Let's talk about the nodule from my thyroid ultrasound

Miscellaneous and Personal Stuff I Must Share
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Standard disclaimers - you’re not my doctor, may not even be a doctor, and I have a follow-up with my endocrinologist on April 17th. tl;dr: solid, hypervasular nodule in heterogenous thyroid.

My TSH (thyroid stimulating hormone) is normally on the low end of normal. The reference range at the lab I use is 0.4 to 4.5mlU/L, and my results are usually between 0.5 and 0.6. I started paying attention to this back in 2019, when I dropped to 0.27. We did some follow-up testing on T3 and T4, and everything seemed normal.

I did some digging through lab reports, and see 0.6ishg readings back to 2005, with a few years around 2012 where I was closer to 1. Since then, it’s been 0.6ish and down.

I have a collection of vague “symptoms” which could very easily be “Yeah, you’re a 50 year old man, it’s just life” or other things. I don’t sleep well, and even when medicated (Ambien, trazadone, melatonin), I wake up a few times during the night and am tired the next morning. I’ve lost 20lbs since the end of 2019 - I did make a minor tweak to my diet around then that probably cut some calories, and the loss has been slow and steady. The biggest “symptom” that I don’t have an easy alternate explanation for is heat intolerance. When out and about with friends, I sweat much quicker and more than others, to the point that my friends occasionally ask me if I’m ok. I’ve always felt that there’s a chance some of this is related to thyroid levels, so I pay attention to those tests in case something pops up that warrants a discussion.

So all that as background - when my reading was low in 2019, my GP ordered a thyroid ultrasound. It was normal - homogenous, no nodes, nothing noted. This year, I my TSH dropped again, to 0.34. I went to an endocrinologist. On physical exam, he noted that my thyroid was a bit asymmetric, and ordered a full thyroid blood panel and a fresh ultrasound. The blood work all came back normal. TSH was 0.63. T3, T3 free, T4, T4 free, and “TISSUE TRANSGLUTAMINASE AB, IGA” were all in reference range. But the ultrasound was not normal.

There’s a nodule that was not there four years ago, and the thyroid is now described as heterogeneous. The nodule is solid and hypervascular. It also notes that the isthmus is 2mm. In the older report, it was noted as 3mm. I assume that could be measurement inaccuracy as likely as it being medically important.

Doing some reading, nodules are not uncommon, and relatively speaking rarely malignant. Solid seems to be somewhat higher risk than liquid filled. Apparently (and surprisingly to me) being hypervascular does not seem to correlate with risk of malignancy.

The report itself suggests a follow-up ultrasound in a year. Of course, I’ll discuss this with my specialist when I see him. I understand that the vast majority of things this could mean (anything from virtually nothing to cancer) is rather treatable, and I’m not overly worried.

Things I’d like to discuss with the doc:
How likely is it that any of the symptoms I mentioned are related? Are there other symptoms that I should watch for?
Does this need further testing? Biopsy, thyroid uptake scan, other? Or just watch it?
Is the isthmus size important?
What does midpole mean? (I’ve read a bunch about the location, but haven’t seen a clean definition for this term.)

And so, I ask my Doper friends - what else should I bring up? Am I missing anything? And does anyone want to provide any color or information based on what I’ve provided?

Here is some of the actual text from the ultrasound report:

FINDINGS:
The right thyroid lobe measures 4.1 x 1.8 x 1.7 cm with heterogeneous parenchymal echogenicity , hypervascular, solid heterogeneous midpole nodule 0.8 x 0.4 x 0.5 cm-new.
The left thyroid lobe measures 4.1 x 1.7 x 1.3 cm with heterogeneous parenchymal echogenicity , hypervascular.
The isthmus 2 mm in the AP dimension.
IMPRESSION:
Heterogeneous thyroid gland.
Right thyroid nodule repeat exam in 12 months, or sooner if clinically indicated, recommended.

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Unless you think your endocrinologist is the kind of doctor who would ignore signs of a problem needing immediate treatment you’ll just have to suffer through the interminable time until your next appointment. I might start making an appointment now with another endocrinologist for a second opinion since I know it can take time to get to see one.

