Thyroid Nodule treatment questions

iVillage Member
Registered: 06-28-2004
Thyroid Nodule treatment questions
15
Mon, 06-28-2004 - 2:23pm
I've never been on this list before, and I'm trying to do as much research as I can to understand what's going on with me. This all started a few months ago when my OB/GYN found a lump on my neck. I had a ultrasound scan my thyroid is enlarged on both sides. I have a 2-3CM nodule on the right posterior side. I'm also having sudden onset high bp for some reason (150/100). I had an echo done on my heart and the cardio said it's fine, so they don't know what the story is on my high BP yet.

My Mom has Graves' disease and my nephew has Hashimoto's.

I just had the RAI scan done last week, and saw my Endo on Friday. Here's what he said:

1. My antibodies are > 70 and should be <2, which indicates Hashimoto's. My free T4 level is 1.1.

2. He forgot or the lab screwed up, and they didn't get a new TSH level, so I had more bloodwork done today to see if it's high or not. (level in March was 3.57)

3. The RAI scan reports said multinodular Goiter with diffuse hot and cold spots throughout. He's not happy with the report, and is going to the hospital to see the scan for himself.

So here's the plan: If, when he reviews the scan, the single larger nodule within the multiglobular mass looks suspicious, then we're going to do a FNA to see if it's malignant. He's going to see if my TSH level is on the high side, and if it is, he's talking about putting me on Synthroid, even though my FT4 is just a little on the low side, but still within normal limits.

Here's my questions -

1. He said he does FNA without local anesthesia, is this typical? He said that it interferes with the pathology if you use locals. How painful is it without a local?

2. It doesn't sound reasonable to me to put me on Synthroid if I'm not even hypo yet. Am I missing something?

3. Does the antibody problem ever resolve itself and go away, or is this something I can just expect to have to deal with forever?

4. I don't really have any symptoms, will high antibodies make me feel sick?

Thanks for listening.

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iVillage Member
Registered: 11-09-2001
Mon, 06-28-2004 - 4:36pm
Hi and welcome - here are your questions:

1. He said he does FNA without local anesthesia, is this typical? He said that it interferes with the pathology if you use locals. How painful is it without a local? - If anyone here has had this, can you help here. I've never had FNA but I can always look it up for you.

2. It doesn't sound reasonable to me to put me on Synthroid if I'm not even hypo yet. Am I missing something?

You are actually hypothyroid. You have a high enough TSH level to be considered hypo. The guidelines have been changed and 3.0 is the new upper limit. That aside, normal TSH levels, for people who have NO thryoid conditions, are between 1 and 2 so you can see just how far 3.7 really is. So yes, synthroid is what you need to be on, that or some other thyroid replacement hormone.


3. Does the antibody problem ever resolve itself and go away, or is this something I can just expect to have to deal with forever?

Thyroid antibodies don't really go away. I was reading about this just yesterday. The antibodies will always be there, maybe to a lesser degree but they will be there. It doesn't matter. It's not like they are responsible for the condition. They are just a sign that something is wrong, not the conditon itself. Once you are hypothyroid, you will always have to deal with it and take medication for the rest of your life. I know this sounds terrible but it doesn't have to be. It's just a matter of getting used to it and of educating yourself as to what you're dealing with. The more you know, the better off you are.

4. I don't really have any symptoms, will high antibodies make me feel sick?

You do have symptoms: Your enlarged thyroid is a symptom. The anitbodies are a symptom. And so is the high blood pressure. You might even have high cholesterol and not know about that yet but it's also a symptom. Fatigue, dry dkin, dry hair, irritability, irregular and/or haevy periods, weight gain for no reason, these are just some of the more common symptoms. The antibodies aren't what you're feeling. It's the hypothyroidism that's causing your condition.

Plus you have a family history of thyroid conditions. This doesn't guarantee that you will have a thyroid condition yourself but it is a good indicator that you may get it sometime in your life.

I can give you more info on antibodies if you are interested but I have to type it all in myself and won't tke the time if you don't need the info. It's no problem to do, just let me know.

I think I have something on FNA so I'll look and post it for you. The good thing about this is that it is treatable and that your doctor has found it before it's gone too far in causing more severe symptoms.

The diffusion in your thyroid is common so it is good that the doctor is going to read it himself. Does this help? Cathy

iVillage Member
Registered: 11-09-2001
Mon, 06-28-2004 - 4:41pm
Here's a good article on FNA:

Fine Needle Aspiration FNA Biopsy of the Thyroid

Questions & Answers


by Mary Shomon

The most common method for evaluation of a suspicious thyroid nodule is a technique known as fine needle aspiration, or FNA.

In an FNA, a very fine, thin needle is inserted into the thyroid, and aspirates (or "suctions") cells and/or fluid from a thyroid nodule or mass into the needle. The sample obtained can then be evaluated for the presence of cancerous cells.

How Does FNA Differ From Needle Core Biopsy?

