Thyroid Nodules & Cancer
While the incidence of pediatric thyroid nodules and cancer has recently increased, the authors report there is a lack of knowledge surrounding prevention and risk factors for development, besides early exposure to ionizing radiation and familial history of autoimmune disease. Thyroid nodules and cancer in children and adolescents typically present with no symptoms besides a thyroid mass. “The majority of thyroid nodules are benign, however, the most common form of thyroid cancer, papillary thyroid cancer, is associated with an increased risk for lymph node metastasis.” wrote Bauer to MedPage Today.
In diagnosing thyroid cancer in children and adolescents, an extensive physical examination and familial history must be completed, Hanley and colleagues indicated. The next step following examination, the patient must undergo ultrasonography to assess the thyroid nodule. Additionally, serum thyrotropin levels should be measured. The primary care physician should refer his or her patient to a pediatric endocrinologist for further assessment and treatment. While the majority of thyroid nodules are benign, the ultrasonography will determine which pediatric patients must undergo surgery following fine needle aspiration. If malignant, the patient should be referred to a pediatric thyroid center.
Most thyroid nodules
are NOT cancer!
3-5 out of 100 nodules
A detailed list of the
causes of thyroid nodules
Follicular Adenoma,Hurthle cell adenoma,
Thyroglossal duct cyst, Subacute viral thyroiditis,
Sporadic C cell hyperplasia
Hurthle cell, Anaplastic, C cell origin, Medullary Carcinoma,
Lymphoma, Metastatic to the thyroid, Kidney, Breast,
parathyroid adenoma, lymph node, Branchial cleft cyst,
Other epithelial cysts
Risk Factors for any given
nodule to harbor cancer
Familial polyposis,Cowden’s and MEA 2
What’s a Goiter?
According to medics, goiter is a swelling in the neck caused by enlargement of the thyroid gland. It can be caused by both an underactive and hyperactive thyroid gland, but the associated features and treatment vary.
“Goiter can be caused by consuming diet deficient in iodine. Selenium deficiency can also contribute to it. A pregnant woman with hypothyroidism can produce a baby with thyroid deficiency,” says Dr Rachna Pande, an internal medicine specialist.
She says hyperthyroidism is a cause resulting from an overactive thyroid gland, which produces too much thyroid hormone. This usually happens as a result of an autoimmune disorder in which the body’s immunity turns on itself and attacks the thyroid gland, causing it to swell, thus leading to goiter.
“Goiter can be due to autoimmune disorders (where the body produces antibodies against itself) like grave’s disease, Hashimoto’s thyroiditis. Benign and malignant tumors of thyroid gland or those metastasizing to thyroid gland can manifest as goiter.Also, women over the age of 40 years, as well as people with the family history of the condition are at a higher risk of getting goiter,” Pande explains.
Francis Kazungu, a general practitioner in Kigali, says excess consumption of foods containing goitrogenic agents (chemicals that interfere with the normal function of the thyroid gland) such as soybean and members of the cabbage family like kale, cabbage and broccoli, also leads to one developing goiter, therefore, consuming them in moderation is essential.
Signs & Symptoms
“Sometimes it is hard to see the signs and symptoms, but in most cases when they occur, they include difficulty in breathing, swallowing and coughing. A visible swelling at neck could be a sign of goiter too,” says Kazungu.
He adds that signs such as nervousness, palpitations, hyperactivity, increased sweating, heat hypersensitivity, fatigue, increased appetite and weight loss may be an indication of goiter mainly caused by overactive thyroid.
Kazungu points out that injection of radioactive iodine may be administered to the patient to provide a detailed picture of the gland. In addition, in order to assess the gland and the size of the goiter, carrying out ultra sound is ideal.
How to go About It?
Pande explains that to avoid developing goiter, maintaining a healthy diet is key.
“Prevention of goiter lies in taking a balanced diet with adequate amounts of fresh fruits, particularly oranges, apples, pineapple and strawberries. Fresh vegetables are also useful. For instance, sea food provides iodine and is a good source of iodine,” she notes.
Pande adds that, it’s advisable to avoid much use of white flour and white sugar.
“One should also keep away from excess use of foods like cabbage, broccoli and cauliflower as they interfere with synthesis of thyroid hormones,” she says.
However, Pande points out that in order to keep the condition at bay, it’s essential to start using iodised salt.
According to a research by Mayo Clinic, the goiter can be managed surgically by removing part of the thyroid gland, especially in cases where one has a large goiter, which in most cases causes discomfort or difficulty in breathing or swallowing.
The research adds that in cases where one has nodular goiter causing hyperthyroidism, surgery is the best option to treat it.
However, Kazungu says diagnosis of the cause of goiter is made clinically.
“Whether it is under functioning or hyperactive thyroid gland, it is determined by assessing the level of thyroid hormones in blood. On the other hand, the cause of goiter is determined by biopsy,” he says.
Medics point out that the treatment for hypothyroidism consists of use of thyroid hormone supplements. Hyperthyroidism is treated by antithyroid drugs.
Surgery is considered in cases where enlarged thyroid gland is compressing adjoining structures, like the wind pipe, sound box or food pipe.
Alternative therapy to surgery for some forms of goiter include RFA radiofrequency ablation,PEI ethanol ablation, and HIFU echotherpy. Centers in the US,Europe and Asia do these. info at thyroid.com, and firstname.lastname@example.org.
Simple Goiter: Not so Simple if you’re not treated
Large biopsy proven Benign Nodular Simple Goiter ( Not due to Hashimotos, and with normal TSH,T4,T3, and negative thyroid antibodies ) is causing local symptoms, and is a cosmetic problem as well. Prior to interventional procedures( ethanol PEI, and radiofrequency RFA ablation done by clinical thyroidologists surgery was the only solution.
