Its also fairly easy to get an ultrasound of your thyroid gland. These sound waves travel through the skin and are bounced back to the transducer when they hit soft tissue or bone, creating an image of the thyroid. Image a and b are sagittal images, image c is a transverse view of both lobes and the isthmus, and image d and e are individual measurements of the right and left lobe respectively.. What Is A Normal Size For Thyroid Nodules Thyroid Nodule Biopsy Thyroid nodules range in sizeyour doctor will decide what to do depending on their size. A thyroid gland that is larger than these measurements is typically considered enlarged. Certain factors increase your risk of thyroid cancer, such as a family history of thyroid or other endocrine cancers and having a history of radiation exposure from medical therapy or from nuclear fallout. However, a nodule that is large and hard or causes pain or discomfort is more worrisome. At the time the article was last revised Calum Worsley had These cookies will be stored in your browser only with your consent. The size of your thyroid nodule is greater than 2.0 cm or 20 mm (a size greater than 1.0 cm or 10 mm may also be worrisome as well) Unexpected weight loss Difficulty swallowing Changes to your voice or hoarseness when you talk Pain or discomfort in the neck area Enlargement of the lymph nodes in or around your neck The chances that a nodule is cancerous are small. Hyperthyroidism. In: Conn's Current Therapy 2019. The thyroid gland is located at the base of the neck, just below the Adam's apple. (2006) ISBN: 9781931884297 -, 4. You can use an ice pack to alleviate any discomfort or swelling. The two major disorders of the thyroid gland are hyperthyroidism and hypothyroidism. Because enlarged benign-appearing lymph nodes are commonly identified in levels IA and IB and are almost universally related to the mouth and not the thyroid, these levels are not included in the standard thyroid protocol. Learn more about the top things patients worry about with thyroid nodules. 1 ). In fact, experts estimate that about half of Americans will have one by the time theyre 60 years old. The risk of thyroid cancer increases with these risk factors: There are really three different ways to test or evaluate your thyroid nodule. Your doctor can do this when you visit him/her in the office. privacy practices. posteriorly:thyroid cartilage, cricoid cartilage, trachea, posteromedially:tracheo-esophageal groove (containing lymph nodes, recurrent laryngeal nerve, parathyroid glands), superior thyroid artery (from the external carotid artery), inferior thyroid artery (from the thyrocervical trunk), if the inferior thyroid artery arises from the subclavian artery it is referred to as an accessory inferior thyroid artery, superior thyroid vein (drains to the internal jugular vein), middle thyroid vein (drains to the internal jugular vein), inferior thyroid vein (drains via plexus to the brachiocephalic vein). Check out my own personal health story. Stephanie Ryan, Michelle McNicholas, Stephen J. Eustace. A small nodule with a diameter of less than 1cm is often benign, but if it reaches a size greater than 2 cm, there is an increased risk of cancer. Enlargement of the thyroid can expand the gland well beyond its typical size and cause a noticeable bulge in the neck. Findings: The thyroid gland is high normal in size. We have even seen rare cases where a small thyroid nodule (less than 1 cm) is a cancer that has spread to lymph nodes in the neck. As such, many thyroid nodules, particularly small ones, cannot be diagnosed as cancerous or benign until the entire nodule has been removed during thyroid nodule surgery where half or the whole thyroid is taken out. Seek medical care if you develop signs and symptoms of hyperthyroidism, such as: Also see your doctor if you have signs and symptoms that may mean your thyroid gland isn't making enough thyroid hormone (hypothyroidism), which include: There is a problem with In: Sarti DA, ed. Thyroid Nodule Removal: Top 4 Facts to Know, Become our patient by filling out the form at this link. Thyroid ultrasound can help determine thyroid nodule size and whether the nodule is solid or filled with fluid. Mayo Clinic. But opting out of some of these cookies may have an effect on your browsing experience. The size of the thyroid gland can increase due to certain conditions like pregnancy or smoking frequently. Mremi et al. The normal size of a healthy thyroid gland is about 4 cm x 2 cm (roughly 1.5 inches x 0.8 inches). Two popular treatments for thyroid nodules are Radioactive Iodine Therapy and Thyroid Radiofrequency Ablation (RFA). Ross DS. Perri F, et al. Each lobe measures approximately 4 cm in length. Doctors will probably recommend that anyone who has a nodule larger than 1 centimeter (cm) in size has a biopsy. Frequently, a needle biopsy before surgery does not yield a definitive diagnosis as to whether a thyroid nodule is cancerous or benign (non-cancerous). Gray's Anatomy. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Our site includes quite a bit of content, so if you're having an issue finding what you're looking for, go on ahead and use that search feature there! What Size Thyroid Nodule Should You Worry About? 7. Its simple: Most people treated with RFA are back to their normal activities the next day with no problems. Eventually, the nodules will cause issues such as difficulty swallowing or breathing, a noticeable lump or mass in the neck, pressure/discomfort (particularly when laying down), and a feeling of a lump or something stuck in ones throat. As mentioned above, the thyroid gland is one of the largest endocrine glands found in humans. Usually, the superior pole is narrower than the inferior pole giving a pear-like shape to each lateral lobe. Ultrasound can help evaluate a thyroid nodule and determine the need for biopsy. Having said that, there are some people that will, which is what we are going to talk about now. Dr Walsh completed surgery training at the Medical College of Georgia and then completed a Head and Neck Endocrine Surgery fellowship at Augusta University Medical Center. The weight of this gland grows heavier in women. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). The first imaging study used in work-up and evaluation of thyroid nodule size and any thyroid problem should always be an expert, skilled, dedicated thyroid and neck ultrasound. Sign up to receive 20% off your first order. AP diameter 3 cm is abnormal. The material from your glands is sent to a laboratory for an in-depth examination. The left lobe is filled with low level echoes and contains multiple thin septal echogenic walls (maroon). Thyroid size was measured by ultrasound, and thyroid volume was calculated. Elsevier; 2020. https://www.clinicalkey.com. The waiting game can cause unneeded stress and anxiety to you the patient as you wait. Courtesy Ashley Davidoff MD Copyright 2010 94503c.8L, Courtesy Ashley Davidoff MD Copyright 2010 96233c01L.8. Or your doctor may uncover it during a scan that was done for another health reason. But that leaves another 5-10% which can be cancerous and should be evaluated. This website uses cookies to improve your experience while you navigate through the website. 3 B). Thyroid nodule size does not correlate directly with the cancerous or benign nature of a thyroid tumor. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Normal transverse thyroid on grayscale ultrasound. As mentioned above, the thyroid gland is one of the largest endocrine glands found in humans. The normal size of the thyroid gland in adults is 4 to 4.8 cm x 1.0 to 1.8 cm x 0.8 to1.6 cm. The image shows the artistic rendering of the small hypofunctioning thyroid (gray) the normal thyroid in the middle (pink), and the hyperfunctioning and enlarged thyroid of thyrotoxicosis. If you have a thyroid nodule AND you have any of these other signs or symptoms, then you may be at a slightly higher risk of thyroid cancer: Let me be clear, though, just having these symptoms does not guarantee that you have thyroid cancer. Hormone Health Network. Kellerman RD, et al. Since no non contrast CT was performed the peripheral increase in density may be due to enhancement or more likely due to iodine or calcification. Indian J Endocrinol Metab. Most thyroid nodules don't cause signs or symptoms. At birth is weighs2-3 grams, reaches 10-15gms at puberty and becomes full size by age 25 when it weighs15-35gms. Advertising revenue supports our not-for-profit mission. Hyperthyroidism can result in weight loss, muscle weakness, heat intolerance, and anxiousness or irritability. C=carotid artery; SM=strap muscles; T=trachea. A biopsy often referred to as a fine needle aspiration or FNA, is the most conclusive way to test your thyroid nodule. At Associated Endocrinologists, we are proud to be one of the first providers of RFA in Michigan. This test can also be used to check the number of nodules, thyroid nodule size, and can even reveal what the blood supply to these nodules looks like. In: Diagnostic Ultrasound. 