I did know someone who had what may be a similar diagnosis and I believe told it was an autoimmune issue but nothing all that unusual or dangerous. I have very little info to go on, just hoping your doctor also concludes your condition is not a big problem.

To editorialize a bit, it’s horrifying how long it can take to follow up with doctors on these issues. It’s likely not your doctor’s problem at all, just our bloated and inefficient medical system.

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Thanks for the thoughts!

I’ve actually only met this doctor once, at my initial consultation, but none of the revies online make me think he’d sit on an important diagnosis. The April 17th date was a one month follow up scheduled at the original appointment, giving me time to get labs done.

The US report was released to the patient portal last night (Friday night), but I’m not sure when the doctor got it. I do agree that it not being flagged for immediate attention is a good thing :smiley: I’m comfortable waiting, although the engineer in me wants to do problem solving and analysis NOW.

My primary care had recommended two other endocrinologists before I found this one. One isn’t accepting new patients with my insurance, and the other doesn’t return phone calls. I may go to that second one in person to set up a second opinion.

There are a few autoimmune diseases that popped up in my searches - things I was a bit aware of because of past research based on the TSH, but things like Hashimoto’s Disease that come up with searching these nodules. That can tie into other things, like memory/attention problems, minor depression, etc. It wouldn’t surprise me if there’s something in this area. Or, not :man_shrugging:

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I had a visible growth on the isthmus of my thyroid that sent me to an endocrinologist back in 1993. My takeaway was that there is such a wide range of symptoms caused by thyroid imbalance that it’s almost impossible to tell what’s thyroid and what’s, say, perimenopause. At the time, I was newly post-partum, so my hair loss, dry skin, fatigue, and weight gain hadn’t pinged my radar as being thyroid symptoms.

Unlike yours, my thyroid had a huge number of growths in it, and although there was no cancer present, the endocrinologist recommended removing it. I don’t remember the pathological description in detail, but the phrase, “the presence of giant multinucleated cells” was used.

All the symptoms you’ve mentioned can stem from thyroid hormone imbalance. Personally, I know it’s time to call the doctor when my fingernails get brittle and I start falling asleep mid-afternoon.

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The one thing I can be fairly certain of is that none of my symptoms are from perimenopause :joy: But I know what you mean.

Most of my research right now is reading about the fact that both lobes were noted as heterogenous. It isn’t clear to me if just having a nodule in the right lobe is enough to mark the whole lobe as heterogenous, but the left is also noted that way, without a nodule. Most of what I read notes that this is suspicious for…something. Some cites suggest that it’s an autoimmune condition. Others suggest that it’s “associated” with them. And others suggest that it might mean I have a nodule…which I do, in one of the lobes.

I’m curious if the node is “hot” - if it’s producing hormones on it’s own. It might explain why my tsh is marginal to low. I think that would lean more towards Graves than Hashimoto’s, but I’m not diving into that without an actual discussion with my doc.

At least I’m learning lingo and concepts! And I’m not falling into the hypochondriac rabbit hole :smiley:

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Are you familiar with ThyCa? They have a lot of literature that can help you work your way through all of your questions and concerns.

You may notice that my avatar is a Thyroid Cancer Survivor image. Yup. Been there, done that, got the cool scar. I had papillary thyroid cancer in 2015, got a total thyroidectomy, and haven’t had any recurrence. The brittle nails and insomnia suck, but they beat the alternative.

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I am not familiar with them, but I’ll check them out!

Right now I’m working on the assumption that this will not be cancerous, but I see they have resources discussing more generic issues too. I’ve just opened a few tabs, and will be spending time there :smiley: Thank you!

I hadn’t noticed the avatar. Glad you got through it (mostly, apparently) fine. One of the things keeping me calm is that everything I read says that just about any scenario this turns out to be - from a non-issue to cancer or anything in between - is very likely treatable and manageable.

