Skillful and Experiences Surgeon In Bangkok

[Kristie J]

Hi guys, 

 

I have thyroid nodules for about a few years now, last month I went for a check up and did FNA, result is indeterminate. but the doctor recommended half remove due to the grow size of nodule. Anyone could recommend skillful surgeon who I can trust with this procedure? I would be very grateful. Thanks!

[Buffy Frobisher]

I would recommend that you go to Thonburi Hospital if you're in Bangkok. Thyroid surgery can be very tricky, but they have some new technology called a CyberKnife which uses robotics and radiation beams to cut through and destroy cancer tissue to the nanometer, far more precise than a surgeon can be. It's also non-invasive so no scars, and the treatment is usually over 5 days but you can live life normally between treatments. It's incredibly successful against cancer, but it is also quite expensive so I hope that you have some health insurance which will cover it. More details here: https://www.mymeditravel.com/cyberknife-treatment-procedures-in-bangkoknoi-bangkok-thailand

[Sheryl]

I believe Cyberknife is reserved for certain severe types of thyroid cancer and or metastatic cases and odds are OP would not be a candidate.

 

OP. How large is the largest nodule? I ask because if under 2 cm there is a minimally invasive endoscopic approach done through the mouth you might qualify for but only few surgeons can do it.

 

otherwise there are many good head & neck surgeons who can handle open approach.

 

Aldo please advise if cost is a significant constraint.

 

And: where in Thailand are you located?

 

And lastly which doctor,  where, recommended the surgery?

[fuehrio]

I had to remove a thyriod cyst 2 weeks ago. I checked multiple hospitals and sensed Bangkok Hospital would be the best option (top surgeon) but unfortunately my insurance refused to pay. So I have chosen Phyathay 2 hospital and Dr. Chantima (female surgeon) did a fantastic job. She is also specialized in head and neck cancer.

[Kristie J]

9 hours ago, Sheryl said:

I believe Cyberknife is reserved for certain severe types of thyroid cancer and or metastatic cases and odds are OP would not be a candidate.

 

OP. How large is the largest nodule? I ask because if under 2 cm there is a minimally invasive endoscopic approach done through the mouth you might qualify for but only few surgeons can do it.

 

otherwise there are many good head & neck surgeons who can handle open approach.

 

Aldo please advise if cost is a significant constraint.

 

And: where in Thailand are you located?

 

And lastly which doctor,  where, recommended the surgery?

The largest one is 5.8cm (from late June ultrasound). 

Is it possible to go endoscopy for this size? is it safer than the conventional one? I have been anxious about this surgery as I am afraid it will affect my voice.

But the symptoms have been growing, that fatigue and anxiety. 

 

I don't live in Thailand, but last time I went to check at Bumrungrad Hospital and consulted with Dr. Rachanon (which gave me a weird impression, as to when I asked him about the cause and the change of my nodule from black to white, his response was 'who cares?' and 'he is not a scientist so he doesn't know), think I will change the consult doctor next time I go. However he recommended Dr. Vichaphan for the surgery. 

 

About the cost, It's okay. Yet, if compare cyberknife procedure would be a little too high. 

Right now, I'm looking at other hospital as well, for as long as I can get a great surgeon and proper treatment on this . 

 

[Kristie J]

19 hours ago, Buffy Frobisher said:

I would recommend that you go to Thonburi Hospital if you're in Bangkok. Thyroid surgery can be very tricky, but they have some new technology called a CyberKnife which uses robotics and radiation beams to cut through and destroy cancer tissue to the nanometer, far more precise than a surgeon can be. It's also non-invasive so no scars, and the treatment is usually over 5 days but you can live life normally between treatments. It's incredibly successful against cancer, but it is also quite expensive so I hope that you have some health insurance which will cover it. More details here: https://www.mymeditravel.com/cyberknife-treatment-procedures-in-bangkoknoi-bangkok-thailand

I agreed with Sheryl that cyberknife is for bigger and severe surgery (not saying mine is not big, you know what I mean). Also, I have read a little about non surgical method which will be using the radiation to reduce the size of the nodules. what I am afraid of is, shrinking the size only for short term as there is no guarantee it won't grow back. 

thank you for the recommendation!

[Kristie J]

5 hours ago, fuehrio said:

I had to remove a thyriod cyst 2 weeks ago. I checked multiple hospitals and sensed Bangkok Hospital would be the best option (top surgeon) but unfortunately my insurance refused to pay. So I have chosen Phyathay 2 hospital and Dr. Chantima (female surgeon) did a fantastic job. She is also specialized in head and neck cancer.

I am sorry, my knowledge on the issue still limited at the moment, is the thyroid cyst and thyroid nodule the same issue/surgery? and how is yours?

How is the post surgery going? and does it affect your voice?

I hope you are feeling better now. 

[Buffy Frobisher]

13 hours ago, Sheryl said:

I believe Cyberknife is reserved for certain severe types of thyroid cancer and or metastatic cases and odds are OP would not be a candidate.

 

OP. How large is the largest nodule? I ask because if under 2 cm there is a minimally invasive endoscopic approach done through the mouth you might qualify for but only few surgeons can do it.

 

otherwise there are many good head & neck surgeons who can handle open approach.

