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Old 04-24-2013, 07:22 AM   #1
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Any insight on labs and ultrasound results welcomed

Hi, I'm Ann - a newb. This is my first post. I hope it's OK that I started a thread.

About 7 years ago, I had a multinodular goitre with three significant nodules and lots of smaller ones, but all biopsies and hormones were normal. I sort of forgot about it and increased my iodine intake because a urine test showed it was 'critically low'. I have noticed one of the nodules getting bigger, but didn't worry about it too much.

Went to a different Dr last week to get it checked and the nodules have more than doubled in size. I can't see an endo until next week because of a waiting list, so any comments would be welcomed as I really don't know what all this means. Thanks in advance! Note that my lab results are from Australia.

TSH (0.5-4.5) < 0.02
Free T4 (10-20) 48 - Well over double of the maximum in the range.
Free T3 (3.5-6.0) 23 - it seems to be 4 times higher than it should be.

Apparently, I'm hyperthyroid. News to me.


Now for the ultrasound.

Multinodular Goitre - growing

There is a diffuse thyromegaly, the right lobe measuring 9.6 X 5.2 x 3.7 (96.6ml), left lobe approx. 9.3 x 3 x 3.6cm with a volume of 48.2ml. Isthmus measures approx. 0.7 cm in thickness.

Multinodular change is noted with a generally heterogeneous echotexture to the thyroid. The largest nodule is at the upper to mid pole on the right where there is a large predominately solid heterogeneous nodule measuring approx. 4.2cm in maximum diameter. The largest nodule on the left at the lower pole measures 3.6cm in maximum diameter and of similar features with a solid heterogeneous nodule. There does appear to be retrosternal extension to the thyroid most marked on the right. No significant increase in vascularity.

Recommended: non contrast CT scan of lower neck and upper chest in correlation with thyroid function tests.


So is this serious?

 
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Old 04-24-2013, 11:27 PM   #2
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Re: Any insight on labs and ultrasound results welcomed

I think just based on stuff I've read, your thyroid is pretty large with two large nodules. Usually they're about half that size. So yours is pretty big. I assume it's causing symptoms of some sort?

What's odd is your lab results, they are high, yet you're claiming no symptoms. It's possible that there was a lab error or a mix up. Also sometimes people have antibodies in their blood that cause lab results to be higher than they actually are.

I would I'd think the following things.

Maybe lab error and T4 and T3 aren't actually high. IE, someone mislabeled your blood samples. Or the tech had a 'Monday'
Maybe anti-mouse antibodies in your blood are interfering with your labs. (google: Human anti-mouse antibody).
It's possible that you have thyroid hormone resistance. T4 and T3 are high because a genetic defect. Unlikely 1 in 50,000 chance, but... with billions of people in the world it's got to happen to someone.

>So is this serious?

Offhand I'd say yes and no. No emergency I think. But might require treatment of some sort. Almost 100% chance this isn't going to kill you.

I think your endocrinologist is going to be kind of interested in what's up with you. If he's not, bail and get another one.

Probably the worst is he may refer you to surgeon since your goiter is large. I get the feeling that surgery is some degree of unpleasant, but not terribly so for most people. But I have no idea if you need that, just keep it in mind so you're not suddenly freaked out. Also might you don't need that now but might need it in the future. Surgeons are an inscrutable lot, so who knows.

I think reasons for surgery are.

Cosmetic. Your goiter spoils the delicate lines of you neck.
Compression symptoms, pain, choking feelings, etc.
'Hot nodule' or Cancer. (Cancer very unlikely, very high cure rate, don't worry)
Likely to become bigger and thus harder to remove later.

If graves they may prescribe drugs to suppress your thyroid, but if you currently feel 'okay' you should be a bit wary of accepting that. I'm not saying don't but the endocrinologists needs to be able to articulate a clear line of reasoning why.

You should have your labs done again along with antibody tests before doing anything else. First to make sure that your earlier labs actually are correct and not due to some mixup or other error.

If your labs still show high T4 and T3, plus low TSH, and you still fell 'fine' then should really consider if you have thyroid hormone resistance. If you have thyroid hormone resistance, and they remove your thyroid, you'd need a lot more thyroid hormones to keep you healthy.

