Need advice regarding lymph node lump and possible biopsy

[somtamgaiyang]

My Thai friend (ex-girlfriend) has had a lump in one of her arm pits for 2-3 months now. I found out about it last month and agreed to go with her to Bangkok Hospital in Koh Samui where we both live. A doctor there felt the lump and then ordered a blood test and x-ray.

They came back showing everything normal. He said that it was probably nothing to be concerned about, but he thought it might be worth doing a biopsy. He gave her some antibiotics and said that if they didn't help after a couple of weeks she should come back for a biopsy. They didn't.

I have done some googling and I think its unlikely this is cancer based on my reading, although I'm certainly as far from an expert as I could be. The lump is not painful or visible to the naked eye, and she says it gets bigger and smaller rather than just getting bigger. But she is understandably concerned and wants to be sure. I don't blame her for that.

Bangkok Hospital is quite expensive. For the initial visit they charged over 4,000 baht. We asked them how much a biopsy would cost and they said probably 20,000 baht. They also said the sample would be sent to a lab in Bangkok because they don't have the facilities here to do the analysis. I didn;t know enough at the time to ask them what type of biopsy they would be performing.

My friend believes that if she goes to Thaksin Hospital in Surat Thani she can get the biopsy for less. She will be paying for this herself, by the way. And she believes it is a good hospital. I don't know if this is the case. We called them for information. They said they can do a biopsy but have to do an examination first, which makes sense. But they would not give us any sense of how much a potential biopsy would cost.

Friends have told me they didn't think Thaksin Hospital was as good as Bangkok Samui, and they probably would not be cheaper. They also thought she would be charged a higher price if I accompanied her. Is this likely?

Anyway, I am looking for some good advise. Is it possible to get a responsibly done biopsy here in Samui? If not, would she be better of in Surat Thani or should she go to Bangkok. On an earlier archived thread from a couple of years ago I saw people talking about 4-5000 baht maximum for a biopsy and related expenses. Is this still what we should expect or is 20,000 baht reasonable?

Thank you in advance for any helpful information.

[Sheryl]

Taksin Hosp is definitely the best private option in that part of Thailand and will be less expensive than Bkk Hosp. The other option is the provincial hospital in Surat Thani which will be the least expensive but being a Govt. Hospital will entail some red tape and waits.

If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

If it turns out to be anything serious then best she get care at whatevet govt hosp she is registeted at as it will be free. But likely that is back in her homeprovince.

[somtamgaiyang]

Taksin Hosp is definitely the best private option in that part of Thailand and will be less expensive than Bkk Hosp. The other option is the provincial hospital in Surat Thani which will be the least expensive but being a Govt. Hospital will entail some red tape and waits.

If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

If it turns out to be anything serious then best she get care at whatevet govt hosp she is registeted at as it will be free. But likely that is back in her homeprovince.

Okay, Thaksin Hospital it is then.

>If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

I will tell her this.

I visited another private hospital here on the island today; Samui Inter. They said that the General Surgeon will be available tomorrow to give a consultation. She was not sure whether he would charge for the consultation or not (either free or 500 baht, not so bad). She said based on his decision it could cost 12,000 for a biopsy without anesthesia (I'm guessing FNA or CNA) or more if she needs anesthesia (guessing open biopsy). I think it might be worth going there to get his opinion and find out which kind of biopsy he would choose. Or maybe he doesn't think she even needs a biopsy.

She doesn't want to go to a government hospital because 1) the long wait and 2) she thinks they will not be as skilled in determining what the problem is. But as you said, if it turns out to be serious then cost-wise it would probably be the only option.

So my last question (hopefully) is, do you have a sense as to what price range is reasonable for a biopsy? The old thread I looked at indicated about 4-5000 baht for FNA, but it was from 2 years ago. Is it really so much cheaper in Bangkok? And do you think she would actually get a better price if there are no farangs involved?

[Tolley]

Taksin Hosp is definitely the best private option in that part of Thailand and will be less expensive than Bkk Hosp. The other option is the provincial hospital in Surat Thani which will be the least expensive but being a Govt. Hospital will entail some red tape and waits.

If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

If it turns out to be anything serious then best she get care at whatevet govt hosp she is registeted at as it will be free. But likely that is back in her homeprovince.

