Ultrasound Classification : Suspicious Thyroid Nodule
Thyroid nodules in this category are considered to be suspicious for malignancy, and all these nodules should be further investigated with FNAC . The first distinctive feature of these suspicious nodules is their hypo-echogenicity . The echo signals of the nodule or part of the nodule are less than the surrounding normal thyroid tissue and sometimes lower than the nearby muscle . It is important to note that these nodules are hypo-echogenic, but they are also predominantly solid in consistency. This property makes their echo signals higher than those of a cystic nodule, which is dark and echo-free. On a spectrum from highest to lowest likelihood of malignancy, predominantly solid nodules have the highest risk, while mixed solid/cystic sit in the middle, and cystic or spongiform have the lowest risk . Furthermore, the suspicious nodule may have disrupted eggshell calcification around the peripheries or lost its smooth round contour, and adopted a lobulated margin . A U4 thyroid nodule is hypo-echogenic, with an irregular outline and possible disrupted calcification at the edges.
Signs And Symptoms Of Thyroid Nodules
The development of thyroid nodules symptoms is not common in fact, nodules are usually found incidentally when other imaging studies are performed and not because a patient had any signs. But some people with thyroid nodules, around 1122 percent, experience whats called compressive symptoms, which can include the following:
- Neck fullness: Sometimes thyroid nodules can be felt when examining the neck and throat, and even seen, which is from swelling at the base of the neck.
- Dysphagia: Dysphagia, or difficulty swallowing, may be a symptom associated with thyroid nodules because the lump is causing a sense of mass in the esophagus or it is impeding the normal passage of food. This can cause pain while swallowing, being unable to swallow or having a sensation of food being stuck in the throat.
- Odynophagia: This is a medical term used for when swallowing causes pain in your mouth, throat or esophagus. Because larger thyroid nodules are creating pressure in the throat and neck, it can be painful in these areas.
- Choking: Because large or swollen thyroid nodules make it difficult to swallow, they can lead to choking.
- Dyspnea: Dyspnea, or difficulty breathing and shortness of breath, may occur with larger thyroid nodules.
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Where Thyroid Cancer Starts
The thyroid gland is in the front part of the neck, below the thyroid cartilage . In most people, the thyroid cannot be seen or felt. It is shaped like a butterfly, with 2 lobes the right lobe and the left lobe joined by a narrow piece of gland called the isthmus.
The thyroid gland has 2 main types of cells:
- Follicular cells use iodine from the blood to make thyroid hormones, which help regulate a persons metabolism. Having too much thyroid hormone can cause a fast or irregular heartbeat, trouble sleeping, nervousness, hunger, weight loss, and a feeling of being too warm. Having too little hormone causes a person to slow down, feel tired, and gain weight. The amount of thyroid hormone released by the thyroid is regulated by the pituitary gland at the base of the brain, which makes a substance called thyroid-stimulating hormone .
- C cells make calcitonin, a hormone that helps control how the body uses calcium.
Other, less common cells in the thyroid gland include immune system cells and supportive cells.
Different cancers develop from each kind of cell. The differences are important because they affect how serious the cancer is and what type of treatment is needed.
Many types of growths and tumors can develop in the thyroid gland. Most of these are benign but others are malignant , which means they can spread into nearby tissues and to other parts of the body.
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What Is A Thyroid Nodule
A thyroid nodule is a discrete lesion within the thyroid gland that is radiologically distinct from the surrounding tissue. Nodules are common and found in 10 percent of the adult population. Luckily, most of them are benign. The clinical importance of thyroid nodules is the need to rule out thyroid cancer, which occurs in 7-15 percent of cases depending on age, sex, radiation exposure, family history and other factors. For the U.S. population, the lifetime risk of developing thyroid cancer is 1.1 percent. When a thyroid nodule is suspicious meaning that it has characteristics that suggest thyroid cancer the next step is usually a fine needle aspiration biopsy .