 

Aldo please advise if cost is a significant constraint.

 

And: where in Thailand are you located?

 

And lastly which doctor,  where, recommended the surgery?

Thanks Sheryl. I'm glad to know that we have a medical specialist on the forum. I just wish that you could hear my now-dead friend's opinion about your belief that Cyberknife is reserved for "severe types of thyroid cancer and or metastatic cases" though. Y'see, he was recommended to have the Cyberknife treatment too for an early-stage nodule about the same size as the OP to PREVENT any metastasis, because the surgery is robotic and way more precise than a human hand; but he didn't listen because he found another armchair expert who thought like you. He opted for surgery and radiation by one of the top surgeons at one of the best cancer hospitals in the US, which missed some cells and it metastasized to brain and liver - and he's dead. With the utmost respect, might I suggest that before you do any more consulting for people with serious health issues (thyroid can be serious), you gain knowledge from a qualified surgeon about Cyberknife so that you offer wisdom, not speculation.

[Sheryl]

13 hours ago, Buffy Frobisher said:

Thanks Sheryl. I'm glad to know that we have a medical specialist on the forum. I just wish that you could hear my now-dead friend's opinion about your belief that Cyberknife is reserved for "severe types of thyroid cancer and or metastatic cases" though. Y'see, he was recommended to have the Cyberknife treatment too for an early-stage nodule about the same size as the OP to PREVENT any metastasis, because the surgery is robotic and way more precise than a human hand; but he didn't listen because he found another armchair expert who thought like you. He opted for surgery and radiation by one of the top surgeons at one of the best cancer hospitals in the US, which missed some cells and it metastasized to brain and liver - and he's dead. With the utmost respect, might I suggest that before you do any more consulting for people with serious health issues (thyroid can be serious), you gain knowledge from a qualified surgeon about Cyberknife so that you offer wisdom, not speculation.

I did not "speculate" I based this on current medical literature and documented approved medical practice guidelines.

 

If your friend was offered CyberKnife he almost certainly had one of the more aggressive types of thyroid cancer such as anaplastic thyroid cancer. (Which is what I  meant when I said "severe" type). ATC would also be consistent with his rapid progression  to a  fatal outcome.

 

OP's situation is vastly different. She does not have documented cancer at all, FNA result was indeterminate (which in 70-80% of cases turns out to have bern benign). 

 

No doctor is going to recommend  CyberKnife in this situation.

[Sheryl]

8 hours ago, Kristie J said:

The largest one is 5.8cm (from late June ultrasound). 

Is it possible to go endoscopy for this size? is it safer than the conventional one? I have been anxious about this surgery as I am afraid it will affect my voice.

But the symptoms have been growing, that fatigue and anxiety. 

 

I don't live in Thailand, but last time I went to check at Bumrungrad Hospital and consulted with Dr. Rachanon (which gave me a weird impression, as to when I asked him about the cause and the change of my nodule from black to white, his response was 'who cares?' and 'he is not a scientist so he doesn't know), think I will change the consult doctor next time I go. However he recommended Dr. Vichaphan for the surgery. 

 

About the cost, It's okay. Yet, if compare cyberknife procedure would be a little too high. 

Right now, I'm looking at other hospital as well, for as long as I can get a great surgeon and proper treatment on this . 

 

To my understanding oral endoscopic approach is not currently used for nodules that big. However endoscopic approach through the neck or uppe chest is quite possible and probably what your doctor had in mind since the head & neck surgeon he referred you, Dr. Vitchaphan (note  spelling), trained in US on endoscopic approach. 

https://www.bumrungrad.com/en/doctors/Vitchaphan-Hemrungrojn

 

Risk of damage to the laryngal nerve is small especially when only lobectomy is performed rather than complete thyroidectomy..as seems to be the plan.

 

There are new molecular genetic tests used in the US to help decide whether to operate when conventional biopsy results are indeterminate. But as far as I have been able to determine it is not yet  available in Thailand.

 

In addition even if a nodule is benign (as majority of "indeterminate" nodules prove to be after removal) it can still be necessary to remove them if they cause symptoms.

 

For second opinion I highly recommend https://www.bumrungrad.com/en/doctors/Jun-Srimanunthiphol

US trained and US board certified. Very bright and very thorough. I think you will feel better going forward after talking to her. 

 

 

 

[Captor]

13 hours ago, fuehrio said:

I had to remove a thyriod cyst 2 weeks ago. I checked multiple hospitals and sensed Bangkok Hospital would be the best option (top surgeon) but unfortunately my insurance refused to pay. So I have chosen Phyathay 2 hospital and Dr. Chantima (female surgeon) did a fantastic job. She is also specialized in head and neck cancer.

What insurance company was that?

[Kristie J]

3 hours ago, Sheryl said:

To my understanding oral endoscopic approach is not currently used for nodules that big. However endoscopic approach through the neck or uppe chest is quite possible and probably what your doctor had in mind since the head & neck surgeon he referred you, Dr. Vitchaphan (note  spelling), trained in US on endoscopic approach. 

https://www.bumrungrad.com/en/doctors/Vitchaphan-Hemrungrojn

 

Risk of damage to the laryngal nerve is small especially when only lobectomy is performed rather than complete thyroidectomy..as seems to be the plan.

