WARNING: This is a very controversial subject and if you are a patient you
must contact your doctor for guidance. The workup of a thyroid nodule is
rapidly changing and the information provided below should be considered out
of date at the time it is posted.
The age, sex of the patient, along with the size of nodule are important.
The older the patient the more malignant are the cancers. Males tend to
have more aggressive tumors than females. In addition, larger tumors which
are found to be cancers are more likely to spread.
Hoarseness or dysphasia
(trouble swallowing) may indicate a malignancy. A benign thyroid goiter,
even if huge, seldom causes these symptoms.
Management: The only definitive diagnostic test and treatment is
removal of the thyroid lobe. However, this procedure has significant
risks (see Thyroidectomy Page) and cannot be performed on half the
If a true vocal cord
paralysis, suspicious neck nodes, distant spread or a hard and fixed mass is
present, excision should be strongly considered because the likelihood of
malignancy is very high.
The procedure of choice in the
evaluation of a thyroid nodule is a fine needle biopsy. It is far more
accurate than thyroid scans and has largely replaced thyroid scans for this
indication. Using a fine needle biopsy has a false-negative rate of 1% to
11% and a false-positive rate of 1% to 8%.
View Article 1993 Annals of Internal Medicine However, this test
is highly dependent upon the skill of the administrator and pathologist.
This technique also has difficulty distinguishing between a benign and
malignant follicular lesion - see below.
Now, let's look at thyroid
cancers. There are in general two types. Those which are low-grade
(papillary or follicular) and those which are very very deadly – analplastic
or undifferentiated thyroid carcinoma. Patients with the later diagnosis
almost universally have a rapid and progressive downhill course. The
low-grade malignancies can still be dangerous. However, in patients under
the age of 45 the survival rate is 100% despite the extent or spread of the
disease (see Thyroid Cancer Survival Page )
Fine needle aspiration can
fairly accurately distinguish between benign and malignant, papillary,
medullary and anaplastic/undifferentiated lesions. Those lesions
suspicious of cancer should be excised. The problem arises when one is
dealing with a follicular neoplasm. Some recommend excision of Hurthle
cell neoplasms (a type of well-differentiated follicular lesion.
(Note: Fine needle aspiration of patients with thyroiditis can be
confused with Hurthle cell neoplasms. Thyroid antibodies should always
be obtained to help in this differential diagnosis.) In follicular
lesions, I sometimes use size, sex and age of the patient to help in
management decisions. However one needs to remember that if a
follicular neoplasm is found on needle biopsy that some studies have found
an incidence of carcinoma as high as 25% in these patients.
NOTE: A needle biopsy which shows benign follicular cells may be
followed conservatively. However, if a follicular neoplasm is found,
one cannot reliably tell benign verses malignant.
Thus, if one is under the age of 45, female, and has a small follicular nodule, less
than 2 cm, then one may elect to suppress the patient’s thyroid and observe
with serial ultrasound examinations. If the nodule increases in size, then
it needs to be removed. Remember, under the age of 45, a follicular cancer
has a 100% survival rate regardless of the size and spread. If the
patient has a larger nodule, is a male, or is over the age of 45, then removal may be
Patients with a positive
needle biopsy need to have a total thyroid lobectomy for diagnosis and
further management if a cancer is found. Patients with a negative needle
biopsy can be followed with serial
ultrasounds to measure any change in size of the nodule. Thyroid
suppression therapy is controversial and
AHRQ recommends against the routine use
for benign nodules.
Patients at high risk for thyroid malignancy are those with a history of
head and neck irradiation, a positive PET Scan, patients with familial
adenomatous polyposis, a family history of medullarly carcinoma or a male
over the age of 60 with a thyroid nodule. These
patients need to be worked up aggressively for consideration of thyroid lobectomy.
Thyroid nodules found on CT or PET scans when looking for other disease are
called Incidentalomas. Those found by CT scan have the same risk of
malignancy as those found on ultrasound or physical exam. Workup for very
small tumors less than 1.0 cm is often watchful waiting since they often
cannot be accurately needle biopsied even with ultrasound guidance.
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