Thyroid Nodule

Recently, I saw a young lady with a lump in the neck. . The lump moves with swallowing. That means it is in the thyroid gland

The young lady wants to know: Is it cancer? Why did she get it? What can be done about it?

Thyroid lumps or nodules are tumors, most of which are benign. But some are malignant and invasive cancers.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules which is known as a multi-nodular goiter. Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 42-77 percent of nodules are simple cysts (colloid nodules); 15 -40 percent are benign tumors (adenomas); and only 8 – 17 percent are cancers. In men, the frequency of cancer in the thyroid nodule is more than 50 percent by 70 years of age.

Radiation treatment to the neck, or any radiation exposure near the thyroid gland, increases the risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

To start with, only one blood test is required –thyroid stimulating hormone (TSH) level – to check if the thyroid is functioning normally or is over-active.

If the thyroid function is normal then the next line of investigation is a fine-needle aspiration (FNA) biopsy. In nine reports (comprising 9119 patients) the FNA showed benign tumor in 74 percent of patients, malignant tumor in four percent, indeterminate results in 11 percent, and inadequate biopsy specimen in 11 percent, says an article in the New England Journal of Medicine (NEJM).

If the TSH is suggestive of an over-active thyroid nodule or the FNA biopsy result is indeterminate then a radio-nuclear scan should be performed to further check the status of the nodule. If it is “hot” – then it is overactive.

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule; if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

What is the treatment of solitary thyroid nodule?

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the needle biopsy is clearly benign and there are no other symptoms suggesting pressure to the surrounding structures, like difficulty breathing or swallowing, then the nodule can be observed with or without thyroid hormone therapy. The nodule may enlarge, shrink or disappear.

Main indications for surgery are: malignant or indeterminate FNA biopsy results, local symptoms, or the gland is so big that it changes the appearance of the neck.

The NEJM article says that in six reports (10,850 patients) the rate of surgery for a solitary thyroid lump varied from 14 to 61 percent.

Why such a big variation in the rates of surgery? For three reasons: differing rates of accuracy of FNA biopsy results among centers, surgeon’s own preference and differing views on whether patients with unclear FNA results should routinely undergo surgery.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

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