Thyroid Nodules And Goiter
A goiter is an enlargement of the thyroid, the H-shaped gland that wraps around the front of your windpipe, just below your Adam’s apple.
A goiter can be smooth and uniformly enlarged, called diffuse goiter, or it can be caused by one or more nodules within the gland, called nodular goiter. Nodules may be solid, filled with fluid, or partly fluid and partly solid.
Thyroid nodules are quite common. When examined with ultrasound imaging, as many as one-third of women and one-fifth of men have small thyroid nodules.
It’s possible for an enlarged thyroid to continue functioning well and producing the right amounts of hormones. In fact, most goiters and nodules don’t cause health problems. However, goiter can also be a sign of certain conditions that cause the thyroid to produce too much thyroid hormone or too little .
Clinical Risk Factors And Thyroid Function
A number of clinical findings indicate an increased risk of thyroid cancer. These include a hard nodule, evidence of local invasion such as fixation to adjacent structures or vocal cord palsy, cervical lymphadenopathy or rapid nodule growth. Other important clinical risk factors include a prior hemithyroidectomy with discovery of thyroid cancer, history of thyroid cancer or thyroid cancer syndrome in first degree relatives and a history of head and neck or whole body irradiation. Incidental focal thyroid uptake on flurodeoxyglucose positron emission tomography imaging is associated with about 33% risk of thyroid cancer which may be more aggressive,.
A serum thyroid stimulating hormone test should be performed routinely. If the serum TSH is low, a radionuclide thyroid scan is useful in assessing if the nodule is autonomous. This finding is important as autonomous nodules are almost never malignant and FNAB is generally not required. On the other hand, a higher serum TSH is associated with an increased risk of cancer in a thyroid nodule,. While the costeffectiveness of routine serum calcitonin measurement is debatable given the low incidence of medullary thyroid cancer, serum calcitonin level should be measured if there is a family history of medullary cancer or MEN2,.
What Causes Thyroid Nodules
Nodules can be caused by a simple overgrowth of normal thyroid tissue, fluid-filled cysts, inflammation or a tumor . Most nodules were surgically removed until the 1980s. In retrospect, this approach led to many unnecessary operations, since fewer than 10 percent of the removed nodules proved to be cancerous. Most removed nodules could have simply been observed or treated medically.
Chronic thyroiditis is an inflammation of the thyroid gland that develops slowly. It frequently leads to a decreased function of the thyroid . Thyroiditis occurs when the body’s immune system destroys the cells in the thyroid gland. Chronic thyroiditis is most common in women and people with a family history of thyroid disease.
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Treatment Of Nodules That Are Overproducing Thyroid Hormone
Nodules that produce too much T3 and T4 may be treated in several ways: radioactive iodine, alcohol ablation, or surgery to remove the nodule and thus cure the excess hormone production.
Radioactive iodine is given as a pill and causes the thyroid gland to shrink and make less thyroid hormone. Radioactive iodine is only absorbed by the thyroid gland, so it does not harm other cells within your body.
Alcohol ablation involves injecting alcohol into the thyroid nodule using a very small needle. The treatment causes the nodules to shrink and make less thyroid hormone.
Is A Thyroid Nodule Cancer
Most patients are concerned whether the thyroid nodule is cancerous or not. This can only be diagnosed by a doctor after conducting the relevant diagnostic investigations. Here are a few points to consider when assessing whether a thyroid nodule is cancerous :
- Solitary nodules are more likely to be cancerous than multiple nodules.
- Thyroid nodules are more frequently seen in females but are more likely to be cancerous in males.
- Age may be a consideration as the thyroid nodules in younger patients is more likely to be cancerous than in older patients.
- Firm, hard and fixed nodules are more likey to be cancerous than soft, smooth and movable nodules.
- Functional nodules that is associated with hyper- or hypothyroidism is more likely to be benign while cold nodules with fairly normal thyroid function is more likely to be malignant .
- A history of thyroid cancer, radiations exposure to the head and neck or malignancies elsewhere in the body increases the risk of the nodule being cancerous.
- Painful or tender nodules are more likely to be benign but severe pain may be due to a rupture of a cyst with hemorrhage which is a medical emergency.
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Fast Facts About Thyroid Nodules
- Thyroid nodules are three times more common in women than in men
- The incidence of thyroid nodules increases with age
- At age 30, 30% of women will have a thyroid nodule, compared to one in 40 men the same age
- 50% of 50-year-old women will have at least one thyroid nodule
- 60% of 60-year-old women will have at least one thyroid nodule
- 70% of 70-year-old women will have at least one thyroid nodule
How Would You Know You Have A Thyroidnodule
Common reasons you can be referred to the endocrinology department for evaluation ofthyroid nodules include:
- The nodule was discovered duringan imaging test for an unrelated reason, such as a carotid doppler ultrasoundor a CT scan that includes your neck.