 

There are new molecular genetic tests used in the US to help decide whether to operate when conventional biopsy results are indeterminate. But as far as I have been able to determine it is not yet  available in Thailand.

 

In addition even if a nodule is benign (as majority of "indeterminate" nodules prove to be after removal) it can still be necessary to remove them if they cause symptoms.

 

For second opinion I highly recommend https://www.bumrungrad.com/en/doctors/Jun-Srimanunthiphol

US trained and US board certified. Very bright and very thorough. I think you will feel better going forward after talking to her. 

 

 

 

At the moment, I am also considering about doing the surgery at Rama hospital (Dr. Vitchaphan also graduated from there, he still in my option) as I heard many many great surgeon are from there.

Do you have another recommendation I should look for? just for the options.

 

With honesty, I want to take a little more time for the surgery, but I am afraid of the growing size, and that the bigger it will be the more damage it could cause. 

Have you ever heard of anyone with experience of nodules got shrunk? 

 

Also, I think I will go with doctor you recommended for the consultation. Thank you!

[Sheryl]

31 minutes ago, Kristie J said:

At the moment, I am also considering about doing the surgery at Rama hospital (Dr. Vitchaphan also graduated from there, he still in my option) as I heard many many great surgeon are from there.

Do you have another recommendation I should look for? just for the options.

 

With honesty, I want to take a little more time for the surgery, but I am afraid of the growing size, and that the bigger it will be the more damage it could cause. 

Have you ever heard of anyone with experience of nodules got shrunk? 

 

Also, I think I will go with doctor you recommended for the consultation. Thank you!

The hospital does not matter much. It is the skill of the surgeon. Which hospital fo you mean by Rama? Ramathibodhi? It is a government hospital so not as easy to use and likely to have wait lists.

 

If you have surgery you will need to be followed by endocrinologists after as well so it is a advantageous (though not absolutely essential) to hsve surgery as same hospital where your endocrine specialist is.

 

What are your symptoms currently? Is it a "hot" nodule (one that secretes thyroid hormone) or causing pressure on your neck for swallowing etc?

 

In some cases -- especially for benign "hot" nodules -- use of radioactive iodine is an option.  But not usually when there is a  suspicion of cancer.

 

Your problem Is that cancer cannot be ruled out, there is 20-30% chance you have cancer. If you do,   surgery is unavoidable and better not delayed. 

 

When you see Dr. Jun you can ask about  whether a repeat FNA might help or if  they have access to Afirma Gene expression testing. (To see if you can get a more definitive result).

[fuehrio]

8 hours ago, Captor said:

What insurance company was that?

Not sure if defamation applies if I mention the full name but it starts and ends with an A...one of the company mostly used by foreigners living here.

[fuehrio]

16 hours ago, Kristie J said:

I am sorry, my knowledge on the issue still limited at the moment, is the thyroid cyst and thyroid nodule the same issue/surgery? and how is yours?

How is the post surgery going? and does it affect your voice?

I hope you are feeling better now. 

Not a specialist either but it read nodule can be caused by thyroid cyst. The surgery procedure for the cyst is called Sistrunk surgery. The post surgery was surprisingly easy, was able to eat soft food, can talk and pain was manageable with pain killers the first few days. Just a large scar remains now which will blur out soon I hope.

[Captor]

4 hours ago, fuehrio said:

Not sure if defamation applies if I mention the full name but it starts and ends with an A...one of the company mostly used by foreigners living here.

OK, then I know. Thanks for the information ????.

[Kristie J]

14 hours ago, Sheryl said:

The hospital does not matter much. It is the skill of the surgeon. Which hospital fo you mean by Rama? Ramathibodhi? It is a government hospital so not as easy to use and likely to have wait lists.

 

If you have surgery you will need to be followed by endocrinologists after as well so it is a advantageous (though not absolutely essential) to hsve surgery as same hospital where your endocrine specialist is.

 

What are your symptoms currently? Is it a "hot" nodule (one that secretes thyroid hormone) or causing pressure on your neck for swallowing etc?

 

In some cases -- especially for benign "hot" nodules -- use of radioactive iodine is an option.  But not usually when there is a  suspicion of cancer.

 

Your problem Is that cancer cannot be ruled out, there is 20-30% chance you have cancer. If you do,   surgery is unavoidable and better not delayed. 

 

When you see Dr. Jun you can ask about  whether a repeat FNA might help or if  they have access to Afirma Gene expression testing. (To see if you can get a more definitive result).

yes, it's Ramathibodhi. As I heard they have up to date equipment and skillful surgeons there. 

 

You made a point about the beneficial of follow up and surgery at the same hospital, as that's what I am thinking too. it could be the impression from my previous doctor that made me a little hesitate with going to bumrungrad now, but the surgeon he recommended seem to have the background and experiences that needed for this surgery. 

 

I had a fatigue and little overwhelmed and anxiety for last several days which is now okay ( I am afraid this could be covd symptoms too, as one of my family members currently have it) 

But I gain weight a little too fast, and some time itchy throat and cough at night. 

What do you mean by hot? I feel the inflammation on the nodule area, could be I indulged much sweet recently, because I noticed the hot increase most of the time after eating sweet.