Okay, Thaksin Hospital it is then.

>If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

I will tell her this.

I visited another private hospital here on the island today; Samui Inter. They said that the General Surgeon will be available tomorrow to give a consultation. She was not sure whether he would charge for the consultation or not (either free or 500 baht, not so bad). She said based on his decision it could cost 12,000 for a biopsy without anesthesia (I'm guessing FNA or CNA) or more if she needs anesthesia (guessing open biopsy). I think it might be worth going there to get his opinion and find out which kind of biopsy he would choose. Or maybe he doesn't think she even needs a biopsy.

She doesn't want to go to a government hospital because 1) the long wait and 2) she thinks they will not be as skilled in determining what the problem is. But as you said, if it turns out to be serious then cost-wise it would probably be the only option.

So my last question (hopefully) is, do you have a sense as to what price range is reasonable for a biopsy? The old thread I looked at indicated about 4-5000 baht for FNA, but it was from 2 years ago. Is it really so much cheaper in Bangkok? And do you think she would actually get a better price if there are no farangs involved?

You could always get an ultrasound on the lymph node.

That is quick and easy and not painful.

They can tell pretty much from an ultrasound whether it is likely to be cancerous.

If it is suspicious then they do a biopsy.

[somtamgaiyang]

Thanks for the info Tolley. I wasn't aware of that option. I wonder why the doctor she went to before didn't suggest it.

[Sheryl]

Ultrasound will only tell if it is fluid filled, vascular etc. If it is a cyst, ultrasound findings can be strongly suggestive but not definitive. You cannot definitely determine if something is malignant by ultrasound.

The big issue in my mind is whether this is a lymph node because if it is, breast cancer is a real concern, as is possibly TB of the lymph nodes. If it is not a lymph node, then this is not relevant.

She is quite right re the waits at a govt hospital but completely wrong re the skill level/quality of care. the best facilities for this type of thing are govt hospitals and indeed, that is likely where a local private hosp would send the specimen.

There is a special tertiary level Camcer Center in Surat Thani (govt) by the way and if there is any likelihood of malignancy this would be where to go. But can start at Taksin Hosp if you like.

Sorry but I do not know what a biopsy would cost. There are many, many variables including how it has to be done - FNA vs. excision which in turn depends on the nature of the mass and how close to the surface etc all of which I do not know. However no way would biopsy be only 4-5,000 at a private hospital - the path exam alone will be around 3,000 and then there is the cost of the excision on top of that.

Costs in private Samui hospitals are considerably higher than in large private hospitals in Bkk.

Taksin Hosp would usually cost less than one of the "name" hospitals in Bkk.

Whatever doctor she sees, be sure to ask pointedly whether the mass is an enlarged lymph node or a separate mass. that much they should be able to tell by physical exam alone.

[somtamgaiyang]

Ultrasound will only tell if it is fluid filled, vascular etc. If it is a cyst, ultrasound findings can be strongly suggestive but not definitive. You cannot definitely determine if something is malignant by ultrasound.

The big issue in my mind is whether this is a lymph node because if it is, breast cancer is a real concern, as is possibly TB of the lymph nodes. If it is not a lymph node, then this is not relevant.

She is quite right re the waits at a govt hospital but completely wrong re the skill level/quality of care. the best facilities for this type of thing are govt hospitals and indeed, that is likely where a local private hosp would send the specimen.

There is a special tertiary level Camcer Center in Surat Thani (govt) by the way and if there is any likelihood of malignancy this would be where to go. But can start at Taksin Hosp if you like.

Sorry but I do not know what a biopsy would cost. There are many, many variables including how it has to be done - FNA vs. excision which in turn depends on the nature of the mass and how close to the surface etc all of which I do not know. However no way would biopsy be only 4-5,000 at a private hospital - the path exam alone will be around 3,000 and then there is the cost of the excision on top of that.

Costs in private Samui hospitals are considerably higher than in large private hospitals in Bkk.

Taksin Hosp would usually cost less than one of the "name" hospitals in Bkk.

Whatever doctor she sees, be sure to ask pointedly whether the mass is an enlarged lymph node or a separate mass. that much they should be able to tell by physical exam alone.