Causes Of Thyroid Nodules
Thyroid nodules, masses in the thyroid gland, can be the result of benign cell overgrowth or actual discrete tumors comprised of thyroid cells that can be benign or cancerous. Thyroid nodules can sometimes contain fluid, which usually collects due to bleeding from the fragile blood vessels in thyroid tumors, so called cystic degeneration. This event sometimes causes the sudden onset of pain and swelling in the front of the neck, which typically subsides over several days.
Fortunately, more than 90% of thyroid nodules are not cancers, but malignancy should be considered in every affected person. Often patients with small thyroid nodules, less than 1 cm in diameter, and no risk factors for thyroid cancer can simply be reexamined or imaged by sonography to be sure the nodule is not enlarging. For larger nodules, additional studies are usually indicated, as described below.
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Can Cystic Thyroid Nodule Be Cancerous
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Thyroid Nodules: Potential Causes
Several conditions may cause or predispose to the development of thyroid nodules including:
Diets deficient in iodine can predispose individuals for the development of thyroid nodules. Portions of the world continue to lack iodine in their diets however in the United States, the presence of iodine in our daily diets makes this an unlikely cause for thyroid nodules.
Overgrowth of normal thyroid tissue
The reason why these thyroid nodules occur is not well understood. These thyroid nodules are commonly called follicular adenomas or thyroid adenomas. . Follicular adenomas are clearly not cancerous and are not worrisome and do not require removal except if they are symptomatic due to their size. The rare follicular adenoma or thyroid adenoma will overproduce thyroid hormone and be the cause of hyperthyroidism. For some reason these excessive thyroid hormone producing adenomas lose their ability to be regulated by the pituitary glands production of Thyroid Stimulating Hormone .
Thyroid cysts are fluid filled cavities caused by degenerating thyroid adenomas, congenital cysts, or overproduction of a fluid produced by the thyroid called colloid.
Inflammatory diseases of the thyroid Multinodular disease of the thyroid Thyroid Cancer
Although the likelihood that a thyroid nodule is a cancer is quite low, the following are associated with an increased malignant risk:
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What Do You Do When Your Child Has A Thyroid Nodule
The first step if your child has a thyroid nodule is to get an ultrasound. This will help your healthcare provider assess the quality of your childs nodule and determine if additional workup is needed. In some cases a repeat ultrasound is needed, and in some cases a biopsy. This all depends on what it looks like on the ultrasound. Some nodules require labs to look at how the thyroid is functioning.
How Is A Thyroid Biopsy Performed
A thyroid biopsy, also called a fine needle aspiration , uses a small needle to take a little sample of the cells in the thyroid nodule. The possible outcomes from a biopsy are:
Non-diagnostic: Non-diagnostic is a technically failed biopsy. There were not enough cells taken during the biopsy so the cytologist was not able to determine anything. These usually need to be repeated.
Benign: Most thyroid nodule biopsies come back benign, meaning your doctor is highly re-assured that it’s not cancerous. Patients can almost always avoid surgery unless the nodule is large and pushing on adjacent structures like the airway.
Indeterminate: Indeterminate means there was enough cells taken during the biopsy, but the cytopathologist was not sure if it is benign or malignant. Indeterminate results occur in about 20% of thyroid biopsies. This is a gray zone and means that the risk of cancer is about 10-30%. These nodules require additional work-up such as a repeat biopsy, molecular marker test, or surgical removal.
Suspicious for Malignancy or Malignant: Results categorized in these two categories are a strong indicator that there is cancer present and usually require surgical removal.
Patients usually wait one week for the cytopathologist to examine the cellular characteristic of the biopsy sample. If your doctor is reassured that it’s benign based on the biopsy result, further work-up is stopped and serial ultrasound surveillance is recommended usually once a year.
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Can A Thyroid Problem Heal Itself
Occasionally, the condition may resolve without treatment. Follow-up appointments are important to monitor hypothyroidism over time, however. If hypothyroidism doesnt go away on its own within several months, then treatment is necessary. If left untreated, this condition eventually may lead to serious health problems.