2013;17(2):219-27. The gland is also covered with a fibrous sheath. If your doctor first orders a CT scan, MRI, or PET/CT scan to evaluate your thyroid problems, you need a second opinion from an expert. This is the question that most people ask themselves and its the question we are going to explore today. For this reason, you never want to judge the risk of thyroid cancer based on the size of your nodule alone. Goldblum JR, et al., eds. Overview of thyroid nodule formation. If the doctor recommends removal of your thyroid (thyroidectomy), you may not even have to worry about a scar on your neck. Hey! I'm Westin Childs D.O. However, the size of the thyroid can vary depending on a number of factors, such as age, gender, and whether you have an underlying medical condition. The weight of this gland in neonates is about 2-3 grams. For these reasons, you really dont want to get a biopsy unless absolutely necessary based on the size of your nodule or based on the features your nodule has on ultrasound testing. I don't practice medicine anymore and instead specialize in helping people like YOU who have thyroid problems, hormone imbalances, and weight loss resistance. People who undergo thyroid gland surgery may need to take thyroid hormone afterward to keep their body chemistry in balance. What are the odds of the nodule being malignant? : r/thyroidhealth - Reddit Fortunately, thyroid size is easily measured with ultrasound which is a safe and relatively inexpensive tool. It is important to recognize and report this normal variant, because nodules can occur in this lobe, and it could potentially be overlooked by the surgeon during a thyroidectomy. Junji Machi, Edgar D. Staren. The thyroid gland is wrapped around the wind pipe. Any enlarged benign-appearing lymph nodes or abnormal-appearing lymph nodes of any size are measured in three planes (anteroposterior, transverse, sagittal). The normal thyroid weighs approximately 15 to 25 g, with each lobe 4 to 6 cm in length and 1.3 to 1.8 cm in thickness. Figure 2:Thyroid nodule size chart demonstrates relative size and the effects large nodules have on the thyroid gland. The weight of this gland in neonates is about 2-3 grams. He has had a goiter for many years and biopsy showed amyloidosis of the thyroid. Clearly, thyroid nodule size matters. The thyroid is butterfly or "H"-shaped and is composed of two lobes, each with a superior and inferior pole. Will Taking Thyroid Medication Cause A Heart Attack? https://www.uptodate.com/contents/search. The isthmus is normal in size. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Accessed Nov. 7, 2019. Ideally, the highest frequency available should be used to evaluate the thyroid gland; however, in certain clinical circumstances the frequency should be decreased to optimize tissue penetration. This imaging test uses sound waves to get pictures of the thyroid gland, surrounding tissue and structures, and the lymph nodes in the neck. Accessed Oct. 31, 2019. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Monday 8:15 a.m 5:00 p.m. Tuesday 8:15 a.m 5:00 p.m. Thrusday 8:15 a.m 5:00 p.m. Friday 8:15 a.m 4:30 p.m. 2021 Copyright Associated Endocrinologists.P.C. "The thyroid gland is mildly enlarged, has decreased echogenicity, and has a coarse echopattern. Need better symptom control? But determining which nodules are cancerous can't be done by evaluating your symptoms alone. Most nodules are benign, but even benign nodules can require surgery. A normal thyroid gland in sagittal (a) and transverse (b) planes is juxtaposed on the atrophied gland(c,d) The gland is mildly heterogeneous. Others are mixed. 4. So, even if you dont have thyroid cancer, you should still have your thyroid nodule evaluated and tested for other conditions which are associated with thyroid nodules. The thyroid hormones also play an important role in carrying out metabolism in the body. The thyroid tends to be larger in women and also larger during the menstrual cycle and pregnancy. Now they didn't provide with the volume of the thyroid but from my math it is at 4,8ml. Less common: However, due to certain reasons, the size of the thyroid gland increases. Restart Medical LLC. The patient is a 70 year female who shows diffuse atrophy of her thyroid by this ultrasound examination. Thyroid nodules. But even larger thyroid nodules are treatable, sometimes even without surgery. Although most thyroid nodules are noncancerous and don't cause problems, ask your doctor to evaluate any unusual swelling in your neck, especially if you have trouble breathing or swallowing. . 