Thyroid Nodules and Thyroid Cancer - Dr Torres-Holmes

When a mass is in the lower neck around the midline, the thyroid gland is the most likely organ involved. The causes are mostly either inflammatory (a thyroiditis either from Grave’s or Hashimoto’s disease), or neoplastic (either benign or malignant). 

After a good history and examination the first test is usually the thyroid function TSH and T3, T4 blood test. I don’t do all the antibodies tests personally and leave that to the endocrinologists if the TFTs are abnormal. A thyroid ultrasound is often the next test while nuclear medicine thyroid scans are rarely indicated. In general any inflammatory causes causing thyroid function abnormalities are managed either by general practitioners or endocrinologists. Head and neck surgeons generally manage nodules and tumours.

By the time a patient sees me they often have a normal thyroid function test and the thyroid ultrasound shows a nodule/s. These nodules may have been incidentally picked up on ultrasound when the patient has investigations for other reasons, such as a mammography. These ‘incidentalomas’ are the reason that the incidence of nodules, both benign and malignant in the thyroid gland are increasing worldwide. Nodules beyond 10mm in size with some worrying features on an ultrasound require a fine needle aspiration biopsy under ultrasound guidance. These cells have to be interpreted by an experienced cytologist and classified correctly according to the TIRADS classification.

Thyroid nodules are very common especially in women and 80% are benign. Accurate ultrasounds and fine needle aspiration biopsies have significantly decreased the need for thyroid surgery. Of course large benign masses can be cosmetically unsightly and when big, compress the airway or swallow-way which require surgery, but it’s the 20% risk of cancer that mostly worries patients. The good news is that malignant neoplasms are mostly well differentiated papillary or follicular carcinomas and have an excellent prognosis. The bad news is that rapidly growing thyroid masses could be a poorly differentiated thyroid cancer or anaplastic cancer which has a very poor prognosis. Early diagnosis is important. 

For thyroid cancers, we make management decisions in a multidisciplinary team in order to achieve the patient's desired and optimal outcomes. Treatment for thyroid cancer almost always involves surgery, either a lobectomy or total thyroidectomy, and the need for radioactive iodine ablation postoperatively depends on both tumour and patient factors. We risk-stratify patients based on certain prognostic factors to determine their risk of having recurrent disease. 

Thyroid surgery should be performed in high volume centres by head and neck surgeons, trained either as otorhinolaryngologists or general surgeons, working in a multidisciplinary team. The larynx needs to be examined before and after surgery to assess the function of the recurrent laryngeal nerves. If the nerve is either damaged preoperatively by tumour or permanently by the surgeon intraoperatively, medialisation thyroplasty techniques will need to be considered to improve quality of life for voice and swallowing. Another important structure to preserve during thyroid surgery are the four parathyroid glands. These control the use of calcium in the body. 

Surveillance of thyroid cancer usually involves serial blood thyroglobulin measurements and thyroid ultrasounds looking for thyroid bed recurrences or nodal and distant metastases. If present these are usually treated surgically but new modalities are always being developed to help better control these common head and neck cancers. 

Please feel free to contact the rooms to make an appointment for an opinion in order to gain clarity. 

Image: National Human Genome Institute