Thyroid Nodules Needle Biopsy: Fn
5 Discussion 5.1 The work-up of a suspicious thyroid nodule for surgery. The indications for surgery in a thyroid nodule suspicious for malignancy are more complicated than benign conditions. A dominant nodule, the largest nodule, in a multinodular goiter should be considered as significant as a solitary or single thyroid nodule. Factors that increase the suspicion of malignancy include [6,13. Of 21 datasets that allowed for comparison of malignancy rates by thyroid nodule size, 81% showed malignancy rates of larger nodules to be similar to or lower than rates of smaller nodules. The.
For this, we do not take in to account nodule size because size is not a factor in the ACR TIRADS guidelines for initial FNA in the TR1 and TR2 categories or in the TR5 category Traditional pathology reports on the surgically removed nodules determined that, out of 257 nodules , 72% were benign, 24% were malignant, and 4% were a type of borderline malignancy that should be surgically removed
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Thyroid Nodule Symptoms: Uncommon But Can Happen
Thyroid nodule patients usually have no symptoms, but when they do have symptoms they are most commonly:
- A lump in the neck
- Uncomfortable pressure sensation on the breathing tube
- A sense of feeling like they need to swallow something or difficulty swallowing
- Discomfort in the neck
Thyroid nodules may also rarely produce the thyroid hormone, thyroxine, in excess. This is uncommon but the reason why all patients with thyroid nodules should have a blood test for thyroid stimulating hormone . Thyroid nodules that produce extra thyroid hormone can cause symptoms of hyperthyroidism which include:
- Unexplained weight loss
- Rapid or irregular heart rate
Thyroid Nodules: When To Worry
Suppose you go to your doctor for a check-up, and, as shes feeling your neck, she notices a bump. Then, suppose she tells you theres a nodule on your thyroid. Is it time to panic?
No, say experts at Johns Hopkins Department of Otolaryngology and Head and Neck Surgery. Thyroid nodules even the occasional cancerous ones are treatable.
Heres what you need to know about thyroid nodules and how concerned you should be if you develop one.
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Youve Been Diagnosed With A Large Thyroid Noduleshould You Be Concerned
The findings from this meta-analysis should prompt you to have a frank discussion with your physician, Dr. Cipriani tells EndocrineWeb.
Many other factors come into play in deciding whether to choose to have surgery to remove a nodule, she says. Certainly If after hearing all the pros and cons of having surgery, and still feeling too unsettled with the idea of active surveillance , then this discomfort must be addressed in the discussion about treatment options and options for next steps, for instance.
On the other hand, for patients who are older and at greater risk of complications from surgery for a thyroid nodule that poses no issues and isnt bothering them, that too should be considered, she says.
What was not known from the studies that Dr. Ciprianiâs team evaluated is the interval between the biopsy and the surgery? When surgery is done, she says, the usual procedure is to remove at least one of the two thyroid lobes. To surgically remove just a nodule is more complicated, she says, but this means that the patient may not need thyroid replacement hormone, which, if necessary, must be taken for the remainder of the patients life.
Less Need for Surgury Is Good News for Patients Long-Term
I do not recommend thyroidectomy based on thyroid nodules size only, she says. Patients have to be symptomatic or the biopsy should show evidence of thyroid cancer in order for me to recommend surgery.
Signs Of Thyroid Cancer
Most thyroid nodules are asymptomatic, non-palpable and only detected on ultrasound or other anatomic imaging studies. The following characteristics increase the suspicion of cancer:
- Swelling in the neck
- Trouble breathing
- A constant cough that is not due to a cold
An FNAB helps determine if a nodule is malignant or benign. But about 30 percent of the time, the results are inconclusive or indeterminate unable to determine if cancer is present. In this case, the recommended follow-up is a repeat FNAB, a core needle biopsy or a lobectomy/thyroidectomy surgery to remove part or all of the thyroid gland. Once removed, the thyroid nodule is thoroughly evaluated by a pathologist to diagnose or dismiss thyroid cancer.
