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What Size Of Thyroid Nodule To Biopsy

What Are The Signs And Symptoms Related To Thyroid Nodules

Thyroid Nodule Biopsy

Most thyroid nodules do not cause any symptoms. Some thyroid nodules show up as a painless lump in the neck that you can feel or see. Thyroid nodules usually move up and down with swallowing.

When thyroid nodules become large they may cause symptoms by pressing on the airway or esophagus. These are also called compressive symptoms. Compressive symptoms include:

  • discomfort with swallowing

At the UCLA Endocrine Center in Los Angeles, multiple layers of evaluation are designed to help you avoid invasive tests and surgery whenever possible. Consultation, ultrasound, and FNA can all be performed in a single visit.

Initial evaluation of a newly discovered thyroid nodule begins with:

  • Assessment by an endocrinologist or endocrine surgeon
  • Thyroid function tests
  • Neck ultrasound performed by your doctor

An ultrasound is a highly accurate tool to visualize your nodule. There is no associated radiation with ultrasounds and it is non-invasive. Ultrasounds are cost-effective as most patients really don’t need any other imaging because the ultrasounds are the best way to look at the thyroid, all present nodules, and the lymph nodes in the neck.

Our cytopathologists evaluate over 1000 samples per year, so we are confident in the accuracy of our biopsies. When biopsy does not give a clear answer, we automatically use molecular profiling to refine the diagnosis.

Nodules Located In The Thyroid Isthmus Are At Greater Risk Of Being Malignant Than Those Found In The Lateral Lobes Whereas Those In The Lower Portion Of The Lobes Are At Least Risk Therefore A Clinician Might Want To Include Nodule Location In The Decision Process To Proceed Or Not With A Nodule Biopsy

The prevalence of nodules on the thyroid seems to be increasing. A study out of Korea suggests that one in three individuals have thyroidal nodular growths1. They are more often found in women, in older populations, and cultures with widespread iodine deficiency1,2.

Few nodules are found through manual palpation. In contrast, though, ultrasounds are an accurate and cost-effective method for locating these growths. Despite the ubiquity of nodule presence in the population, when they are discovered, a patient’s initial fear is malignancy.

Malignant nodules are found in about 10% of the total nodules found3-5. A procedure called Fine Needle Aspiration is used to biopsy the nodule. FNA is a safe and straightforward procedure, yet it is still invasive. Because of this, some researchers have sought to find characteristics that can help determine the risk of a cancerous nodule, thus making the decision to have an FNA, or not, more reasonable.

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How Should I Prepare

Please notify your physician if you are taking any blood thinning agents, such as aspirin, Lovenox®, Plavix® or Coumadin®.

Usually, no special preparations are required for this procedure.

For biopsies performed in children, sedation may be used. Specific instructions will be given at the time of scheduling.

What Is The Thyroid Gland

Updated Thyroid Nodule Guidelines Give Recommendations on ...

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 hormones help the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

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What Happens After A Fine Needle Aspiration Biopsy

Most people will be able to resume their normal activities right away. You can remove your bandage within a few hours.

The site of the biopsy might be sore for a day or two after the procedure. You can take over-the-counter pain medicines if you need to. Follow any other specific instructions that your healthcare provider gives you.

It may take several days to get your test results from the pathology lab. Ask your healthcare provider when you can expect to get your results back.

If your thyroid nodule is not cancer, you might not need any further treatment. Your provider may want to monitor your nodule, though, and you might need another biopsy in the future. In some cases, your healthcare provider may offer thyroid hormone pills. These can sometimes decrease the likelihood of nodules growing back.

You will probably need surgical treatment if your nodule appears cancerous. Luckily, most thyroid cancers are curable.

Sometimes, the pathologist cannot determine for sure whether your nodule is cancer. In this case, your healthcare provider might recommend a repeat biopsy or surgery. Whatever your test results, you can work with your healthcare provider to develop the best possible treatment plan for you.

What Are Thyroid Nodules

The thyroid gland is located in the lower front of the neck, below the voicebox and above the collarbones.

A thyroid nodule is a lump in or on the thyroid gland. Thyroid nodules are detected in about 6 percent of women and 1-2 percent of men they occur 10 times as often in older individuals, but are usually not diagnosed.

Any time a lump is discovered in thyroid tissue, the possibility of malignancy must be considered. More than 95 percent of thyroid nodules are benign , but tests are needed to determine if a nodule is cancerous.

Benign nodules include:

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Location Is Of Critical Importance

A recent study published in Thyroid looked at the risk of malignant nodules based on location in the thyroid4. Their specific aim was to determine if the location of a nodule made it more or less likely to be malignant. The thyroid was divided into four locations: isthmus, upper, middle, or lower portions of the thyroid lobe.

Note that this and other studies have found no differences between left and right side nodules3-5, so location data were collapsed across the two sides. Other variables included: gender, age, family history, and ACR-TIRAD measures. The study used multivariate regression modeling on retrospective ultrasound data from 3,241 nodules.

“This is a provocative study that used the same data sets that helped establish the ACRTIRAD,” endorses endocrine expert, Bryan McIver, M.D., Deputy Physician-in-Chief, Department of Head and Neck, and Endocrine Oncology at the Moffitt Cancer Center.

Nodules In The Isthmus Are At Greater Risk

Thyroid Nodule: Fine Needle Biopsy

The regression model revealed that location was an independent predictor of malignancy. Meaning that when all other variables were held constant, such as the ACR-TIRAD score, where the nodules were found was significant. Nodules in the lower lobe were least at risk, a result confirmed by two earlier studies using smaller sample sizes3,5. Only 8.1% of nodules in the lower portion of the lobe were cancerous.