So we will go to a local private hospital tomorrow to confer with a doctor and hopefully get a better idea as to whether or not it is lymph node and what kind of further tests are recommended. If she needs a biopsy we will go to Taksin Hospital.

Thank you Sheryl. You've been immensely helpful.

[somtamgaiyang]

Just to let you know, Sheryl. I took my friend to a local hospital today to get their opinion and possibly price for biopsy. She was seen by the general surgeon who examined the lump manually. He told her that at this point there is nothing to be concerned about. The lump is fairly small, not painful, and shrinks and grows over time.

He had her make an appointment for 3 month from now to check it again. I think it was the lymph node but did not seem concerned. Please let me know if you think we should be more concerned than he is.

Thanks again.

[Sheryl]

That it is not painful is of no significance.

That its size is not constant makes it less likely to be a malignancy, but still cannot totally rule it out plus there are other possible infectious causes.

As to whether to be more concerned: it depends on whether this really is a defined mass as opposed to a lymph node of normal size that is occasionally a little larger than at other times. Which is something I have no way of knowing.

Being able to slightly feel the axillary lymph nodes is not abnormal. Have you compared both sides to see if this is really larger?

Does she ever have a fever? Any other symptoms?

Prior to the appearance of the lump, did she have any sort of bite or cut etc on her arm or chest?

Was a breast exam and mammogram performed? How old is she?

[Issangeorge]

Taksin Hosp is definitely the best private option in that part of Thailand and will be less expensive than Bkk Hosp. The other option is the provincial hospital in Surat Thani which will be the least expensive but being a Govt. Hospital will entail some red tape and waits.

If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

If it turns out to be anything serious then best she get care at whatevet govt hosp she is registeted at as it will be free. But likely that is back in her homeprovince.

Okay, Thaksin Hospital it is then.

>If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

I will tell her this.

I visited another private hospital here on the island today; Samui Inter. They said that the General Surgeon will be available tomorrow to give a consultation. She was not sure whether he would charge for the consultation or not (either free or 500 baht, not so bad). She said based on his decision it could cost 12,000 for a biopsy without anesthesia (I'm guessing FNA or CNA) or more if she needs anesthesia (guessing open biopsy). I think it might be worth going there to get his opinion and find out which kind of biopsy he would choose. Or maybe he doesn't think she even needs a biopsy.

She doesn't want to go to a government hospital because 1) the long wait and 2) she thinks they will not be as skilled in determining what the problem is. But as you said, if it turns out to be serious then cost-wise it would probably be the only option.

So my last question (hopefully) is, do you have a sense as to what price range is reasonable for a biopsy? The old thread I looked at indicated about 4-5000 baht for FNA, but it was from 2 years ago. Is it really so much cheaper in Bangkok? And do you think she would actually get a better price if there are no farangs involved?

The general surgeon will be there tomorrow, because he works at Nathon Hospital. Go to the Government Hospital there, skip the expensive private ones. I have had several biopsies done at my government hospital, I can't remember the cost, but I know they were less than ฿1,000. I had to have a cancerous tumour removed from my foot, including a skin graft from my stomach and one nights stay in the hospital and the lab tests some drugs, the total cost was around ฿6,000, stick to the Government Hospitals.

[somtamgaiyang]

That it is not painful is of no significance.

That its size is not constant makes it less likely to be a malignancy, but still cannot totally rule it out plus there are other possible infectious causes.

As to whether to be more concerned: it depends on whether this really is a defined mass as opposed to a lymph node of normal size that is occasionally a little larger than at other times. Which is something I have no way of knowing.

Being able to slightly feel the axillary lymph nodes is not abnormal. Have you compared both sides to see if this is really larger?

Does she ever have a fever? Any other symptoms?

Prior to the appearance of the lump, did she have any sort of bite or cut etc on her arm or chest?

Was a breast exam and mammogram performed? How old is she?

>Being able to slightly feel the axillary lymph nodes is not abnormal. Have you compared both sides to see if this is really larger?

I don't think I have. I'm sure she has, but I will check.

>Does she ever have a fever? Any other symptoms?

Quite possibly. She has been sick a few times in recent months but never for more than a couple of days. I will talk with her about it.