22 The limits of normal thyroid volume are 10 to 15 mL for adult females and 12 to 18 mL for So, your thyroid is not enlarged, it is about average - that's good! Ralph Weissleder. Additionally, as these nodules grow, they can extend into the chest cavity, or push on the windpipe (trachea) or swallowing tube (esophagus), or grow behind the voice box. The strap muscles include the sternohyoid and sternothyroid anterior to the thyroid, the sternocleidomastoid muscles anterolateral to the thyroid, and the longus colli muscles posteriorly. Additionally, this method is excellent to look for thyroid cancer that has spread to lymph nodes in the neck. The size of the thyroid changes with age. As a patient, though, you can use the size of your nodule as a quick and dirty way to assess whether or not you should be worried. To provide you with the most relevant and helpful information, and understand which (2011) Page 43, 194. Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland. Learn which foods you should avoid if you have thyroid disease of any type. If you find it difficult to eat or breathe due to discomfort or pain in your thyroid region, notify your doctor immediately. The risk of bleeding or infection is small, but they are still real and present. This method helps in diagnosing any underlying disorder. Lymphatic drainage is multidirectional and initial lymph drainage is to perithyroid lymph nodes then on to prelaryngeal, pretracheal and paratracheal nodes (level 6 lymph nodes). Sonographic normal thyroid lobe measurements (cm) References Cole-Beuglet C. Ultrasonography of the thyroid, parathyroid and neck masses. https://www.thyroid.org/hypothyroidism/. Pediatric Radiology Normal Measurements | OHSU 5th ed. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. This heat kills the cells inside the nodule, and the nodule itself shrinks dramatically over the next few months. The isthmus is normal in size. Volume of thyroid 4,2ml Measurements in 2023: The thyroid is normal in size and echotexture. Conclusions The highest malignancy risk was observed in nodules <2 cm and no increase in malignancy risk for nodules >2 cm. All rights reserved. Normal thyroid lobe dimensions change from birth into adulthood: the length (L or craniocaudal) diameter is 1.8 to 2.0 cm in newborns and 4.0 to 6.0 cm in adults, while the A-P dimension measures 0.8 to 0.9 cm in new-borns and 1.3 to 1.8 cm in adults.22 The limits of normal thyroid volume are 10 to 15 mL for adult females and 12 Heres what you need to know about thyroid nodules and how concerned you should be if you develop one. Symptoms and signs of the disease depend on the size and location of the goiter. Patients should also realize that thyroid biopsies are only as good and reliable as the people performing them and the pathologists who are evaluating the cells. (1961) ISBN: 0028523903 -. It escalates up to 50% during the early part of the menstrual cycle. These findings suggest age related involution of the gland. Normal radiology reference values and measurements - RadioGyan When Should you Worry About Thyroid Nodules? 6 Signs to Know What is a normal size for the isthmus of the thyroid? The gland is mildly heterogeneous. The gland is not usually palpable on clinical examination. The ligament of Berry is a posterior extension of the thyroid capsule which attaches to the cricoid cartilage and the upper tracheal rings. Inenlarged lobes, the measurements ranged from 4.0 to11.5 cm. While the risk for cancer and spread to lymph nodes increased with large nodules (10.4%- 22%), not all big nodules are cancerous. If you are concerned about the presence of nodule growths in your thyroid, contact one of our Michigan practices via our online form to book a thyroid ultrasound or fine needle aspiration biopsy with our team of endocrinologists. If your thyroid is functioning normally, you shouldnt be able to feel it externally. What Size Thyroid Nodule Should Be Removed Finally, ultrasound is also used to perform needle biopsies of thyroid lumps and lymph nodes to see if they are cancerous or not. Learn more about The Clayman Thyroid Center here. Thyroid nodule surgery, involving removal of half or the whole thyroid, is often necessary to diagnose and cure these nodules, regardless of thyroid nodule size. <13 cm is