 

I am preparing for another follow up around early September, and then I will decide whether if I should do the surgery asap or it can wait longer, in case (hopefully) there is a change for the good. With honesty, I tried to avoid surgery if possible. 

[Sheryl]

4 hours ago, Kristie J said:

yes, it's Ramathibodhi. As I heard they have up to date equipment and skillful surgeons there. 

 

You made a point about the beneficial of follow up and surgery at the same hospital, as that's what I am thinking too. it could be the impression from my previous doctor that made me a little hesitate with going to bumrungrad now, but the surgeon he recommended seem to have the background and experiences that needed for this surgery. 

 

I had a fatigue and little overwhelmed and anxiety for last several days which is now okay ( I am afraid this could be covd symptoms too, as one of my family members currently have it) 

But I gain weight a little too fast, and some time itchy throat and cough at night. 

What do you mean by hot? I feel the inflammation on the nodule area, could be I indulged much sweet recently, because I noticed the hot increase most of the time after eating sweet.

 

I am preparing for another follow up around early September, and then I will decide whether if I should do the surgery asap or it can wait longer, in case (hopefully) there is a change for the good. With honesty, I tried to avoid surgery if possible. 

A "hot"  nodule is one the secretes thyroid hormones causing you to be hyperthroid. Nothing to do with feeling hot. Your blood thyroid panel tests would show this. Since you do not mention abnormal blood test of thyroid function you probably do not have a "hot" nodule. And I see you also do not mention any problem speaking or swallowing (as one would expect since the nodule is still not that big)

 

If I am correct in all this then you have an asymptomatic nodule. (the various symptoms you mentioned are likely stress related not physically caused  by the nodule).

 

The only reason for surgery with an asymptomatic nodule is if they are cancerous. Cancerous nodules need to be removed and the sooner the better as delay can lead to metastasis requiring more extensive treatment and in some cases (especially with certain less common types of thyroid cancer that are unusually aggresdive) even death.

 

Your dilemma is that, with an indetetminate biopsy result, you do not know if it is cancerous or not much less (if it is) what type of cancer. 

 

I strongly urge against delaying this until September. If it is cancer that would increase the chances of it spreading into lymph nodes or even other organs requiring much more extensive surgery and other treatments.

 

 See Dr. Jun as soon as possible. Having not been happy with 1 doctor in a hospital in no way means you will be unhappy with another. Doctors vary greatly not just in their competence but also in their communication and interpersonal skills.  I think you will find a big difference with Dr. Jun. Ask her specifically:

 

1. Would it help, in terms of getting clearer diagnosis,  to get a repeat FNA? FNA depends a lot on the doctor sampling the right parts of the nodule and getting enough tissue -- and on the skill of the pathologist who reads the sample. Knowing that you had a prior indeterminate result, she might be able to get better/more extensive samples and/or direct them to a particularly good pathologist. No guarantee but worth discussing with her.

 

2. Is there any way to access Afirma Gene Expression Classifation (if necessary, by sending sample abroad?). This can help decide if a sample is malignant or not, through genetic markers. 

 

If you can get a more definite biopsy result through either of the above approaches that would end the dilemma.  A benign result would mean no surgery. A malignant result would mean surery is unavoidable. Either way you have a clear answer and know what to do.

 

The doctors at Ramathibodhi also work at other hospitals including Bumrungrad. The equipment there is not better than in the large private hospitals and sometimes indeed the opposite. If for financial reasons you had to use a government hospital then, for thyroid surgery, Ramathibodhi would be a good choice but makes no sense if you can afford to be treated by the same doctors at a private hospital, especially since you do not live in Thailand and presumably speak no Thai.    It is very difficult and time consuming to access care in a government hospital.  You usually have to go in person just to make appointment and there will often be long wait to get it. Then long wait on day of appointment. Not unusual  for it to be canceled without you being told in advance. Any tests etc needed will usually require additional trips. All in all, what you could do in a single day in a private hospital will take weeks in a government one -- especially impractical for someone not living in Thailand. Lots of complicated bureacracy that can be hard to figure out.  Language barriers are considerable -- senior doctors will speak English but not admin and nursing staff. This makes it very hard to navigate the system for a non-Thai speaker. And can make for a pretty scary experience as an inpatient (imagine being prepped for surgery, and cared for post op,  by people you can't communicate with). 

 

While it is certainly worth trying to get a more definitive  diagnosis, should that prove impossible-- or should you get one but with result of cancer - you should not be unduly fearful as risks are much smaller than you seem to think.  Risk of permanent damage to the laryngeal nerve (affecting speech) is well under 1% in an  endoscopic lobctomy. More like 0.1%. (One in one thousand,)

 

I have recently discovered thyroid nodules myself and just went through the ultrasound and FNA process so I can relate to what you are feeling.  During the  wait for results I had plenty of time to consider what I would do and to extensively research options and complication rates.  There was no question in my mind that I would get surgery ss soon as possible -' preferably just a lobectomy, and done endoscopically-- if the nodule proved malignant. Which does not mean I wouldn't be apprehensive/scared and dread it...just that I knew it was by far the safest, wisest course.

 

Sometimes  we have to compartmentalize our feelings for our own good as emotions are not good decisions makers. 