>Prior to the appearance of the lump, did she have any sort of bite or cut etc on her arm or chest?

I will ask her.

>Was a breast exam and mammogram performed? How old is she?

No it wasn't and she is 27. After checking her height and weight they whisked her into a back room. I thought the nurse was giving her a preliminary exam but when she cam out a few minutes later she said she had seen the doctor and he said not to worry. I tried to question the nurse but didn't get very far. She kept saying its okay, and no charge.

Well, I thought she was all clear but sounds like we have a bit more investigating to do. So she should insist upon a biopsy and a mammogram, even if the doctor says its not necessary?

[somtamgaiyang]

Taksin Hosp is definitely the best private option in that part of Thailand and will be less expensive than Bkk Hosp. The other option is the provincial hospital in Surat Thani which will be the least expensive but being a Govt. Hospital will entail some red tape and waits.

If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

If it turns out to be anything serious then best she get care at whatevet govt hosp she is registeted at as it will be free. But likely that is back in her homeprovince.

Okay, Thaksin Hospital it is then.

>If the mass is an enlarged lymph node she should also have a manual breast exam and mammogram done, very important.

I will tell her this.

I visited another private hospital here on the island today; Samui Inter. They said that the General Surgeon will be available tomorrow to give a consultation. She was not sure whether he would charge for the consultation or not (either free or 500 baht, not so bad). She said based on his decision it could cost 12,000 for a biopsy without anesthesia (I'm guessing FNA or CNA) or more if she needs anesthesia (guessing open biopsy). I think it might be worth going there to get his opinion and find out which kind of biopsy he would choose. Or maybe he doesn't think she even needs a biopsy.

She doesn't want to go to a government hospital because 1) the long wait and 2) she thinks they will not be as skilled in determining what the problem is. But as you said, if it turns out to be serious then cost-wise it would probably be the only option.

So my last question (hopefully) is, do you have a sense as to what price range is reasonable for a biopsy? The old thread I looked at indicated about 4-5000 baht for FNA, but it was from 2 years ago. Is it really so much cheaper in Bangkok? And do you think she would actually get a better price if there are no farangs involved?

The general surgeon will be there tomorrow, because he works at Nathon Hospital. Go to the Government Hospital there, skip the expensive private ones. I have had several biopsies done at my government hospital, I can't remember the cost, but I know they were less than ฿1,000. I had to have a cancerous tumour removed from my foot, including a skin graft from my stomach and one nights stay in the hospital and the lab tests some drugs, the total cost was around ฿6,000, stick to the Government Hospitals.

Thanks for the advise Issangeorge. I'm not sure I can get her to listen to me but I will talk to her about it. It seems very counterintuitive. Normally I would expect the private hospitals to provide better care. Better funded, better paid doctors.

[Sheryl]

You need to ascertain the history first.

If she had a cut or other obvious local infection in the area that would drain into this lymph node prior to its becoming enlarged then just watching it may suffice.

If there is no apparent explanation for its enlargement then further investigation is warranted. If she is having fevers, even low grade fevers at night, an infectious disease expert rather than a surgeon would be the next logical step as need to consider Tb of the lymph nodes. She also needs to have an HIV test.

[somtamgaiyang]

You need to ascertain the history first.

If she had a cut or other obvious local infection in the area that would drain into this lymph node prior to its becoming enlarged then just watching it may suffice.

If there is no apparent explanation for its enlargement then further investigation is warranted. If she is having fevers, even low grade fevers at night, an infectious disease expert rather than a surgeon would be the next logical step as need to consider Tb of the lymph nodes. She also needs to have an HIV test.

I will check all of this out.

She did have an HIV test during her initial visit, which was negative. She also had some other blood test and an x-ray. The doctor at that time saw no problems.

[Issangeorge]

Unless things have changed the private hospitals on Koh Samui, use the same doctors as the Government Hospital, and the fact the general surgeon wasn't coming in until the next day, suggests to me that this is probably still the case.

[somtamgaiyang]

Unless things have changed the private hospitals on Koh Samui, use the same doctors as the Government Hospital, and the fact the general surgeon wasn't coming in until the next day, suggests to me that this is probably still the case.

I am curious now to find out if you're right.