Thyroid Nodules

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.

Does radiation
cause nodules?

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.

A detailed list of the
causes of thyroid nodules

1Benign, Colloid goiter nodule, Hashimoto’s thyroiditis
Follicular Adenoma,Hurthle cell adenoma,
Thyroglossal duct cyst, Subacute viral thyroiditis,
Sporadic C cell hyperplasia
2Malignant, Follicular cell origin, Papillary, Follicular,
Hurthle cell, Anaplastic, C cell origin, Medullary Carcinoma,
Lymphoma, Metastatic to the thyroid, Kidney, Breast,
Lung, Melanoma
3Non thyroid lesions mimics, parathyroid cyst,
parathyroid adenoma, lymph node, Branchial cleft cyst,
Other epithelial cysts

Risk Factors for any given
nodule to harbor cancer

1Radiation exposure
2Family history of thyroid cancer: syndromes associated
Familial polyposis,Cowden’s and MEA 2
3Age 65
4Men > women they have higher proportion of cancer
5History of kidney, breast, lung and melanoma
6Vocal cord paralysis
7Abnormal lateral neck lymph nodes
8Firm nodule fixed to surrounding tissues

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 dr.guttler@thyroid.com.

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

1Normal TSH,T4 is not a reason not to treat the goiter with T4. The thyroid hormone output of the goiter will be decreased to 30% and the thyroid hormone therapy will fill in the rest. This is because the goiter is inefficient and will always need more TSH to replace the damaged parts with new thyroid cells. The new cells and the old damaged parts result in progressive slow enlargement. An example is the lady with a goiter bigger than her head with normal TSH,T4,T3 and no antibodies. Located in this massive goiter was enough normal thyroid to keep the blood tests normal while progressive enlargement occurred by TSH stimulated new thyroid cell growth. The vast majority of her goiter was non-functional and causing obstructive symptoms not to mention a major cosmetic problem.
2We first make sure there are no suspicious nodules growing already, and that the goiter is not simple but due the Hashimoto’s thyroiditis.A repeat biopsy would also inclue the latest Molecular markers BRAF RET/PTC and RAS etc. The initial evaluation to see if you are a candidate for either PEI or RFA is $2500.
3First I try a 6 month trial of thyroid hormone suppression. A growth marker called thyroglobulin or TG is drawn before therapy and repeated after 6 months. TG is increased by an enlarging goiter. The TG usually decreases by 50% if the goiter is responsive to T4 therapy. I continue T4 in those patients who respond. The ones who do not respond with TG decrease are followed at 6 month intervals watching for the the onset of nodules and cancer by neck exams and endocrine neck ultrasound.
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.
4Complex Cyst formation can now be treated without surgery. However, your physician may only know about surgery. You need to refuse surgery and seek a thyroidologist to do ethanol ablation therapy PEI for your FNA biopsy benign large cyst. I remove the cyst fluid and replace it with ethanol in a simple outpatient procedure. It saves you the morbidity of a thyroidectomy, hospital stay and recovery for $2,500 vs a $50,000 surgery. Go to Video Endocrinology journal or Vimea or Utube for my video of PEI. The evaluation and therapy for PEI is $5000. One year follow up with neck examinationsTSH and ultrasounds is $1500 for 1,3,6,9 12 month visits.
5Large benign solid nodules can be treated with usually one visit to a radiofrequency ablation RFA endocrinologist. An outpatient procedure that solves the symptoms and cosmetic problems of the nodule and reduces the size progressively over 4 years without a second RFA procedure in most cases. Again a simple non-surgical therapy for a simple goiter. I will do the pre-RFA evaluation in my center average fee of $ 2500 and send you to Asia or Europe for the RFA procedure as it is not FDA approved in the US as of 2015. With my evaluation ultrasound and biopsies you can spend as little as 3 days in the town where the RFA is done.. The fee for the RFA procedure is around $4000 if you are not a EU citizen, and free if you are. Korea is the second place that is expert in thyroid RFA. After you return to he US I can follow up with blood and ultrasound to determine the extent of nodule reduction at 3,6,12,24 months. The post RFA follow up is for ultrasounds. The fee is $500/ visit including neck examinations and TSH.
6The last non-surgical alternative for benign large goiter is radioiodine therapy. Because the uptake of iodine is relatively low in simple goiters a booster shot of a very small amount of Thyrogen ( rTSH ) is usually needed to increase the uptake and drive the radioiodine into the goiter. This is the least used of the alternatives because many patients do not like the idea of radiation even if it has a low complication rate.

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.

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.

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Thyroid nodules are nodules raised areas of tissue or fluid which commonly arise within an otherwise normal thyroid gland. They may be hyperplasia or a thyroid neoplasm, but only a small percentage of the latter are thyroid cancers. Small, asymptomatic nodules are common, and many people who have them are unaware of them. But nodules that grow larger or produce symptoms may eventually need medical care. Goitres may have nodules or be diffuse.