In large thyroid nodules, 4 cm or bigger, the FNAB results are highly inaccurate, misclassifying half of all patients with reportedly benign lesions. Additionally, Inconclusive FNAB results display a high-risk of differentiated thyroid carcinoma. Diagnostic lobectomy is strongly considered in patients with a significant thyroid nodule regardless of FNAB results.
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Thyroid Nodules Causes And Risk Factors
Thyroid nodules are very common and there are several conditions that can cause them to develop in your thyroid gland, including the following:
- Iodine deficiency: Low iodine levels are associated with an increased risk of developing goiters or an enlarged thyroid gland.
- Hashimotos disease: Hashimotos disease causes inflammation of the thyroid gland and can cause the thyroid gland to become enlarged. This disorder results from the underproduction of thyroid hormone and can lead to the gradual destruction of the thyroid gland itself.
- Overgrowth of thyroid tissue: Sometimes theres an overgrowth of normal thyroid tissue, which is called a thyroid adenoma. Its unclear why this happens, but it can lead to lumps in the thyroid gland and an overproduction of thyroid hormones.
- Thyroid cyst: A fluid-filled cyst can develop in the thyroid, which may be the result of abnormal thyroid tissue growth. These cysts are often a mix of solid and fluid components and are usually benign. Sometimes, however, solid components in a cyst can be malignant.
- Thyroid goiter: A goiter an abnormal enlargement of the thyroid gland that causes a bulge in the neck. This can occur when theres an overproduction or underproduction of thyroid hormones.
- Thyroid cancer: Most thyroid nodules are benign and are caused by other factors, but sometimes a nodule is caused by cancerous cells in the thyroid. If a nodule is hard, large and painful, there is a greater risk of malignancy.
Ultrasound Classification : Indeterminate/equivocal
On assessment of the thyroid nodule, there are situations in which, among a collection of benign sonographic appearances, there are certain features that place doubt on the diagnosis. Occasionally, the nodule may be markedly hyper-echogenic , or part of the nodule may appear cystic and contain echogenic foci . Further Doppler assessment of the nodule may demonstrate a mixture of both peripheral and intra-nodular vascularity . These sonographic features are classified as indeterminate. FNAC should be performed, taking into consideration the clinical information .
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Thyroid Cancer Affects Thousands Of People
Although thyroid cancer has a low death rate compared to most other cancers, it still has far-reaching effects.
An estimated 62,450 people in the United States will develop thyroid cancer and 1,950 people will die from it this year, according to the American Cancer Society .
The key to successful recovery from thyroid cancer lies in early detection.
The ACS reports that nearly 100 percent of people with stage 1 or 2 thyroid cancer survive at least five years, a number that drops to around 50 percent by stage 4. By screening for thyroid nodules, doctors can catch cancer at its earliest stages.
An annual physical examination of the thyroid is recommended in asymptomatic individuals as well as examination in anyone with symptoms that could suggest thyroid disease, said Alexander. Most nodules are asymptomatic, hence the routine examination of the neck and thyroid structures is very important for detection of nodules and potential thyroid cancer.
Currently, the ATA recommends that people with benign thyroid nodules get checked every six to 18 months. If the nodules do not grow in size, this interval can be extended to three to five years.
How Big Is Too Big
When it comes to thyroid nodules, the size matters quite a bit.
Studies have shown time and time again that larger thyroid nodules tend to turn into thyroid cancer at a higher rate compared to smaller thyroid nodules.
The magic number in terms of size is 1 cm or 10mm.
But size isn’t the only thing that matters.
It has been shown that even small thyroid nodules can be cancerous if they have certain and specific findings on thyroid ultrasound.
The number of nodules and their size are not predictive of malignancy, as a nodule smaller than 1 cm is as likely as a larger nodule to harbor neoplastic cells in the presence of suspicious US features.
For this reason, you never want to judge the risk of thyroid cancer based on the size of your nodule alone.
You will notice that while the size is certainly a risk factor, you should also look at other risk factors including whether or not the nodule is causing symptoms, your age, and what the nodule looks like on ultrasound.
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.
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