 

Luckily for me I got a clear benign result, big relief. But during the 3 days wait (which felt like 3 years!) for the result my mind went through all the possible scenarios in vivid detail...so I do understand your feelings.  But for your own sake don't make an emotion based decision or put things off.

 

[Kristie J]

On 7/27/2022 at 8:39 PM, Sheryl said:

A "hot"  nodule is one the secretes thyroid hormones causing you to be hyperthroid. Nothing to do with feeling hot. Your blood thyroid panel tests would show this. Since you do not mention abnormal blood test of thyroid function you probably do not have a "hot" nodule. And I see you also do not mention any problem speaking or swallowing (as one would expect since the nodule is still not that big)

 

If I am correct in all this then you have an asymptomatic nodule. (the various symptoms you mentioned are likely stress related not physically caused  by the nodule).

 

The only reason for surgery with an asymptomatic nodule is if they are cancerous. Cancerous nodules need to be removed and the sooner the better as delay can lead to metastasis requiring more extensive treatment and in some cases (especially with certain less common types of thyroid cancer that are unusually aggresdive) even death.

 

Your dilemma is that, with an indetetminate biopsy result, you do not know if it is cancerous or not much less (if it is) what type of cancer. 

 

I strongly urge against delaying this until September. If it is cancer that would increase the chances of it spreading into lymph nodes or even other organs requiring much more extensive surgery and other treatments.

 

 See Dr. Jun as soon as possible. Having not been happy with 1 doctor in a hospital in no way means you will be unhappy with another. Doctors vary greatly not just in their competence but also in their communication and interpersonal skills.  I think you will find a big difference with Dr. Jun. Ask her specifically:

 

1. Would it help, in terms of getting clearer diagnosis,  to get a repeat FNA? FNA depends a lot on the doctor sampling the right parts of the nodule and getting enough tissue -- and on the skill of the pathologist who reads the sample. Knowing that you had a prior indeterminate result, she might be able to get better/more extensive samples and/or direct them to a particularly good pathologist. No guarantee but worth discussing with her.

 

2. Is there any way to access Afirma Gene Expression Classifation (if necessary, by sending sample abroad?). This can help decide if a sample is malignant or not, through genetic markers. 

 

If you can get a more definite biopsy result through either of the above approaches that would end the dilemma.  A benign result would mean no surgery. A malignant result would mean surery is unavoidable. Either way you have a clear answer and know what to do.

 

The doctors at Ramathibodhi also work at other hospitals including Bumrungrad. The equipment there is not better than in the large private hospitals and sometimes indeed the opposite. If for financial reasons you had to use a government hospital then, for thyroid surgery, Ramathibodhi would be a good choice but makes no sense if you can afford to be treated by the same doctors at a private hospital, especially since you do not live in Thailand and presumably speak no Thai.    It is very difficult and time consuming to access care in a government hospital.  You usually have to go in person just to make appointment and there will often be long wait to get it. Then long wait on day of appointment. Not unusual  for it to be canceled without you being told in advance. Any tests etc needed will usually require additional trips. All in all, what you could do in a single day in a private hospital will take weeks in a government one -- especially impractical for someone not living in Thailand. Lots of complicated bureacracy that can be hard to figure out.  Language barriers are considerable -- senior doctors will speak English but not admin and nursing staff. This makes it very hard to navigate the system for a non-Thai speaker. And can make for a pretty scary experience as an inpatient (imagine being prepped for surgery, and cared for post op,  by people you can't communicate with). 

 

While it is certainly worth trying to get a more definitive  diagnosis, should that prove impossible-- or should you get one but with result of cancer - you should not be unduly fearful as risks are much smaller than you seem to think.  Risk of permanent damage to the laryngeal nerve (affecting speech) is well under 1% in an  endoscopic lobctomy. More like 0.1%. (One in one thousand,)

 

I have recently discovered thyroid nodules myself and just went through the ultrasound and FNA process so I can relate to what you are feeling.  During the  wait for results I had plenty of time to consider what I would do and to extensively research options and complication rates.  There was no question in my mind that I would get surgery ss soon as possible -' preferably just a lobectomy, and done endoscopically-- if the nodule proved malignant. Which does not mean I wouldn't be apprehensive/scared and dread it...just that I knew it was by far the safest, wisest course.

 

Sometimes  we have to compartmentalize our feelings for our own good as emotions are not good decisions makers. 

 

Luckily for me I got a clear benign result, big relief. But during the 3 days wait (which felt like 3 years!) for the result my mind went through all the possible scenarios in vivid detail...so I do understand your feelings.  But for your own sake don't make an emotion based decision or put things off.

 

I am delaying the follow up with doctor because as I gathered info regarding biopsy, it says between 1-2month after the first one, and until now it's been only a month, and the result won't be showing any much different below 1month as the first one already said indeterminate (if it says suspicious, than I do believe as soon as one more follow up or surgery is a must). Also, I want to wait until September, due to the fact that I need time to research about the surgery and options available, and to hear from those with history of doing  the surgery, to find out what will I be facing.

I have also met another specialist doctor in my home country within this one month, for advice and opinions as well.

My most likely decision on this will be surgery despite what could the result of next biopsy be since there hasn't been a result on the internet about shrinking nodules. (non standardly, I heard from elders how CBD could shrink it tho, one of the reason I have been hesitating as well) 

At the moment, I need to be emotionally prepare for the surgery. It's normal to imagine the worst so that when it comes I can be prepare. 