Often these abnormal growths of thyroid tissue are located at the edge of the thyroid gland and can be felt as a lump in the throat. When they are large, they can sometimes be seen as a lump in the front of the neck.

Sometimes a thyroid nodule presents as a fluid-filled cavity called a thyroid cyst. Often, solid components are mixed with the fluid. Thyroid cysts most commonly result from degenerating thyroid adenomas, which are benign, but they occasionally contain malignant solid components.

After a nodule is found during a physical examination, a referral to an endocrinologist, a thyroidologist or otolaryngologist may occur. Most commonly an ultrasound is performed to confirm the presence of a nodule, and assess the status of the whole gland. Measurement of thyroid stimulating hormone and anti-thyroid antibodies will help decide if there is a functional thyroid disease such as Hashimoto’s thyroiditis present, a known cause of a benign nodular goitre.  Fine needle biopsy for histopathology is also used.

Thyroid nodules are extremely common in young adults and children. Almost 50% of people have had one, but they are usually only detected by a physician during the course of a health examination or fortuitously discovered during the investigation of an unrelated condition.

Ultrasound imaging is useful as the first-line, non-invasive investigation in determining the size, texture, position, and vascularity of a nodule, accessing lymph nodes metastasis in the neck, and for guiding fine needle aspiration cytology (FNAC) or biopsy. Ultrasonographic findings will also guide the indication to biopsy and the long term follow-up. High frequency transducer (7–12 MHz) is used to scan the thyroid nodule, while taking cross-sectional and longitudinal sections during scan. Suspicious findings in a nodule are hypoechoic, ill-defined margins, absence of peripheral halo or irregular margin, fine, punctate microcalcifications, presence of solid nodule, high levels of irregular blood flow within the nodule  or “taller-than-wide sign” (anterior-posterior diameter is greater than transverse diameter of a nodule). Features of benign lesion are: hyperechoic, having coarse, dysmorphic or curvilinear calcifications, comet tail artifact (reflection of a highly calcified object), absence of blood flow in the nodule, and presence of cystic (fluid-filled) nodule. However, the presence of solitary or multiple nodules is not a good predictor of malignancy. Malignancy is only diagnosed when ultrasound findings and FNAC report are suggestive of malignancy. Another imaging modality, which is ultrasound elastography, is also useful in diagnosing thyroid malignancy especially for follicular thyroid cancer. However, it is limited by the presence of adequate amount of normal tissue around the lesion, calcified shell around a nodule, cystic nodules, coalescent nodules.

Fine Needle Aspiration Cytology (FNAC) is a cheap, simple, and safe method in obtaining cytological specimens for diagnosis by using a needle and a syringe.  The Bethesda System for Reporting Thyroid Cytopathology is the system used to report whether the thyroid cytological specimen is benign or malignant.

Risks for cancer

Solitary thyroid nodules are more common in females yet more worrisome in males. Other associations with neoplastic nodules are family history of thyroid cancer and prior radiation to the head and neck. Most common cause of solitary thyroid nodule is benign colloid nodules and second most common cause is follicular adenoma.

Radiation exposure to the head and neck may be for historic indications such as tonsillar and adenoid hypertrophy, “enlarged thymus”, acne vulgaris, or current indications such as Hodgkin’s lymphoma. Children living near the Chernobyl nuclear power plant during the catastrophe of 1986 have experienced a 60-fold increase in the incidence of thyroid cancer. Thyroid cancer arising in the background of radiation is often multifocal with a high incidence of lymph node metastasis and has a poor prognosis.

Investigations

  • TSH – A thyroid-stimulating hormone level should be obtained first. If it is suppressed, then the nodule is likely a hyperfunctioning (or “hot”) nodule. These are rarely malignant.
  • FNAC – fine needle aspiration cytology is the investigation of choice given a non-suppressed TSH.
  • Imaging – Ultrasound and radioiodine scanning.

Thyroid scan

85% of nodules are cold nodules, and 5–8% of cold and warm nodules are malignant.

5% of nodules are hot. Malignancy is virtually non-existent in hot nodules.

Surgery

Surgery (thyroidectomy) may be indicated in the following instances:

  • Reaccumulation of the nodule despite 3–4 repeated FNACs
  • Size in excess of 4 cm in some cases
  • Compressive symptoms
  • Signs of malignancy (vocal cord dysfunction, lymphadenopathy)
  • Cytopathology that does not exclude thyroid cancer

Ultrasound

An alternative using high intensity focused ultrasound or HIFU has recently proved its effectiveness in treating benign thyroid nodules. This method is noninvasive, without general anesthesia and is performed in an ambulatory setting. Ultrasound waves are focused and produce heat enabling to destroy thyroid nodules.[22]

Focused ultrasounds have been used to treat other benign tumors, such as breast fibroadenomas and fibroid disease in the uterus.

Treatment

Levothyroxine is a stereoisomer of thyroxine which is degraded much slower and can be administered once daily in patients with hypothyroidism.

source Wikipedia

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