Using the lower lobe, then, as the reference, the odds ratios for the other three areas were calculated. Nodules found in the isthmus were 2.4 times more likely to be malignant than those in the lower lobe = 1.6-3.6). This was followed by the upper portion with an OR of 1.9 , and the middle portion with an OR of 1.3 times . Thus, location without any other additional information can provide insight into the need for an FNA.

Lead author Sina Jasim, M.D., Assistant Professor of Internal Medicine, Division of Endocrinology, Washington University School of Medicine, says this about their work: “The findings support the concept that thyroid tissue should not be considered homogenous, and may determine not only the propensity to form nodules but also risk of malignant transformation. Further research to help elucidate the pathophysiology of this observation is indicated.”

Malignancy risk also decreased with age. While older individuals had more nodules, they were also more likely to be benign . Younger individuals had a slightly greater risk of malignant nodules.

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When Would I Need A Biopsy

A biopsy helps your doctor find the cause of a nodule or goiter. But you donât need it for all thyroid problems. For example, your symptoms, blood tests, and imaging will be enough to tell if you have Gravesâ disease.

Your doctor will likely want to check on any nodule bigger than about 1 centimeter , especially if imaging shows that the nodule is solid, has calcium on it, and doesnât have clear borders around it.

You might also get a biopsy without a nodule if youâre in a lot of pain and your thyroid is growing quickly.

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.

For instance:

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.

Thyroid Nodules by Popoveniuc and Jonklaas

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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What Are The Risks Of Thyroid Fine Needle Aspiration Biopsy

Thyroid fine needle aspiration biopsy is a very safe procedure, but it does carry some slight risks. These include:

  • Bleeding at the biopsy site
  • Infection
  • Damage to the structures near the thyroid

Because most healthcare providers use ultrasound to guide the procedure, this last complication is rare.

There is also a small risk that the fine needle aspiration biopsy will not show for sure whether the nodule is cancerous. If this happens, you might need a repeat biopsy.

Signs Of Thyroid Cancer

Association between thyroid nodule size and surgical ...

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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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.

Who Needs A Fna Needle Biopsy Of Their Thyroid Nodule

FNA biopsy should be done on any nodule that the doctor thinks may be cancerous

  • FNA needle biopsy of thyroid nodules is generally done on any thyroid nodules that is big enough to be felt. This means that they are larger than about 1 centimeter across.
  • FNA biopsy is indicated on any thyroid nodule that causes symptoms. We have an entire page on symptoms caused by thyroid nodules.
  • FNA biopsies should be done on any swollen or abnormal lymph nodes in the neck. This may be more accurate in diagnosing thyroid cancer than FNA of the thyroid nodule itself!
  • FNA biopsy should be done on thyroid nodules that have a certain characteristic under the ultrasound.

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What Does The Equipment Look Like

The needle used is a thin, fine-gauge needle that is smaller in diameter than the needle used in most blood draws . The aspiration may be done with a needle or with a needle that is attached to a syringe. The syringe may be in a plastic or metal holder to make it easier for the doctor to aspirate the cells.

Ultrasound is used to guide accurate placement of the needle within the thyroid nodule.

Ultrasound scanners consist of a computer console, video display screen and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers during a single exam. The transducer sends out inaudible, high-frequency sound waves into the body and then listens for the returning echoes. The principles are similar to sonar used by boats and submarines.

The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination. The ultrasound image is immediately visible on a video display screen that looks like a computer monitor. The computer creates the image based on the loudness , pitch and time it takes for the ultrasound signal to return to the transducer. It also takes into account what type of body structure and/or tissue the sound is traveling through.

What To Read Next

Thyroid Nodules – When to Worry? (Signs your nodule could be something more) is an educational service of the Clayman Thyroid Center, the world’s leading thyroid cancer surgery center.

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How Common Are Thyroid Nodules

Thyroid nodules are very common, especially in the U.S. In fact, experts estimate that about half of Americans will have one by the time theyre 60 years old. Some are solid, and some are fluid-filled cysts. Others are mixed.

Because many thyroid nodules dont have symptoms, people may not even know theyre there. In other cases, the nodules can get big enough to cause problems. But even larger thyroid nodules are treatable, sometimes even without surgery.

Is It Necessary To Get A Biopsy For Thyroid Nodules

From time to time Ill receive a question from someone who has one or more thyroid nodules about whether or not they should get a biopsy. Of course their main concern is that the thyroid nodule will be cancerous. Just like any other procedure, everything comes down to risks vs. benefits. And while there is a small risk with obtaining a biopsy, it still is an invasive procedure, and it doesnt always rule out a malignancy. On the other hand, there is also a risk of not getting a biopsy and then finding out at a later time that you have a cancerous nodule. In this article I will give my opinion about whether a biopsy is necessary.

Before I talk about whether getting a biopsy is necessary, lets first talk about thyroid cancer. There are a few different types of thyroid cancer, including papillary thyroid cancer, follicular thyroid cancer, medullary thyroid cancer, and anaplastic thyroid cancer. Im not going to discuss the different types, but if you want more information I would recommend taking a look at the article Thyroid Cancer Types, Stages and Treatment Overview. Of the four different types of cancer I listed, papillary cancer is the most common type of cancer, with follicular cancer being the second most common. The chances of long-term survival is high with the first three types of cancers, whereas anaplastic is more aggressive.

Fine Needle Aspiration vs. Core Needle Biopsy

When Should Someone Receive A Thyroid Biopsy?

1) Microcalcifications of the thyroid nodule

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