Thyroid nodules are very common and not all of them need to be removed. Nodules that are most likely benign include:
Thyroid nodules are more common in women but men are more likely to have a cancerous nodule. Factors suggesting a malignancy include:
A nodule in a person younger than age 20 has a 20-50% chance of being cancerous
The thyroid gland is first evaluated with physical examination, laboratory tests of thyroid function (thyroid stimulating hormone, thyroid hormone levels) and an ultrasound. A large nodule size, increasing size or activity of the nodule, or other suspicious symptoms warrants other exams which may include laboratory tests for autoimmune disease and a fine needle aspiration. If this shows malignant or indeterminate cells, the gland should be removed. If metastatic spread is suspected, further imaging studies such as CT or MRI may be needed.
Benign nodules can be observed or suppressed with oral thyroid hormone supplementation. Some glands have many nodules which is termed multinodular goiter. Sometimes nodules or a goiter becomes large enough to cause difficulty breathing, difficulty swallowing, or hoarseness from pressure on the recurrent laryngeal nerve (the nerve that moves the vocal cords). If any of these occur, then the gland should be removed. Sometimes a multinodular goiter can become “toxic” and cause symptoms of severe hyperthyroidism. If this cannot be managed with medications, then surgery may be required.
The four major types of thyroid cancer are papillary, follicular, medullary, and anaplastic. Most thyroid cancers are papillary. These tend to spread to the neck lymph nodes but the presence of lymph nodes does not adversely affect survival for papillary thyroid cancer. The treatment recommended is usually surgical excision of the entire gland with neck dissection if there is any spread to lymph nodes. Postoperative radioactive iodine and thyroid suppression is often recommended.
Approximately 15% of thyroid cancer is follicular. Follicular carcinoma is difficult to diagnose with a fine needle aspiration so often a surgical specimen must be obtained. Follicular carcinoma tends to spread through the blood. The treatment recommended is usually total thyroidectomy with postoperative radioactive iodine and thyroid suppression treatment.
Medullary carcinoma accounts for 6-10% of thyroid cancers. About 15% are familial (genetic) most commonly as a component of multiple endocrine neoplasms (MEN) syndromes. All patients with MEN syndromes should have a urinary metanephrine screen for pheochromocytomas. All first degree relatives of patients with medullary carcinomas should be tested for mutations in the RET proto-oncogene. The treatment recommended is usually a subtotal or total thyroidectomy with elective neck dissection. For patients with the familial form, a total thyroidectomy is recommended.
Anaplastic carcinoma is a rare tumor with the worst prognosis of the thyroid cancers. Treatment is usually tailored to relieving symptoms. Occasionally lymphoma of the thyroid gland can appear similar to anaplastic carcinoma. Treatment of the lymphoma with systemic medications is needed with surgery reserved for treating severe symptoms such as airway obstruction only.
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