In a needle core biopsy, a thicker, large needle is used to obtain a "core" tissue sample for analysis., and the larger sample that can be recut for smaller samples that can be sent out for further analysis. Needle biopsies are typically done using local anesthesia, and these procedures have slightly greater risk of bleeding associated with them, so they are more often done by a surgeon in outpatient or ambulatory surgical facilities.

If an HMO or community does not have practitioners with expertise in performing FNA, or there are not cyopathologists available to do the unique form of interpretation needed for FNA results, patients are likelier to have a core needle biopsy, as this procedure, while more invasive for patients, requires less skill to obtain a valid sample, and less skill for pathologists to read and interpet.

Who Should Perform an FNA?

Typically, FNAs are done by by endocrinologists, cytopathologists, or surgeons. The cells are studied and assessed by a cytopathologist.

Make sure that the practitioner has extensive experience in doing fine needle aspirations. Ask how many aspirations the practitioner does each month, and ask their "unsatisfactory" or "inconclusive" specimens rate. Don't always assume an endocrinologist is particularly skilled in this technique - he or she may not regularly perform this procedure.

The rate of non-diagnostic or unsatisfactory specimens - samples that cannot be used for laboratory assessment, and must be redone -- can be high for some less experienced practitioners. Yolanda Oertel, M.D., a cytopathologist from the Washington Hospital Center who spoke about FNA at the September 2000 Thyroid Cancer Survivor's Association (ThyCa) Conference in Washington, DC, cautions patients to find out the rate at the facility where their aspiration is taking place. The average can run from 5% to 15%. Dr. Oertel, whose practice focuses on thyroid and breast aspirations, and who aspirates approximately 90 thyroids each month, has a "non-diagnostic" rate is less than 0.5 percent.

Where Is an FNA Performed?

Many FNAs are performed in a doctor's office, although some might be done as outpatient surgery.

At ThyCA 2000, however, Dr. Oertel recommended that patients not get an FNA outside a hospital setting. While the procedure is generally safe, and things seldom go wrong, there is a very small risk of hermorrhage, but that could be quickly treated in a hospital setting.

What is an Ultrasound-Guided FNA?

When a nodule is palpable - meaning, you can feel it with your hand - most practitioners don't need to use ultrasound to guide the FNA process.

Some nodules are very low lying or can only be felt when you are swallowing, or can't be felt but were picked up by ultrasound, cat scan or MRI. In these cases, a practitioner may use ultrasound to ensure that the FNA is accurately performed.

Is FNA Risky?

Thyroid FNA is generally considered safe, and almost never results in any complications.

What Can You Expect During Your FNA?

You may have your test sitting up, but many practitioners will begin by having you lie down on the examining table. You'll be asked not to swallow, talk, or move while the aspirations are taking place.

The needle is fairly small and fine. Some practitioners use a needle with a handle. According to Dr. Oertel, these types of needles -- sometimes known as a syringe pistol -- are preferable. (Click here to see a syringe pistol.) The handle allows the practitioner to leave one hand free to feel the neck and nodule, and ensure that the needle doesn't move around, but rather, is guided right into the nodule to be tested. With a handle-less needle, many practitioners have to use both hands to insert the needle, which can be a factor for error, as the pathologist may not be able to accurately aim the needle into the nodule without a free hand to guide it.

The entire procedure shouldn't take more than a ten to twenty minutes. Most practitioners peform two to four aspirations on every nodule of concern. In her presentation at ThyCa 2000, Dr. Oertel mentioned that she takes a minimum of three samples, from the center, bottom and top of the lump, and sometimes several more, depending on her judgment as to the quality of the samples.

Many practitioners advise that you apply pressure to the area for approximately 20 minutes after the aspiration in order to minimize bruising or swelling.

Will It Hurt?

That depends on the skill of the practitioner, your own perceptions of pain. Some practitioners will use lidocaine, a local anesthetic, to numb the injection site. But patients complain that this can hurt more than the actual FNA procedure. Other practitioners don't use anesthetic. At ThyCa 2000, Dr. Oertel discussed that she does not use an anesthetic, she prefers to use an ice pack to numb the skin. Her rationale - an anesthetic needle creates a lump - some swelling - around the injection site that can interfere with the ability to get an accurate sample.

How Will it Feel Afterwards?

You might have slight pain with some swelling and bruising at the injection locations, and possibly slight discomfort in swallowing. Ask your doctor about recommendations regarding post-FNA pain medication - many recommend taking acetominophen or ibuprofen as directed to minimize any residual discomfort.

Can You Go Back to Work?

Most people are comfortable enough to go back to work the same day or next day after having an FNA.

But you should avoid vigorous physical activity, sports for approximately 24 hours after the FNA.

What Kind of Results Can You Expect?

A nodule is more likely to be cancerous if it falls into certain risk factors:



Larger nodules - over 4 centimeters, are more likely to be cancerous than nodules less than 4 centimeters

Men's nodules are more likely to be cancerous than women's nodules

A solitary nodule is more likely to be cancerous than nodules found in a "multinodular" thyroid

Nodules in a person younger than 20 or older than 70

History of external neck irradiation during childhood

"Cold" characterization on ultrasound - meaning that the nodule does not absorb iodine or make thyroid hormone

Ultimately, however, approximately 5% of all thyroid nodules are cancerous.