- Your primary care doctor felt alump in your neck during a routine physical examination .
- You have symptoms such as swellingin the neck or front of the throat, trouble swallowing, or a hoarse voice.
A thyroid ultrasound is the best way toevaluate these nodules. We use an ultrasound machine to see if any nodules are present,their size, and whether there are signs that the nodule might be cancerous.
We do not usually worry about nodules that aresmaller than 1 cm in size or if we see a thyroid cyst , asthey are usually benign. Other nodules either should be followed on ultrasoundor evaluated further with a biopsy, depending on what they look like.
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Are Thyroid Nodules Cancer
The vast majority more than 95% of thyroid nodules are benign . If concern arises about the possibility of cancer, the doctor may simply recommend monitoring the nodule over time to see if it grows.
Ultrasound can help evaluate a thyroid nodule and determine the need for biopsy. A thyroid fine needle aspiration biopsy can collect samples of cells from the nodule, which, under a microscope, can provide your doctor with more information about the behavior of the nodule.
Types Of Thyroid Nodules
There are different types of thyroid nodules that arenât cancerous:
Toxic nodules make too much thyroid hormone. This can lead to hyperthyroidism, which makes the metabolism speed up.
Multinodular goiters have several nodules. They may also make too much thyroid hormone and may press on other structures.
Thyroid cysts are full of fluid, sometimes with other debris. They may happen after an injury.
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What Is The Thyroid Gland
The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroids job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.
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
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What Are The Symptoms Of A Thyroid Nodule
Most thyroid nodules do not cause symptoms. Often, thyroid nodules are discovered incidentally during a routine physical examination or on imaging tests like CT scans or neck ultrasound done for completely unrelated reasons. Occasionally, patients themselves find thyroid nodules by noticing a lump in their neck while looking in a mirror, buttoning their collar, or fastening a necklace. Abnormal thyroid function tests may occasionally be the reason a thyroid nodule is found. Thyroid nodules may produce excess amounts of thyroid hormone causing hyperthyroidism . However, most thyroid nodules, including those that cancerous, are actually non-functioning, meaning tests like TSH are normal. Rarely, patients with thyroid nodules may complain of pain in the neck, jaw, or ear. If a nodule is large enough to compress the windpipe or esophagus, it may cause difficulty with breathing, swallowing, or cause a tickle in the throat. Even less commonly, hoarseness can be caused if the nodule invades the nerve that controls the vocal cords but this is usually related to thyroid cancer.
The important points to remember are the following:
- Thyroid nodules generally do not cause symptoms.
- Thyroid tests are most typically normaleven when cancer is present in a nodule.
- The best way to find a thyroid nodule is to make sure your doctor checks your neck!
Treatment For Cancerous Nodules
Fortunately, the majority of thyroid cancers are curable with early intervention and treatment. Surgery is the most common treatment for thyroid cancer. Therefore, in nodules found to be cancerous , surgical removal by an experienced thyroid surgeon is the standard treatment. RAI treatment may also be utilized to aid in the eradication of any remaining thyroid cancer cells.
Hoag Thyroid Cancer Program provides a multidisciplinary team of specialists in surgery, medical oncology, endocrinology, radiology, radiation oncology, pathology, and genetic counseling. Hoags team also includes a clinical nurse navigator and other professionals who help patients and their families to cope with the emotional and practical aspects of the disease.
This multidisciplinary team approach ensures that patients receive comprehensive and personalized treatment plans that take into account all facets of care. Treatment plans vary, but most often include surgical resection, radioactive iodine treatment, and other targeted therapies specific to the type and stage of cancer for best outcomes.
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Treatment For Benign Thyroid Nodules
If a thyroid nodule isnt cancerous, there are several treatment options:
Observation. Thyroid nodules that are benign, or too small to biopsy, should be watched closely. This usually means having a physical exam, thyroid blood work, and imaging tests, such as ultrasound at regular intervals. Youre also likely to have another biopsy if the nodule grows larger.
Surgery. Surgery may be recommended even for a benign nodule if it continues to grow, or develops worrisome characteristics over the course of follow up. Surgery may also be considered for large multinodular goiters, and for nodules causing hyperthyroidism that is unresponsive to other treatments. In addition, nodules diagnosed as indeterminate or suspicious upon biopsy may be surgically removed so they can be fully examined for signs of cancer.
Radioactive Iodine Therapy. RAI may be used to destroy thyroid tissue if the nodule is hyperfunctioning , leading to hyperthyroidism.