They also may order an FNA biopsy of your two largest nodules. This is usually not a big deal. Likely hood of cancer is low, and most thyroid cancer has a nearly 100% cure rate. And what you say looks more like standard autoimmune disease or some sort.

Good Luck.

 
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Old 04-25-2013, 03:45 AM   #3
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Re: Any insight on labs and ultrasound results welcomed

Thanks for your response. I was anxious because it was unexpected. I forgot to mention a couple of things. My mother was diagnosed with hyper just this year. Last month she had to take a radio active iodine tablet. She's doing better so far.

My nodules are visible and have been for a while. In fact, I can only sleep resting on one side, but I never thought to worry about it. Now I realize that I have had a few of symptoms, but only for the last month or two: Itchy skin/rashes/swollen feet (especially at night), hair loss on scalp (for years), and maybe I have been feeling a bit hot and tired for the past few months, but we've just finished a hot summer over here. I haven't had a day off work in a year or so I don't feel that bad.

Hopefully, the endo will do some further investigating. My Dr did say surgery was likely. I guess I'll just have to wait and see. I'll post back and report what happens. Again, I really appreciate your info. Especially the stuff about the antibodies. It has been interesting reading this forum.

 
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Old 05-03-2013, 07:10 PM   #4
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Re: Any insight on labs and ultrasound results welcomed

Thought I'd post an update. I'm so glad I went to the specialist. I have a tendency to focus on work and completely ignore my health. I didn't even realize I was sick. I had no idea my heart rate was 120 and that I am hypertensive at 37 years of age.

Apparently I have thyrotoxicosis caused by a toxic multinodular goiter. I was told that it could be hyperthyroidism or Graves (he doubts the latter because my eyes are normal, but I have to get an antibodies test). Endo also said that I would need a total thyroidectomy, as it's too big. This can't be done for several months until I'm back under control. I was subscribed beta blockers and I have to take carbimazole (30 mg/day) for one month before submitting bloodtests. He might reduce the dose after that.

I also had a thyroid scan (the nuclear/iodine uptake one), but I haven't got the results back yet. I'm just glad the endo didn't pussyfoot around like I've heard some of them do.

 
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Old 05-07-2013, 12:55 AM   #5
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Re: Any insight on labs and ultrasound results welcomed

Got a Nuclear Medicine thyroid scan. Not due to see the Dr for a while, so I picked up my own results. Don't really know what it all means, but I'm curious.

Procedure: Following the injection of radiotracer, multiple images of the thyroid were performed.

There was heterogeneous distribution of tracer throughout both thyroid lobes, with both lobes appearing enlarged. There was relatively increased tracer uptake seen in the midpole region of the right thyroid lobe. There was functioning thyroid tissue in the upper pole of the left thyroid lobe. There was decreased tracer uptake with a rounded appearance in the upper pole of the left thyroid lobe and in the isthmus/lower pole of the left thyroid lobe. The thyroid appeared to extend below the level of the sternal notch. Background and salivary gland activity was suppressed.

Thyroid uptake 9% (normal 0.4-4%)

Conclusion:

The findings on today's study show a multinodular goitre. There is a hyperfunctioning nodule in the mid pole of the left thyroid lob. The findings in the upper pole of the right thyroid lobe and the lower pole of the left thyroid lobe/isthmus have the appearance of 'cold' nodules. Correlation with ultrasound and fine needle aspiration biopsy of these sites, if appropriate, is suggested. Suppression of these regions could give a similar appearance, although the upper pole of the left thyroid lobe appears relatively uniform and less suppressed than these two regions.

 
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Old 08-22-2013, 07:15 AM   #6
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Re: Any insight on labs and ultrasound results welcomed

Just thought I'd post an update because I don't see many threads with non-Graves toxic multinodular goitre.

After four months on carbimazole (30mg/day), my hormones are finally in normal range (except for TSH which has always been non-existent). The first two months, I was really, really sick. I could barely walk up a flight of stairs or catch the bus to work, but I started to get better after that.

I still don't feel quite right, but my muscles and limbs are much stronger and I can walk more than a km again. There are no more rashes, itching, night sweats, insomnia, rapid heartbeat or swelling. I haven't put on any weight as I've heard happens on this med.

