion in the mid pole.

Left thyroid: Measures 1.6 x 5.4 x 1.4 cm. Homogeneous echogenicity.
There is a mixed cystic and solid 2.1 x 1.5 x 1.5 cm lesion with
indistinct margins in the lower pole.

Isthmus: measures 0.3 cm. . There is a 0.8 x 0.4 x 0.6 cm hypoechoic
lesion with indistinct margins.

IMPRESSION: Multiple bilateral thyroid nodules as described above.
Six-month follow-up is recommended.

POS- VMG
1 Responses
Avatar universal
Hi Michelleb73,

I think the new guidelines recommend biopsy of the nodule if it is larger than 2 cm, so I'm not sure why the recommendation is follow-up in 6 months.   According to the guidelines written on my ultrasound, there is a very low suspicion for nodules greater or equal to 2 cm with very low sonographic pattern (spongiform) (less than 3% risk of cancer), and low suspicion for greater than 1.5 cm with isoechoic or hyperechoic patterns (5-10% risk of cancer), but they still recommend biopsy of nodules of those sizes.  Since your ultrasound doesn't say whether that 2.1 cm nodule is hypoechoic or hyperechoic, and that the left lobe is homogenous echogenicity, there's a good chance that the solid portion of the nodule is homogenous echogenicity (same as the rest of the left lobe, which would be low risk), but  it is unclear.  Things that would increase the risk for a nodule are: hypoechoic, irregular margins, vascularity, calcifications.  Indistinct margin is not the same as irregular - I think indistinct in this case means it is difficult to tell where the nodule ends and the regular thyroid tissue begins - which makes sense if it is isoechoic/homogenous with the rest of the left lobe (and according to my ultrasound sheet, even with partially cystic nodules that is in the low category (5-10% risk)).

Your other nodules are too small to recommend biopsy for them at this point but still need follow-up ultrasounds because "hypoechoic" would put them in an intermediate category if they were bigger (10-20% according to my sheet).

Most nodules are not cancerous, and with thyroid cancer even if the nodules are cancerous, most thyroid cancer is very slow growing, which is why they can hold off on biopsies until it reaches a certain size threshold.  Maybe they are recommending no biopsy because it is just above a size threshold of 2cm?

I'm sorry you are going through this and I know the waiting game is very frustrating.  Here are my thoughts if it were me... That 2.1 cm nodule is already big enough to biopsy, and it would probably give you some peace of mind to get it biopsied and find out if it is benign or not.   I don't think it would "hurt" to wait and follow-up in 6 months with another ultrasound, but if you are like me and are probably going to worry about it in the meantime, I'd push for having the biopsy done now.  

Do you have a specialist helping you to diagnose your nodules or just a primary care physician giving you recommendations at this point?  As soon as my ultrasound results came back (I have multinodular goiter with lots of nodules), I got a call from an ENT to schedule an appointment before I even knew what the results said!  (I also got a call from my ENT's scheduler to schedule my surgery before I even knew I needed the surgery, so my ENT is a bit "too" on top of things I think).  

4 Comments
Thank you very much. I was going to ask for the biopsy because I rather know now and not worry about it.

So far I have only been working with my PCP but she did just put in a referral for an endocrinologist and ENT.

I have been having dizzy spells for 8 months with no answers. I’m trying to find out why. Not sure the thyroid has anything to do with it but I need to speak with a specialist to explore.

Good lick to you and thank you again.
No problem.  I'm glad you are going to see a specialist - my PCP wasn't the greatest at interpreting my ultrasound and biopsy results.

If your doctors haven't already, they should test your thyroid hormones (TSH, free T3, and free T4) to see if your thyroid is functioning properly.  There are a lot of things that can cause dizziness, I know hypothyroidism can cause low blood pressure and dizzy spells, so you should at least look at that as a possible cause.  

My younger sister has extremely low blood pressure and dizzy spells off and on, she's never had her thyroid levels tested but since my diagnosis I've been pushing for her to get her thyroid hormone levels checked next time she's in for a check-up.

I hope all goes well for you with your biopsy!  
My TSH is 1.29.  Free T4 is 1.14 and total T3 is 1.02.  I asked her to do the Free T3 and for some reason she did total T3.  Getting frustrated with my doctor.
Hi Michelleb73,

I would post the reference ranges so people can help figure out if your thyroid is working properly or not.  TSH is usually a pretty standard range, but for T3 and T4 the reference ranges can vary from lab to lab.  I would post a new question for help interpreting your thyroid hormone results with your current numbers and the reference ranges, mentioning your hypo symptoms/dizziness, so people who have more experience with these hormone tests will see it.  

I have had one hormone test and know the basics of reading the results, but I'm very new to thyroid problems and I'm not an expert on what the hormone test results mean.  I know you want to be in the top halves of "normal" for both freeT3 and free T4.  TSH of 1.29 is pretty good usually, but TSH is not the best test for measuring thyroid function.
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