The results from your FNA will fall into the following breakdown:

Benign 70%

Malignant 5%

Suspicious 10%

Nondiagnostic 15%

What If It's Benign?

If you have a benign nodule, your doctor will likely treat the nodule, typically using thyroid hormone to help shrink the nodule.

What If It's Malignant/Cancerous?

If you are diagnosed with thyroid cancer, your first stop should be the following article, An Introduction to Thyroid Cancer, which is a good starting point for information about thyroid cancer, including papillary, follicular, medullary and anaplastic cancer, including support groups and followup treatments.

What If It's Suspicious?

Typically, a second test will be conducted. But most suspicious nodules usually result in thyroid surgery. An estimated 25 percent of those nodules labeled suspicious are found to be malignant with surgery.

What If It's Nondiagnostic?

If you get a nondiagnostic sample, you will need to wait a month before retesting, otherwise, it's likely that the only thing aspirated will be a blood around the site of the initial aspiration.

Can You Have a False Diagnosis?

False results, such as false negatives showing your FNA results are benign when they are actually cancerous, or false positives showing a benign nodule as malignant, are more common than you think. Some experts estimate that an average of approximately 2 to 4% of all FNAs may be false results.

Do You Need a Second Opinion?

If you have a negative result, but have risk factors for or family history of thyroid cancer, in particular, you should consider getting a second opinion on your FNA. And, if you have a positive result indicating cancer, a second opinion is also important. You may feel uncomfortable about mentioning this to your doctor, or feel that it will be perceived negatively by your doctor, but, as Dr. Oertel said in her presentation to the ThyCa conference, "Get a second opinion. My ego will recover, but you might not!"

Where Can You Get More Information on FNA?


Fine Needle Aspiration Biopsy of Thyroid Nodules - from the Thyroid Foundation of Canada

Fine Needle Aspiration - from Thyroid Manager



iVillage Member
Registered: 06-28-2004
Mon, 06-28-2004 - 4:55pm
Cathy, Thanks so much for the info, your response on the antibodies makes sense, and if it's not too much trouble I would like that additional info. I'm supposed to get my TSH re-test results this week, and the doc said that if they are even a little high he's going to start me on synthroid.

Thanks,

Cathy in Tx (by the way cathypem, does the 'pem' stand for Pembroke?)

iVillage Member
Registered: 04-12-2004
Mon, 06-28-2004 - 7:13pm
I just had the FNA done . . . it wasn't bad at all. Really, don't even worry about it. Easy, easy . . . if I had to chose whether to get a tooth filling or get another FNA, I'd get the FNA and I have a great dentist. good luck! P.S., mine came back benign, as do most.
Avatar for cl_calley7
iVillage Member
Registered: 03-20-2003
Mon, 06-28-2004 - 9:45pm

Hi Texcat99,


I have also had a FNA and it was not a problem for me.

 

Calley7

iVillage Member
Registered: 11-09-2001
Mon, 06-28-2004 - 10:36pm
Close! It's Pemberton. My husband's family was from England. Mine was from Italy. It makes an interesting combination! :) I'll get that other info to you tomorrow, ok? I'm glad to help. Cathy :)
iVillage Member
Registered: 06-28-2004
Tue, 06-29-2004 - 10:03am
Thanks Cathy, I appreciate it. Also thanks to all who responded to the FNA question, I'm glad it won't be as bad as it sounds!

Cathy in Tx.
iVillage Member
Registered: 06-28-2004
Tue, 06-29-2004 - 4:15pm
I just talked to my Endo. He said that my new TSH level is 3.2, and that he reviewed the RAI U scan and that he and the docs at nuc medicine agree that there's no clear cold spots that are suspicious, that there's less-bright and brighter spots throughout (typical of multinodular goiter, apparently) so he wants to wait 6 months, do labs again and do another ultrasound so they can see if there's a downward trend yet in my FT4 levels ( he says it's just a matter of time ) and if there's a change in the nodules that would warrant the FNA. He said that I'm so marginal right now, and knows that in the future I will have to start synthroid, that he doesn't want to do it just yet. Does this sound logical?

Thanks,

Cathy in Tx.

iVillage Member
Registered: 11-09-2001
Tue, 06-29-2004 - 5:27pm
Well, you have TSH level at 3.2, which is within the range of diagnosable hypothyroidism -it just makes it. And you have the enlarged thyroid, the high blood pressure etc - what is the point of waiting until things get worse?? That's just my opinion and this kind of thing just makes me so aggravated but ..... that's just me! It's up to you whether or not you want to wait the 6 months or try to find another doctor to treat you now. Or talk to this doctor and tell him that based on your family history, your tsh level, your high blood pressure and the enlargement, you'd like to be treated now and followed up on 6 weeks to see how you're doing!!! What do you think? Cathy :)
iVillage Member
Registered: 06-28-2004
Tue, 06-29-2004 - 6:55pm
I admit that I was kind of surprised at his response. Are there risks to taking synthroid that would make him not want to start me on it yet?

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