I do have forgetfulness and unclear thinking at times as well as high blood sugar. I had to take at least 20 working days off over the past few months (for which I wasn't paid). Last year I took zero days off. I also had to switch to afternoon work because I used to feel so sick every morning.

The endo and surgeon agree that the entire thyroid must come out ASAP due to its size and toxicity. They say that remission is highly unlikely. The endo never ordered an FNA.

My surgery date is Sept 9 - just over two weeks away. It's such a relief after 4 months of waiting for my hormones to get back in range. I just have to get a CT scan to see just how far it's grown into the chest, EKG (I have a genetic heart murmur) and a couple of other tests.

(This is only relevant for Australians). I have private health insurance - top hospital- but it was still going to cost me $3500 out of pocket in total (he's one of the best surgeons in Sydney, so can charge what he likes and there's the anesthetist). I found another surgeon in a smaller town who was willing to do it with no out of pocket extras, but I was nervous about how experienced the surgeon might be and what their specialty was.

When I told my expensive surgeon and endo that I couldn't pay (this is true) and to put me on a public list, I was surprised to get a call the next day. There is virtually no waiting for me - less than two weeks. I thought that public hospital waiting lists were at least 12 months or more. This is the biggest city centre hospital, so I am ecstatic that there is no wait.

Only if someone has something more serious will the date get bumped. So everything will be 100% free of charge with the exact same surgeon. You've got to wonder what the point of private health insurance is. I've been paying it for years, and have never made one claim. For Australians, I would advise you to ask for everything on public and insist on it. I got scans in the public hospital, bloodwork in a bulk-billed medical center and so on. My only costs have been about $50/month for all the meds. I pay all my taxes, so why not?

Will post again after surgery, as reading everyone's immediate post-surgery experience has been reassuring for me.

 
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Old 08-27-2013, 07:39 AM   #7
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Re: Any insight on labs and ultrasound results welcomed

Only 13 days to go til my TT!

T3 & T4 are finally normal after ~ four months. TSH remains non-existent.

Iron and Vitamin D are now 'sufficient'. Yay! I have taken supplements every day for months, so it's good to know they really work. Just make sure you get the right iron tablets.

Got a non-contrast CT scan today to find out the extent of retrosternal (chest) extension. It's not too bad. I have a whopping big nodule (51mm). Is it all kinds of wrong that I want to keep my thyroid in a jar in the living room? Anyway, what I have learned is that ultrasounds, nuclear scans and CT scans can be vastly different in measurements.

CT Neck and Chest
Report: Multiple nodules are present in both lobes of the thyroid. The right lobe measures 8.2cm in length. There is a dominant nodule at the upper pole measuring 51mm. The right lobe does not extend retrosternally.

The left lobe measures 7.2cm in length. The nodules are more difficult to discern discretely. The bulky lower pole extends less than 1cm inferior to the sternal notch.

Both lobes of the thyroid contain small areas of calcification. There is thickening of the isthmus which measures up to 23mm in depth.

The trachea is not narrowed. There is displacement towards the right.

COMMENT

Multinodular goiter with enlargement of both lobes. Mild retrosternal extension on the left. No tracheal compression.

Last edited by Insubordination; 08-27-2013 at 07:45 AM.

 
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Old 09-13-2013, 08:10 PM   #8
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Re: Any insight on labs and ultrasound results welcomed

Had my total thyroidectomy on Monday (5 days ago). I was in hospital for three nights - mainly because the drain wouldn't stop bleeding and my calcium was on the low side.

Surgeon said it was a really difficult operation for him and took over four hours (I think I was under for at least 8 hours). I was over the moon that I could speak straight away. My voice is hoarse, but I think it's going to be fine. That was my biggest worry. The discharge papers say something about a parathyroid being re-implanted, but no other complications.

The biggest problem for me was the anesthetic. I woke up in extreme pain and was really distressed. The morphine and/or codeine they gave me made me nauseous, so I couldn't eat for a while and had a pretty much permanent headache for 48 hours at least.

I didn't have to do the bedpan thing (I am stubborn), so they wheeled me over the toilet the first few times. I was OK after that first night. I was pleased to be able to shower unassisted.