How Do I Know If I Have Thyroid Nodules
Most thyroid nodules do not produce any symptoms. However, if you have several nodules, or large nodules, you may be able to see them. Although rare, nodules can press against other structures in the neck and cause symptoms, including:
Hyperfunctioning thyroid nodules can lead to overproduction of thyroid hormones, also known as hyperthyroidism. Symptoms of hyperthyroidism include:
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How Is A Thyroid Nodule Evaluated And Diagnosed
Once the nodule is discovered, your doctor will try to determine whether the rest of your thyroid is healthy or whether the entire thyroid gland has been affected by a more general condition such as hyperthyroidism or hypothyroidism. Your physician will feel the thyroid to see whether the entire gland is enlarged and whether a single or multiple nodules are present. The initial laboratory tests may include measurement of thyroid hormone and thyroid-stimulating hormone in your blood to determine whether your thyroid is functioning normally.
Since its usually not possible to determine whether a thyroid nodule is cancerous by physical examination and blood tests alone, the evaluation of the thyroid nodules often includes specialized tests such as thyroid ultrasonography and fine needle biopsy.
The report of a thyroid fine needle biopsy will usually indicate one of the following findings:
- This result is obtained in up to 80% of biopsies. The risk of overlooking a cancer when the biopsy is benign is generally less than 3 in 100 tests or 3%. This is even lower when the biopsy is reviewed by an experienced pathologist at a major medical center. Generally, benign thyroid nodules do not need to be removed unless they are causing symptoms like choking or difficulty swallowing. Follow up ultrasound exams are important. Occasionally, another biopsy may be required in the future, especially if the nodule grows over time.
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Thyroid Molecular Markers Allow Patients To Avoid Surgery
We want to help patients find that perfect balance between under-treatment and over-treatment. The people-gram shows how molecular testing can help patients avoid unnecessary surgery.
Left Path: Before the use of molecular markers, everyone with an indeterminate biopsy went to surgery. Of those who went to surgery, cancer was found in only 25% of those cases . 75% of the surgical patients turned out not to have needed surgery at all because their nodules were benign .
Right Path: Today, if you have an indeterminate biopsy, you also undergo molecular testing.50% of patients were categorized as benign from the molecular test and safely avoided surgery. Of the surgical patients who received a suspicious molecular test result , cancer was found in 50% of those patients .
It is very rare that patients end up having cancer because of a false negative test. Still, it is UCLAs standard of care to have a safety net and follow every patient after molecular testing, regardless of their result. Those patients will get ultrasounds every 12 months to ensure that nodules do not grow or change in appearance.
Thyroid Nodule: Evaluation And Tests
The following are a list of tests that are required in the evaluation of a patient with a thyroid nodule.
- Complete Medical History and Physical Examination
- T3 and T4
- Thyroglobulin Antibody
Medical history and physical examination is required for all patients with a thyroid nodule
If there is a suspicion that you may have a thyroid nodule, your health care professional will want to know your complete medical history. You will be asked questions about your possible risk factors, symptoms, and any other health problems or concerns. If someone in your family has had a diagnosis of thyroid cancer or other endocrine cancer, these are important factors.
Your doctor will examine you to get more information about possible signs of thyroid cancer and other health problems. During the exam, the doctor will pay special attention to the size and firmness of your thyroid and any enlarged lymph nodes in your neck. Examination of your voice box is part of the physical examination obtained by the surgeon for any thyroid lump. A small lighted microscope is used to look at the voice box to determine how the vocal cords of the voice box are functioning. Even though a patient does not report change in their voice does not insure that the vocal cords are working normally. A vocal cord that is paralyzed greatly increases the concern that a thyroid nodule may be a cancer.
Ways To Improve Thyroid Nodules
Conventional treatment for thyroid nodules may include thyroid-damaging treatments, such as radioactive iodine or surgery. However, you may be able to reduce or eliminate your thyroid nodules by addressing their root cause.
If your thyroid nodule is benign, there are two main treatment options that may help:
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What To Read Next
- Thyroid Cancer Overview – An introduction to thyroid cancer, what it is, and the prognosis of the different thyroid cancers.
- Thyroid Nodules – what are Thyroid Nodules and how are they treated ?
Thyroid Cancer Center Coronavirus Response
Corona Virus Update: Friday January 7, 2022. We have moved to the new Hospital for Endocrine Surgery. This hospital is dedicated to endocrine surgery–there are no COVID patients in our hospital–it does not have a medical ward–just thyroid, parathyroid and adrenal surgery. This is the safest hospital for you! We screen every patient for the virus with a 10-minute rapid test when you arrive at the hospital in the morning. FAA regulations for air quality are more stringent than even the operating rooms which we work. We are caring for patients from around the world. Traveling on airplanes is safe. Our hotels are ready for you and VERY clean. At our beautiful new hospital you can have one family member with you at all times. We take special measures to make this the safest place in the world to have your operation — you will be in and out. Our commitment is to take exceptional care of you!
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