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From a pathologist’s standpoint:

“Mid-pole” means that a finding is roughly in the middle of either the right or left thyroid lobe, as opposed to upper/lower pole of a lobe.

“Heterogenous” signifies that the thyroid parenchyma is not uniform, suggesting a degree of nodularity, which can be due to conditions like nodular goiter, Hashimoto’s thyroiditis and subacute granulomatous thyroiditis, as well as neoplasia (benign or malignant).

Most times when a fine needle aspiration biopsy is performed it’s because of size, ultrasonographic features which are concerning and/or growth of a nodule. Nodules less than 1 cm in greatest dimension that don’t have any suspicious features are typically followed up with repeat exam/ultrasound at a later time.

Discuss your concerns with the endocrinologist, who hopefully can provide reassurance and an explanation of optimal followup.

More on evaluation of thyroid nodules including “incidentalomas” can be found here.

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Thanks! Especially for the clarification on mid-pole, since I was coming up blank on finding discussions on that. And I’ve added that link to my collection - it’s well written and pretty easy to digest. Much appreciated.

My nodule is less than 1cm, so if it isn’t suspicious we could be just monitoring. It is solid but the report does not mention hypoechoic. I’m not sure if it’s taller than wide - the dimensions are given as 0.8 x 0.4 x 0.5 cm, but I’m not sure which one indicates which axis. If it’s the same order as the lobe, then it seems like it would be taller than wide.

In other news, I was just cross checking test results and such, and it looks like Quest ran the wrong test. I have a copy of the original order, and he requested Thyroid Peroxidase Antibodies (TBO), which screens for the autoimmune possibilities. Directly below that on the work order is a spot for Tissue Transglutaminase Ab, IGA. The TBO one is checked, the TTaB is not. But my test results are for TISSUE TRANSGLUTAMINASE AB, IGA.

The good news is I’m not celiac! Guess I’ll call the doc’s office tomorrow and see if they want to issue a new order for me.

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Doc called yesterday evening to discuss the blood work. Apparently he hadn’t gotten either of my voice mails telling him they ran the wrong test, but he noticed it himself, of course. He also hadn’t seen the ultrasound yet, so I had to tell him what it says.

Unless he reads something into later when he officially gets it, the plan is to cancel my April 17th follow up, and schedule one for Sept. We’ll do a new round of blood tests and a new ultrasound. He says if nothing changes, the protocol would be to do ultrasound every 6 months for a little bit, then drop to yearly.

He wasn’t overly concerned by the fact that the nodule was solid or that the lobes are heterogenous, as long as the blood work is normal.

I see my GP in July, and I’ll get the right Antibody test done then, as an extra data point.

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Well, it’s been 6 months, and I had my follow-up ultrasound and blood work. The above mentioned antibody test came back as 1, which is negative. The rest of my numbers this cycle were in the nominal reference range.

The new ultrasound report was just posted. I have a call into my endocrinologist to discuss it. Curiously, it specifically states that it does not show a nodule.
It also says “Heterogeneous echotexture of the thyroid gland suggestive of thyroiditis. This was not seen in the previous study.” But the previous report noted things like " heterogeneous parenchymal echogenicity". So… I feel like I know a little less now than I did before this test.

I’m looking forward to discussing the differences with the doctor. I suspect the overall guidance will be “The bloodwork is ok so we’ll continue to monitor”.

Right lobe measures 51 mm sagittally x 19 mm transversely x 18 mm in AP dimension.
Left lobe measures 44 mm sagittally x 16 mm transversely x 17 mm in AP dimension.
The isthmus measures 3 mm anteroposteriorly.
An area of dilated, prominent vessels seen at right lobe (previous solid nodule area).
No focal solid or cystic nodules are identified. Heterogeneous echoes are seen in both lobes.
Vascular structures and trachea are unremarkable.
Overlying strap muscles are unremarkable.

IMPRESSION:

  1. No nodule is appreciated in the right lobe of the thyroid gland in the present study.
  2. Dilated vessels are seen in the region of the previously mentioned nodule.
  3. Heterogeneous echotexture of the thyroid gland suggestive of thyroiditis. This was not seen in the previous study.
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That test as you said is hard to get; i had a similar thyroid test recently but have to meet with my primary for further analysis.