 

I was advised by my follow up doctor in here, similar to what you said. He asked about how I feel and what I am afraid of, and to compare (as  a way to comfort me) between keeping it(with current indeterminate result) and doing the surgery which one would give more weight/damage on the situation. which by far, I guess the best direct and helpful advice I have heard and want to hear. so Thank You!

 

you know I have met doctors who push me to surgery before the result come out, I have met one who haven't even done any tests push me to surgery too. They just look and says it's best to do surgery. I feel a resistance inside me every time they say that, because despite how small or big the surgery is, surgery always come with consequences and I tried to avoid it unless it really is unavoidable.

[Kristie J]

On 7/27/2022 at 8:39 PM, Sheryl said:

A "hot"  nodule is one the secretes thyroid hormones causing you to be hyperthroid. Nothing to do with feeling hot. Your blood thyroid panel tests would show this. Since you do not mention abnormal blood test of thyroid function you probably do not have a "hot" nodule. And I see you also do not mention any problem speaking or swallowing (as one would expect since the nodule is still not that big)

 

If I am correct in all this then you have an asymptomatic nodule. (the various symptoms you mentioned are likely stress related not physically caused  by the nodule).

 

The only reason for surgery with an asymptomatic nodule is if they are cancerous. Cancerous nodules need to be removed and the sooner the better as delay can lead to metastasis requiring more extensive treatment and in some cases (especially with certain less common types of thyroid cancer that are unusually aggresdive) even death.

 

Your dilemma is that, with an indetetminate biopsy result, you do not know if it is cancerous or not much less (if it is) what type of cancer. 

 

I strongly urge against delaying this until September. If it is cancer that would increase the chances of it spreading into lymph nodes or even other organs requiring much more extensive surgery and other treatments.

 

 See Dr. Jun as soon as possible. Having not been happy with 1 doctor in a hospital in no way means you will be unhappy with another. Doctors vary greatly not just in their competence but also in their communication and interpersonal skills.  I think you will find a big difference with Dr. Jun. Ask her specifically:

 

1. Would it help, in terms of getting clearer diagnosis,  to get a repeat FNA? FNA depends a lot on the doctor sampling the right parts of the nodule and getting enough tissue -- and on the skill of the pathologist who reads the sample. Knowing that you had a prior indeterminate result, she might be able to get better/more extensive samples and/or direct them to a particularly good pathologist. No guarantee but worth discussing with her.

 

2. Is there any way to access Afirma Gene Expression Classifation (if necessary, by sending sample abroad?). This can help decide if a sample is malignant or not, through genetic markers. 

 

If you can get a more definite biopsy result through either of the above approaches that would end the dilemma.  A benign result would mean no surgery. A malignant result would mean surery is unavoidable. Either way you have a clear answer and know what to do.

 

The doctors at Ramathibodhi also work at other hospitals including Bumrungrad. The equipment there is not better than in the large private hospitals and sometimes indeed the opposite. If for financial reasons you had to use a government hospital then, for thyroid surgery, Ramathibodhi would be a good choice but makes no sense if you can afford to be treated by the same doctors at a private hospital, especially since you do not live in Thailand and presumably speak no Thai.    It is very difficult and time consuming to access care in a government hospital.  You usually have to go in person just to make appointment and there will often be long wait to get it. Then long wait on day of appointment. Not unusual  for it to be canceled without you being told in advance. Any tests etc needed will usually require additional trips. All in all, what you could do in a single day in a private hospital will take weeks in a government one -- especially impractical for someone not living in Thailand. Lots of complicated bureacracy that can be hard to figure out.  Language barriers are considerable -- senior doctors will speak English but not admin and nursing staff. This makes it very hard to navigate the system for a non-Thai speaker. And can make for a pretty scary experience as an inpatient (imagine being prepped for surgery, and cared for post op,  by people you can't communicate with). 

 

While it is certainly worth trying to get a more definitive  diagnosis, should that prove impossible-- or should you get one but with result of cancer - you should not be unduly fearful as risks are much smaller than you seem to think.  Risk of permanent damage to the laryngeal nerve (affecting speech) is well under 1% in an  endoscopic lobctomy. More like 0.1%. (One in one thousand,)

 

I have recently discovered thyroid nodules myself and just went through the ultrasound and FNA process so I can relate to what you are feeling.  During the  wait for results I had plenty of time to consider what I would do and to extensively research options and complication rates.  There was no question in my mind that I would get surgery ss soon as possible -' preferably just a lobectomy, and done endoscopically-- if the nodule proved malignant. Which does not mean I wouldn't be apprehensive/scared and dread it...just that I knew it was by far the safest, wisest course.

 

Sometimes  we have to compartmentalize our feelings for our own good as emotions are not good decisions makers. 

 

Luckily for me I got a clear benign result, big relief. But during the 3 days wait (which felt like 3 years!) for the result my mind went through all the possible scenarios in vivid detail...so I do understand your feelings.  But for your own sake don't make an emotion based decision or put things off.