Simple Goiter is a common thyroid disorder that because the thyroid blood tests for TSH and T4 are normal, the physician does not consider referring to a thyroid specialist for evaluation for therapy until things start to go wrong. When the thyroid goiter enlarges and causes symptoms they rush you off the the surgeon to have it removed. When the goiter starts to grow nodules they send you to a radiologist for a biopsy. Even if the biopsy is benign there is still a strong possibility you will see a surgeon who will tell you it is better to remove it. If the goiter causes rapid growth with or without pain and the ultrasound shows a cyst, your physician will again send you to the surgeon. After years of following your goiter without therapy it now becomes a cosmetic problem for you, he sends you to the surgeon. As you can see an untreated goiter that has not been evaluated and treated with non-invasive methods available to a clinical thyroidologist will usually end up under the surgeon’s knife.
Alternative to eventual surgery for simple goiters
TG was first used to follow thyroid cancer patients, but all thyroid cells make it so it is a cancer marker after thyroidectomy only. Normal thyroid glands and goiters make TG. The larger the goiter the higher the TG.
Well your simple goiter is not so simple after all. That is why you must request a referral to a non-surgeon endocrine thyroidologist, sonologist who is certified in endocrine neck ultrasound ECNU by American College of Endocrinology. Check thyroid.org for one near you, or visit me for a overnight complete evaluation to see if you are a candidate for any of these therapy options instead of waiting for the eventual referral by your physician to have your goiter removed.
If you have a thyroid nodule, you should have it evaluated by a physician trained in the diagnosis and management of thyroid nodules. Endocrinologists and clinical thyroidologists are the right specialists to see for nodule evaluation.
At Thyroid Center of Santa Monica, Richard Guttler, MD will take a careful history for risk factors for thyroid disease (including radiation exposure), do a physical examination, and order blood tests to check the activity of the gland. Some of the ways we can treat thyroid nodules using interventional thyroidology include nuclear medicine, ultrasound-guided PEI, and radioactive iodine.
How common are
nodules in the thyroid?
It is estimated that about 50% of the population will develop a small, unnoticeable thyroid nodule at some time in their life, making them very common.
Most nodules are never detected and do not cause problems. In fact, they are only found by doing an ultrasound, a CT scan, or MRI for other reasons. This is called a thyroid nodule incidentaloma.
Only 4-7% of the population will have a nodule that is large enough to be found by a physician feeling for it. They are more common in women and the incidence of nodules increases with age.
About 4% of women aged 20 years have a palpable nodule whereas 9% of women over age 70 have a palpable nodule. Nodules are only found in about 1% of men.
How do I tell
if I have a nodule?
You can check your own thyroid by standing in front of a mirror. Look at the area of your neck just above the notch where the collarbone comes together and just below the Adam’s apple. This is where the thyroid gland is located.
If possible, have a light shine from the side to throw a shadow over the area. Then tilt your head back slightly and watch this area for any shadows while you swallow.
If you see any prominence or enlargement in this area, you may have a thyroid nodule or an enlarged thyroid gland (goiter). See your physician for a more complete evaluation, as this does not mean that you do or do not have a nodule, but it can be an indicator.
You should also have your thyroid gland area examined during a general physical examination by a medical care provider.
Certain forms of radiation have been associated with increased risk of cancerous nodules in the thyroid. The risk is small and you have to be exposed to very high amounts of radiation.
For example, radiation at Hiroshima, Chernobyl, and nuclear weapons testing sites in the United States in the 1940s to 1970s have all been associated with increased risk of thyroid nodules and cancer.
Regular X-rays, dental X-rays, and sun exposure are not known risk factors. However, if you had radiation treatments to your head, neck, tonsils, or thymus, you may be at a slightly increased risk of thyroid cancer. If you are concerned that you had exposure, see your doctor for an evaluation to determine whether you have thyroid nodules.
DR.Guttler’s Patient Alert to Epidemic of small harmless thyroid cancers that should not be biopsied
New patients with small thyroid nodules read this before you allow a thyroid biopsy to be done
This is a wake up call for all patients who have small thyroid nodules
The AMERICAN THYROID ASSOCIATION recognizes that the recent increase in incidence of thyroid cancer in the United States and other countries is, in large part, due to the over diagnosis of indolent papillary microcarcinomas that will never result in symptoms or death, and which only rarely will enlarge or spread beyond the thyroid gland. The issues surrounding this problem are twofold: First, medical imaging is identifying small nodules, well below the limits of clinical detection. Second, these small nodules are subjected to ultrasound-guided FNA, and about 5% reveal cancer cells. The usual next step is surgical removal, often followed by radioactive iodine and life-long thyroid hormone therapy. This approach is costly, creates risks from the treatments, and in most patients offers little or no benefit.
AMERICAN THYROID ASSOCIATION Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Thyroid, 2016) address this issue with three important recommendations/suggestions: (1) do not perform thyroid FNA on nodules < 1 cm unless there is evidence of extrathyroidal extension or of lymph node or distant metastases; (2) restrict surgery (currently the Standard of Care) to lobectomy and avoid radioactive iodine in those with low risk features; and (3) conduct further research (preferably in the setting of an IRB-approved clinical trial) to define the role of active surveillance instead of surgery for patients with low risk tumors (as is currently done for men with indolent prostate cancer).
While additional scientific and medical knowledge is required, the AMERICAN THYROID ASSOCIATION advises that, in the interim, these recommended clinical measures may reduce the recent increased incidence of thyroid cancer and prevent overtreatment of low risk cancer.