normal. (Modified) Back to the table of contents Gastrointestinal Appendix Normal appendix References: However, dimensions that fall outside of this. As these nodules enlarge, some need to be removed with surgery just based on size alone. In: Goldman-Cecil Medicine. The endocrine system consists of glands which produce hormones. health information, we will treat all of that information as protected health Because of this superficial location, ultrasound is the imaging modality of choice for evaluation of the thyroid gland. If you feel a lump at the base of your neck or one becomes visible on your skin, contact your primary care doctor to have it assessed. Goiter | Radiology Reference Article | Radiopaedia.org When you get your nodule tested, be sure to also look for other thyroid conditions which are frequently associated with thyroid nodules. The enlarged gland may reflect hyperthyroidism, hypothyroidism or a nodular euthyroid gland, and further biochemical and imaging evaluation is necessary. The bilateral internal jugular chains are imaged in the transverse plane from the clavicle to the level of the hyoid (levels III, IV, and VI). To learn more and become a patient, please see our resources below. This test is inexpensive, accurate, and pain-free, with results available on the same day. For more information regarding thyroid nodules and evaluation, see our article Top 5 Worries About Thyroid Nodules. A large mostly hypoechoic mass expands the left lobe of the thyroid on the ultrasound of this 54 year female who presents with an enlarged thyroid gland. Hoang JK, et al. If you have a question for our surgeons, However, after histopathological results, the patient was counseled for Figure 2. . P.S. What size is normal for thyroid isthmus A 20-year-old female asked: Thyroid ultrasound the right thyroid lobe measures 4.7 x 1.6 x 2.4cm.the thyroid isthmus measures 7mm.the left thyroid lobe measures 5.2 x 1.6 x 1.7cm? Size and sonographic characteristics of the nodes should be assessed. Ferri FF. Ultrasound is the best imaging modality for comprehensive evaluation of the thyroid. Elselvier; 2018. https://www.clinicalkey.com. measuring 2.0 cm (AP) 1.4 cm (T) 3.1 cm (CC) in size. If we combine this information with your protected The gland is enlarged measuring 6.2cms in Craniocaudal dimension (length) by 3cms in anteroposterior dimension by 3cms in transverse dimension. RFA is a non-invasive, non-surgical procedure approved by the FDA, which uses alternating electric currents to generate heat inside a thyroid nodule. This content does not have an English version. The parathyroid glands lie posteromedially and are sometimes intracapsular. The esophagus is most commonly located posterior to the left lobe of the thyroid and can contain air ( Fig. As I mentioned previously, most thyroid nodules (about 90% or so) are benign. Morwood, James., Taylor, John, 1955 Apr. If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. Thyroid nodule size, however, does not always tell the whole story. 2016; doi:10.1038/nrendo.2016.110. there are multiple bilateral cysts and nodules. The Pocket Oxford Classical Greek Dictionary. All thyroid cancers start small, so just because a thyroid nodule is small does not mean it is benign. (2005) ISBN: 9780781742917 -, 5. Then, suppose she tells you theres a nodule on your thyroid. . Thyroid cancer management: From a suspicious nodule to targeted therapy. The Her TSH is elevated at 12 mIU/L. The thyroid is a bilobed structure in the neck that is located anterior to the trachea, with the lobes extending vertically along the right and left sides of the trachea ( Fig. Join endocrinologist Paul Ladenson, M.D., as he outlines the signs and symptoms of the various thyroid disorders and discusses the interplay among other diseases and the thyroid. Measurements should be obtained for each lobe including the anteroposterior, transverse, and sagittal dimensions. And this makes a lot of sense, considering the thing you should be worried about is your risk of cancer. In: Rosai and Ackerman's Surgical Pathology. Because each thyroid nodule, regardless of the size, has a small risk of turning into thyroid cancer. Most thyroid nodules are benign, but some are cancerous (roughly 5%). ThyroidCancer.com is an educational service of the Clayman Thyroid Center, the world's leading thyroid surgery center operating exclusively at the new Hospital for Endocrine Surgery. A nodule with mixed solid-cystic composition of size 3.3 cm x 2.0 