Thyroid Problems/Thyroid nodule

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Question
Hello Dr,

I am 29yo, female.

History of intense anxiety and hypochondria for many years. No other serious illnesses. My mother had breast cancer at age 52.

A week ago I have discovered an incidental thyroid nodule on an ultrasound. The nodule is 4mmx3mm, very small. Hypoechoic, homogenous, smooth margins, more wide than tall. The doctor noticed 1-2 slight microcalcifications and a slight vascularization. The rest of the thyroid is normal and of normal size.

Blood work 4 days ago shows the following:

TSH 1.50 [0.35-4.94]
FT4 1.09 [0.7-1.48]
TPO Ab 115 [<5.6]
Tg Ab 33.5 [<4.2]
Calcitonin 0.87 [<9.8]
PTH 27 [15-65]
Prolactin 18.2 [5.2-26.5]

Also in general I'm cold almost all the time, even when people around me are wearing short sleeves I sometimes need a sweater. Cold hands and feet. My body basal temperature measured orally in the mornings (6am) is between 96.5 - 97.2. For years I've been feeling irritable and suffered from high anxiety.

What are the odds that the nodule is a cancer with this features and what kind of cancer would it be more likely to be? Does the low calcitonin exclude medullary cancer? Is anaplastic a possibility at this size and with these features?

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I should also mention that one year ago I had a bad episode with night sweats, intolerance to heat, hot & cold flashes, extreme tiredness and brain fog. Also high blood pressure - in the 150-170 when I'm normally around 110. My eyes were closing with fatigue, couldn't focus, felt like I was under a glass dome. Very bizarre. It lasted 2-3 months and went away.

During this period I had these test results:
TSH 4.06 [0.27 - 4.20]
FT4 16.9 [12 - 22]
T3 1.26 [1.3 - 3.1]

They didnt pursue this issues and told me I was fine with those results. So I didn't do the antibodies back then. Now I'm thinking maybe it was related and I had a hypo episode.

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Are the antibodies levels high in malignant nodules, or rather because of possible autoimmune thyroiditis?

I've seen 2 endocrinologists and they both told me I should wait and watch it for a few months as chances that it's malignant are small and thyroid cancer is often slow growing and indolent. They told me it's too small to biopsy and more than that I do not want to biopsy it because I'm concerned with possible cancer cell seeding along the needle tract and even causing metastases. I know the studies suggest this happens very rarely but I don't want to risk it.

I've decided that I should watch it and if it grows as little as 2mm, especially within a short time frame, I will take it out and go from there.

Do you think this is reasonable?

How often do you think I should do ultrasounds to monitor it?

Also, I am trying to get pregnant (now I've taken a break with the nodule). If it doesn't grow in 3 months, do you think it alright to start trying again? If I get the surgery and it's cancer, will I still be able to get pregnant without a thyroid? What about after radioactive iodine therapy?

Thank you so much for any help. I'm just trying to figure out what is best for me and make the right decisions and I really appreciate you volunteering your expertise.

Answer
Cristina Ch,
The nodule, TPO antibodies and variation in TSH indicate Hashimoto's Thyroiditis.
Calcification and vascularisation, is bit alarming. But It doesnt mean its malignant and metastasizing. Type of cancer is to be confirmed by FNAC. And regional lymph node biposy will give us idea whether it is showing metastasis. Low calcitonin could mean hyperparathyroidism. Its common in some patients to have multiple endocrine disorders. So please check Calcium, PTH levels. And till nodule is atleast 1 cm large, they generally do not do thyroidectomy. Also if there is any problem with parathyroid, then that also will be removed simultaneously. So my opinion is just wait till its 1 cm then get FNAC done, later you can go for removal.

My recommendation is test TSH once in 3 months and ultrasound once in 6 months.

You can try to conceive. But you need to strictly monitor TSH because in Hashimoto's its highly variable. So be in continuos touch with doctor, adjust dosage keep TSH below 2. I dont want to discourage you but when thyroid antibodies are there in body they tend to cause miscarriages. So make sure your doctor knows it. Yes after thyroidectomy by taking thyroxine tablets you can get pregnant(but TPO antibodies could make it bit difficult). Radioactive iodine therapy is not recommended during pregnancy. Instead total, sub-total thyroidectomy is better option.

Thanking you!


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Thyroid Problems

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