This is a true clinical story. For obvious privacy reasons, the names of the patients, the doctors and their titles and the institutes have been omitted.
I´d had swellings around my neck from my thyroid for years. Most years I´d had ultrasounds and blood tests which had always been fine, and one year I even had a biopsy just to make sure it wasn´t cancer… which of course it wasn´t.
Last year the ultrasound showed a slight change in one of the lumps so my endocrinologist wanted to take a biopsy. I´d had one before and it hadn´t been too much of a bother so I wasn´t at all worried when I went to have it done.
When I came home after the biopsy I couldn´t help but notice the feeling that there was something in my throat. I went to look in the mirror and saw that there was swelling in the place where the biopsy had been taken. It seemed to get bigger and I found it gradually harder to breathe. By the next morning I was panicking… the swelling had become the size of a tangerine and every time I lay down I felt like I was being choked. I phoned up my doctor and he told me that all I needed to take thyroid supplements and the swelling would go down. This didn´t seem right to me so I got hold of the number of another specialist and phoned him. He told me to come and see him straight way.
The first thing he did was place a needle in the swelling and suck all the blood out. It was miraculous, suddenly there was no feeling of pressure on my throat and I was able to breathe again. I went home relieved and pleased that I´d made the decision to go and find someone else apart from my initial doctor.
My relief was short lived. Over the next few days the swelling reappeared and I started to get the same feeling in my throat. I spoke to everyone I knew and went to see all the best doctors in my area. Each one had a different idea of what needed to be done. Some said I needed an operation, but no one agreed on which one. Others recommended thyroid supplements but I didn´t want to be taking thyroid hormone for the rest of my life.
At this point I didn´t know where to turn. I wanted to know what the best treatment was and where I could get it. I was also worried that maybe it was something really dangerous that my doctors didn´t understand. I started trying to find out more and came across the Medical Opinions website. I realized I needed to get advice from somebody who really new the field and through Medical Opinions I got my case to be checked by one of the best endocrinologists in the world. I knew I was going to get the best advice that could be given.
My file was sent to a world center in the
I feel tremendous relief now that I know I’m getting the right care through Medical Opinions. I’d recommend them to all those who are not sure if they are getting the right medical care and want to be certain they end up getting the best treatment.
A forty year old lady with an unremarkable history apart from mitral valve prolapse presented with a ten year history of thyroid nodules, the largest of which being in her right lobe. She was asymptomatic with thyroid function within normal limits. She had regular thyroid ultrasounds and one previous needle aspiration four years ago.
All tests indicated a diagnosis of “multinodular colloid-cystic goiter”.
Last year the patient had a thyroid ultrasound with the following results: “Slightly dysmorphic thyroid due to the size of the right lobe which has a
As recommended a needle aspiration was carried out. The biopsy showed a “hemorrhagic colloid nodule with a solid part anterior to the right thyroid lobe”.
Immediately after the needle aspiration was performed, swelling appeared in the nodule on the right lobe. The patient reported that the swelling developed to the size of a “tangerine” and with this dyspnea which worsened on lying supine.
She informed the physician who had performed the procedure and a repeat ultrasound was performed. Given the considerable increase in size of the nodule, the endocrinologist advised that therapy should be started immediately with thyroxine.
The patient was did not wish to take the therapy, so she had another ultrasound performed at another center where she was seen by another endocrinologist. He aspirated bloody serum from the nodule and the swelling promptly subsided.
However, as predicted by the endocrinologist, the swelling gradually reoccured, resulting in the patient consulting with various specialists. They have provided various options including a hemithyroidectomy, a total thyroidectomy, removal of the single nodule and thyroxine therapy.
It should be emphasized that the patient is not in favour of taking the hormone therapy for the rest of her life.
1) What therapies do you recommend?
2) What is the prognosis?
3) Where are the centres of excellence for this condition?
The expert´s opinion
I had the pleasure of reviewing this case in order to provide for a second opinion.
Unfortunately, her ultrasound (
I will review the provided information first: The patient is 40 years old female with a
several year history of a multinodular goiter. She did not have any clinical or
biochemical evidence of hypo or hyperthyroidism. Four years ago, she underwent a fine needle aspiration of the dominant right sided nodule. It is unclear if only one nodule was aspirated or multiple nodules were tested for malignancy. The final conclusion was that it was a multinodular colloid-cystic goiter.
Last year, she had an
Immediately post aspiration she had an increase in the size of the neck associated with dyspnea. She was seen at another center and hemorrhagic fluid was drained from the right side leading to reduction in the nodule size with substantial symptomatic improvement. However, swelling recurred and now the question is how to proceed. She has been asked to consider hemithyroidectomy or total thyroidectomy. Another opinion is to use thyroxine supplementation. The patient is not in favor of taking any thyroid supplementation for the rest of her life.
1. What therapies do you suggest?
My clinical impression is that patient had bleeding during procedure (FNA) leading to a sudden increase in the size of the nodule compressing the trachea causing dyspnea. The symptoms were relieved with cyst aspiration but there was re-accumulation of fluid within a short period of time.
There is no definite evidence that supplementation of levothyroxine will lead to significant reduction in the size in a mixed cystic-solid thyroid nodule. The levothyroxine supplementation in my mind is only required if patient has clinical and biochemical evidence of hypothyroidism. I would check that by testing her thyroid function tests.
As far as the treatment for thyroid cystic nodule is concerned, there are few possibilities.
If patient has persistent compressive symptoms like dyspnea, swallowing difficulty etc then she should consider re-aspiration of fluid vs. hemi-thyroidectomy.
My feeling is that right hemithyroidectomy is more appropriate for the following reasons:
-It will preserve the left lobe of the gland which will be enough to keep her euthyroid (though that will need to be monitored post operatively)
-it will remove the abnormal lobe with multiple nodules and hence will not require close monitoring
-it will give a definite diagnosis of these nodules.
The disadvantage is that it is more aggressive therapy, will require hospitalization, may make her permanently hypothyroid (unlikely, unless left side is also involved).
The advantage of cyst aspiration is that it is fairly straightforward; however, the disadvantage is that there is a risk of bleeding and there is likelihood that there will be re-accumulation of fluid within a short period of time.
Total thyroidectomy should only be considered if the whole gland is affected. In that case she would require life-long levo-thyroxine supplementation.
Cystic nodules that have a definite capsule can sometimes be treated with alcohol injections. In the
If patient does not have any symptoms but the size of the nodule is increasing then she should consider right hemithyroidectomy. On the other hand, if the size of the nodule is decreasing then patient can be monitored with serial ultrasounds and monitoring her TSH to ensure biochemical euthyroid status. However, in that case these nodules need to be monitored for malignancy and compressive symptoms.
Finally, it should be ensured that patient is not on any anti-coagulation therapy and does not have any bleeding disorder.
Excellent, with appropriate treatment.
3. What are the Centres of excellence for this condition?
Please let me know if you have any questions or concerns.
I would be happy to see this patient in my practice if she wishes to travel to the
Professor of Medicine