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I had whack bloodwork. First, I showed LOW blood calcium. Months later, I had HIGH blood calcium. I get the order for a thyroid U/S. The radiologist report mentions something about the parathyroid (not the professional thyroid, but the parathyroid).

My primary care doctor refers me to an endocrinologist.

The endo and I discuss diuretics. I currently was taking Dyazide, and had been taking it for 150 years or so. When originally diagnosed with high blood pressure, the doctor put me on Hygroton. I ended up with low blood potassium, and had to take potassium supplementation. Yuck. Another doctor switched me to Dyazide, saying it was a lovely, potassium-sparing diuretic.

The endocrinologist explained that some people who took Dyazide for 150 years developed rollercoaster levels of blood calcium. He placed me on a different diuretic, along with a rather innocuous potassium supplement that was preferable to that potassium liquid. Yuck.

Once the diuretic business is handled, the topic changes to not the professional thyroid, but the parathyroid. The doctor pokes and squeezes my throat and neck, and he wants to do a biopsy.

The word “biopsy” can raise eyebrows. I was having the fine needle aspiration version. The needle is damn near invisible. I think four samples were taken. I felt absolutely nothing. And the pathology report showed no problems.

Reading on my own about the parathyroid (not the professional thyroid) is an adventure in itself. Most people have four. Some people have more. Some people have parathyroid tissue in places other than nestled in the thyroid itself.

Little bits of information that absolutely belong in the MPSIMS category!

~VOW

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The doc finally called me back. His best guess is that the nodule noted 6 months ago was an over-read of the ultrasound. The thyroiditis would be notable except my antibodies test was normal. He says it’s a little strange and he can’t really explain it, but since my blood work is good and there are no obviously related symptoms, we’ll recheck in another 6 months.

I think that seems reasonable. The other option I would have is to get a second opinion based on the ultrasounds, but my gut feeling is there isn’t much value there right now.

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It seems to me that’s good news Digital! I didn’t know really know ultrasounds can overead.

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I’ve had thyroid nodules for 15 years. It was a bit of a concern at first as I had radiation to the neck as a teenager, but they haven’t changed significantly in over a decade. I get an ultrasound every couple of years to monitor them.

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I’m nine years out from a total thyroidectomy after a diagnosis of Papillary thyroid cancer. The worst part of the whole ordeal, aside from the biopsy, was that dreadful Low Iodine Diet.

I see my endocrinologist once a year, get quarterly blood work, and a yearly ultrasound. I had my surgery in late August of 2015 and RAI that December. Since then all I have to worry about is getting my levothyroxine dosage right.

Hang in there. If you need any information or resources, go to Thyca.org. They can put you in touch with support groups and they have conferences throughout the year.

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Quick update. Saw my endocrinologist this morning. I did my blood work in advance, so we were able to review it. My thyroid panel is actually the best that it’s been in a while. My TSH was up to a whopping 0.7.

We discussed the differences in the previous two ultrasounds. He says it’s likely due to technique/measurement issues causing noise in the data. He also says that roughly 2/3 of his patients who present with my level of symptoms are either stable as is, or improve. He doesn’t think I’m going to end up in the 1/3 that needs treatment.

I’m set to return in another 6 months, at which point we will do a third ultrasound. If everything is stable at that point, he’s inclined to discharge me.

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I agree with the assessment that you should get a second opinion if for no other reason than to put your mind at ease. Anxiety can affect sleep and, since you seem to be heat sensitive, a warm bedroom can wake you up also. Unless we’re suffering through a polar air mass, I keep my window cracked 2 to 6 inches even in the winter, otherwise I wake up and have a hard time getting back to sleep.

Low end of NORMAL should be no concern. People vary as individuals. My blood sugar is invariably borderline high, but that has always been normal for me, and I feel great.

The only potential concern I see here is the nodule. Just keep a steady eye on it and the overall health of your thyroid.