cm can be seen in the medial peripheral part of the left lobe. However, if you have developed thyroid nodules, you may be able to feel lumps on your neck, depending on the nodules size. The good news is that most nodules are NOT cancerous and there are certain signs and symptoms, if present, that do increase the chance that your nodule may be harboring cancer. Thyroid nodule. read more about my own personal health journey, free thyroid downloads, resources, and PDFs here, If you have a thyroid nodule and you are younger than 20 years old or if you have a thyroid nodule and you are older than 70. This rounded shape in the transverse dimension is a clue to the presence of the enlarged gland, even before the measurements are taken and evaluated. But, even if you request the information, you should have your doctor also evaluate this information to help you understand it. Several conditions can cause nodules to develop in your thyroid gland, including: Overgrowth of normal thyroid tissue. An overgrowth of normal thyroid tissue is sometimes referred to as a thyroid adenoma. 3 thyroidectomy, but unfortunately he did not turn up. This website uses cookies to improve your experience. At the time the article was created Frank Gaillard had no recorded disclosures. Choosing an experienced specialist can mean more options to help personalize your treatment and achieve better results. Nodular size of 1 - 1.9 cm was more prevalent among cancer patients than in benign cases (p<0.001). 4 ). Treatment options depend on the type of thyroid nodule you have. The biggest fear that most people have when it comes to thyroid nodules is whether or not they should worry about it. Thyroid nodule size is certainly important, but is not the only clinical factor that determines whether a biopsy, surgery, and/or surveillance is needed. 11-. A normal ultrasound of the thyroid gland (a,b) is juxtaposed with the ultrasound of a 78 year female with hypothyroidism (c,d) A diffusely enlarged, heterogeneous thyroid gland is seen in the hypothyroid patient. As mentioned above, the thyroid gland is one of the largest endocrine glands found in humans. Even a benign growth on your thyroid gland can cause symptoms. The structure of the thyroid gland is also very peculiar which makes identification of the gland very easier. Report / Delete Reply ann19043 LAHs The left lobe of the thyroid measures 4.1cms (craniocaudad), by .8 cms (A-P) by 1.1cms (transverse). Obviously, thyroid cancer is not nearly as common which means that most people with thyroid nodules do NOT get thyroid cancer. The isthmus measures less than 4 to 5 mm. Accessed Oct. 31, 2019. Thyroid cancer. Your entire thyroid can grow larger or it can develop one or more small lumps called thyroid nodules. Not all large nodules are bad, and not all small nodules are benign. Solid/cystic (1-point) Hyperechoic (1-point . information highlighted below and resubmit the form. Hey There! #2 Thing to Know About Thyroid Nodule Size: Thyroid Nodule Size Over 4 cm Requires Surgery As noted above, thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. The isthmus is2-6mm inA-P diameter and is up to 20 mm. But if you do have these signs/symptoms then its probably a good idea to get checked out by your doctor with advanced testing such as ultrasound or even a biopsy (more information below). On the axial cuts the goiter with central avascularity is again noted compressing on the trachea and pushing it to the right (teal blue) the esophagus is also pushed rightward. the unsubscribe link in the e-mail. These hormones are essential for maintaining proper heart rate, body temperature and blood pressure. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. The findings are consistent with a thyroiditis. But size isnt the only thing that matters. Problems can occur when a nodule or goiter produces thyroid hormone, leading to an excess amount of the hormone in the body. As noted above, thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. (Solid nodules are more likely to be cancerous.) The gland is heterogeneous particularly well seen on the sagittal view (c). Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, Mayo Clinic Q and A: Women and thyroid disease, Be seen, often as a swelling at the base of your neck, Press on your windpipe or esophagus, causing shortness of breath or difficulty swallowing, Sudden weight loss even though your appetite is normal or has increased.
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