The hardest thing about recovery were the other extremely noisy patients in the room. It was a din 24/7 and I couldn't sleep. There were a couple with mental health issues (really - on antipsychotics) and the other was a heavy smoker waking up after and anesthetic (so glad I don't smoke because it sounded like she was going to die!). I thought hospitals were quiet!

As soon as I got home, I slept and now I can feel I'm healing. There was more pain for me than others seem to have reported (and I'm no wimp). I take two panadol every six hours or so. Any other kind of pain killer makes me feel sick.

My tip - get someone to bring one of those big triangular pillows for you. The hospital beds/pillows made it impossible to find a good angle. A lot of my pain/annoyance game from the draining tube site. It felt like it was pulling and I kept dropping the draining bag. I'm sure this is why I was bleeding so much. The tape they attached it with made my skin irritated and itchy, so they nurse took it off and I think I lost some support. It also made it hard to get up to go to the toilet. Was glad when it came out (getting it taken out didn't hurt like I'd heard).

I'm taking two weeks off before going back to work. I'm impressed that some people go back to work days afterwards. I still feel groggy and sore and my incision smarts a bit. I haven't felt like reading, going online or watching TV until today.

What else? Have no problems swallowing or eating. In fact, there seems to be a lot of extra room in there now that the goiter has gone. I do some little head/neck exercises to prevent stiffness.

The surgeon said that the pathology results will be back in a week or so, but he's sure it'll be benign. He's some kind of head and neck cancer specialist, so I hope that's accurate 'cos obviously there were no lymph node problems. I just can't wait till cancer is ruled out though - I guess we all fear it deep down even if the stats for thyroid cancer are really low.

I'm already on Thyroxine 100, but they only gave me five pills and no prescription - so I guess I'll get an update when I see the surgeon in a few days. I'm sure they wouldn't have given me thyroxine if they expected future RAI.

Thyroidectomy was not a cinch for me ( I'm 37 and have had two other surgeries and this was the hardest) , but you've just got to ride it out and soon the worst will be over. I'm glad the horrible lumps have gone from my neck. A scar (which is still covered in tape) doesn't bother me in the slightest when compared the the choking feeling of a goiter.

Now just takin' it easy (and thanks to whomever suggesting buying some drinking straws).

 
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Old 09-17-2013, 07:56 PM   #9
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Re: Any insight on labs and ultrasound results welcomed

Got pathology report - no malignancy. I'm so happy and would wish that outcome for everyone. I was worried because of the calcification and solid nodules on previous scans. Interested that it said I perhaps have Graves. Hadn't been diagnosed with that previously.

Am feeling a lot better 9 days after surgery. I go outside for short walks. Neck is still not flexible enough to drive safely but a couple more days should do it. Now it will all be about hoping my dosage of thyroxine is the right one.

Surgical Pathology Report
Macroscopic - right lobe
The specimen consists of a right hemithyroid 94X32X37mm weighing 68g. The capsule is ragged and intact. There is a 47mm nodule arising from the inferior pole of the specimen. The remainder of the gland has a multinodular appearance. Serially sectioned into twenty two transverse slices, the cut surface shows numerous cystic colloid nodules, featuring hemorrhage and scattered fibrosis. No discrete mass lesion is seen.

Left lobe specimen 77X44X38 mm weighing 54g. The capsule is ragged and appears intact. The gland has been replaced by numerous nodules of varying size. The multinodular changed are more pronounced in the inferior half of the specimen. Sectioned into 23 transverse slices, the cut surface shows numerous colloid nodules, one of which has a single focus of calcification. The large inferior nodule has a lobulated fleshy consistency. No discrete mass lesion is seen. The remnant unaffected gland appears normal.

Microscopic
The sections from both lobes of thyroid show features of nodular goitre with additional changes of hyperplastic and adenomatoid nodules. The gland has multiple ill-defined nodules that contain follicles of varying size. Many follicles have abundant thick colloid though there are numerous follicles that are hyper and also show well developed cytological features of hyperplasia. The hyperplastic features include irregularly shaped follicles due to a colloid depletion and cells with abundant vacuolated cytoplasm and some anisonucleosis. The adenomatoid nodules have significantly increase cellularity with minimal colloid. All of these are circumscribed though not encapsulated. There is no evidence of malignancy. No parathyroid tissue is present in the sections.

Comment: The hyperplastic features raise the possibility of Graves disease.

 
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