 

Also, I have thought about how switching hospitals for surgery and follow up back and forth could be at disadvantage too, which I agree with you on sticking to just one. For Rama, I have heard of the queue to meet and consult and the long wait and everything, but one thing I have yet to know of is the surgeons' background which make it impossible for me to choose. At least, at the Bumrungrad, there is background to check and learn what surgeons' ability and result we could expect from.

 

About the Endoscopy, I checked and learned that the tubes have to go through from different place (armpit or chest depending on doctor and how big it is) to perform it. So I was wondering if it could, by chance, affect the other areas during the process?

 

[Sheryl]

3 hours ago, Kristie J said:

Also, I have thought about how switching hospitals for surgery and follow up back and forth could be at disadvantage too, which I agree with you on sticking to just one. For Rama, I have heard of the queue to meet and consult and the long wait and everything, but one thing I have yet to know of is the surgeons' background which make it impossible for me to choose. At least, at the Bumrungrad, there is background to check and learn what surgeons' ability and result we could expect from.

 

About the Endoscopy, I checked and learned that the tubes have to go through from different place (armpit or chest depending on doctor and how big it is) to perform it. So I was wondering if it could, by chance, affect the other areas during the process?

 

They insert the tiny tube through area chosen because if is free of major blood vessels ect Endoscopic approach has excellent safety record. 

 

Since your nodule is asymptomatic, the only reason to remove it at this time is if it is cancer. 

 

Benign thyroid nodules can sometimes go away on their own but this is rare, usually they either stay the same or increase in size. CBD won't affect it.  If a benign module keeps increasing in size it will eventually cause sympyoms requiring removal. If it stays the same, you can live with it indefinitely-- IF it is benign.

 

A cancerous nodule must come out and the sooner the better, delay is inadvisable.

 

I don't think waiting will change biopsy results. What would is getting the sample tested by Afirma GEC. And possibly better technique by doctor doing it and/or more skill by pathologist who reads it.  I would trust Dr. Jun's judgment as to whether there is any point in a repeat biopsy.

 

While I understand your need to prepare emotionally, imagine how you will feel if the surgery finds it is cancer and it has has spread. Requiring more extensive surgery etc. You will always wonder if that could have been prevented by acting sooner ... and maybe it coild have. And emotionally  you will be much worse off.

 

 

 he delsy u 

 

[Kristie J]

1 hour ago, Sheryl said:

They insert the tiny tube through area chosen because if is free of major blood vessels ect Endoscopic approach has excellent safety record. 

 

Since your nodule is asymptomatic, the only reason to remove it at this time is if it is cancer. 

 

Benign thyroid nodules can sometimes go away on their own but this is rare, usually they either stay the same or increase in size. CBD won't affect it.  If a benign module keeps increasing in size it will eventually cause sympyoms requiring removal. If it stays the same, you can live with it indefinitely-- IF it is benign.

 

A cancerous nodule must come out and the sooner the better, delay is inadvisable.

 

I don't think waiting will change biopsy results. What would is getting the sample tested by Afirma GEC. And possibly better technique by doctor doing it and/or more skill by pathologist who reads it.  I would trust Dr. Jun's judgment as to whether there is any point in a repeat biopsy.

 

While I understand your need to prepare emotionally, imagine how you will feel if the surgery finds it is cancer and it has has spread. Requiring more extensive surgery etc. You will always wonder if that could have been prevented by acting sooner ... and maybe it coild have. And emotionally  you will be much worse off.

 

 

 he delsy u 

 

 

My point of view on the second biopsy is that, if the first one says indeterminate, then within a month time it's  unlikely to be spread this fast, unless it's already stated cancerous/suspicious which mean bethsda category V. I think doing another biopsy during that time won't give me different result unless, again, it's cancerous which I am hopefully not. 

On the others hand, if it's to spread, then I am sure another test, which I will do within 4weeks times, will give me a more accurate result. So then, I can be more determine on doing the surgery or not. At the meantime, I am following up with the blood test of my thyroid in my home country to see if it's growing or any change in form. 

my family doest have history of cancer, also from doctor's explanation on the ultra sound, they also told me it's very unlikely to be cancerous depending on the shape and what is in it (cancerous normally non liquid and it doesn't look round, mine is round and more liquid). I am aware it could develop, and I don't want to delay it that much, as having this didn't give me much of full rest since I keep worrying, but I do need to look at this in another way than pursing immediate surgery. Also, certain type of nodules could develop or change due to the rapid biopsy, so I think two FNA (if the second one needed) within two months is my best shot. 

 

for Afirma Gene Expression Classification, this matter I could email to ask them, or perhaps asking for a direct contact with the doctor to see if they could do it. Otherwise, if they couldn't do it, then going for another trip just to ask that would be a waste. 

Right now for my next visit, I planned to ask everything, and perhaps another biopsy if necessary, if not I would proceed to surgery if it keeps growing in size or what is in it keep changing. If It seem like keeping it causing a lot more stress than removing it, then I think removing it would be wiser. 

What I am worry most is it could grow to the other side which would lead to full removal of the thyroid. 

[Sheryl]

Spreading of cancer is not what might  make a second biopsy more definitive. Rather it is skill of the doctor and the pathologist. Time interval is not relevant. 

 

AFIRMA GEC would certainly be best if you can get it but I am not sure you will get an accurate answer to that by email unless you can find a way to email the  doctor directly.  The clerks who answer emails will not even know what it is and it won't show on any test of procedure lists they might refer to. If possible to do it would likely involve sending  specimen elsewhere.

[Kristie J]

On 7/31/2022 at 12:44 AM, Sheryl said:

Spreading of cancer is not what might  make a second biopsy more definitive. Rather it is skill of the doctor and the pathologist. Time interval is not relevant. 

 

AFIRMA GEC would certainly be best if you can get it but I am not sure you will get an accurate answer to that by email unless you can find a way to email the  doctor directly.  The clerks who answer emails will not even know what it is and it won't show on any test of procedure lists they might refer to. If possible to do it would likely involve sending  specimen elsewhere.

Hi again, I am now in Thailand. But I have one concern regarding the visa (if you have any information), Right now I don’t have a clear schedule (exact date for surgery yet), but they estimated around 2weeks. But just for any change of schedule that require me staying longer, where can I go to do the visa or requested? 

[Sheryl]

13 hours ago, Kristie J said:

Hi again, I am now in Thailand. But I have one concern regarding the visa (if you have any information), Right now I don’t have a clear schedule (exact date for surgery yet), but they estimated around 2weeks. But just for any change of schedule that require me staying longer, where can I go to do the visa or requested? 

How did you come to Thailand? A tourist visa, or visa exempt? Did you enter by air or by land border?

[lopburi3]

The major hospitals have immigration contacts and can do inhouse I believe.  If using Bangkok Hospital/Bumrungrad or such check with them.

 

As one who had operation about 10 years ago (one side solid mass but inconclusive biopsy) had no effect on speech and only minor effect on swallowing.  The biopsy was negative but Thyroid remaining did not work so taking pill each day.

[Kristie J]

19 hours ago, Sheryl said:

How did you come to Thailand? A tourist visa, or visa exempt? Did you enter by air or by land border?

By air. I can stay in Thailand for 14days without visa. also, I met with Dr. Jun. Thank you for a good recommendation. 

she suggested an open surgery, by Dr. Vatana, and I asked about the endoscopy, she recommended Dr. Angkoon.

At the moment, I’m in a considering stage. I am anxious in case the other half nodule can’t function properly. Any opinions? Or thoughts?

[Kristie J]

13 hours ago, lopburi3 said:

The major hospitals have immigration contacts and can do inhouse I believe.  If using Bangkok Hospital/Bumrungrad or such check with them.

 

As one who had operation about 10 years ago (one side solid mass but inconclusive biopsy) had no effect on speech and only minor effect on swallowing.  The biopsy was negative but Thyroid remaining did not work so taking pill each day.

Hi, Yes, I raised the concern to my doc and she told me not to worry about it because they have immigration office at Bumrungrad. 

 

By minor effect on swallowing, you mean it hurts when swallow?

I am sorry to hear about your other thyroid not working properly. How do you adjust to taking pill everyday? I had to ask because kind of feel a little anxious about the surgery. 

 

and did you do the biopsy twice? Mine says indeterminate which make it very hard to decide on surgery. 

if it’s benign, and it would be unjust to cut it. 

[Kristie J]

19 hours ago, Sheryl said:

How did you come to Thailand? A tourist visa, or visa exempt? Did you enter by air or by land border?

also if you have a good recommendation for a nice apartment nearby, please let me know too. I have searched and been staying at hotel but I don’t think it’s very efficient.

[Sheryl]

2 hours ago, Kristie J said:

By air. I can stay in Thailand for 14days without visa. also, I met with Dr. Jun. Thank you for a good recommendation. 

she suggested an open surgery, by Dr. Vatana, and I asked about the endoscopy, she recommended Dr. Angkoon.

At the moment, I’m in a considering stage. I am anxious in case the other half nodule can’t function properly. Any opinions? Or thoughts?

That is a problem as it seems you are from Cambodia or other ASEAN country and entered under bilateral agreement. Those stays cannot be extended except for medical extension, but you can only get a medical extension if you are unable to travel (for example, if you have had the surgery already but not yet fit to travel home). In that case the hospital can help arrange extension for you.But if you are just waiting for the operation, you cannot get extension, you would have to go back to Cambodia and then come again. If you have to do that I recommend you try to get a tourist visa after going back as that will allow you to stay up to 90 days (you get 60 days on arrival and can extend another 30 days). In addition, on tourist visa you can leave and return within that time period by getting a re-entry permit.

 

There is no reason to think the remaining lobe of the thyroid would not function after surgery. What does sometimes happen is that if the biopsy of the removed lobe indicates the cancer has spread beyond it, they may have to go back and take out more.

 

In your case, if it were me and if Dr. Jun and the surgeon concur with a  lobectomy, I would go ahead and do that in hopes of saving the other lobe of the thyroid. This can help avoid or minimize the need to take hormones. Even if you do need to take hormone the amount you'd need and the amount of hormone flunctuation would be less than with a complete removal of the thyroid.

 

Endoscopic surgery gives a better cosmetic result (smaller scar) is easier on the patient, easier recovery, usual less time in hospital. However it usually costs more.

 

Regarding repeat biopsy what id Dr. Jun suggest? and did you ask about possibility of getting Afirma Gene test?