Management of Thyroid Nodules

Question 1

‘Nodule’

Answer 1

Growth of abnormal tissue – typically firm and palpable

Question 2

‘Thyroid nodule’ >1 cm

Answer 2

And difficult to palpate until >2 cm unless on the thyroid surface & thin neck

Question 3

‘Small thyroid lesions’ < 1 cm

Answer 3

Only radiologically detectable (clinically undetectable)

Question 4

Thyroid- Follicular cells / ‘Thyrocytes’

Answer 4

-> Thyroglobulin

Question 5

Thyroid- Para-follicular cells / ‘C-cells’

Answer 5

-> Calcitonin

Question 6

Thyroid- Colloid / thyroglobulin store
Iodination in colloid

Answer 6

-> Thyroxine

Question 7

Thyroid- Lymphocytes

Answer 7

Any lymphocytes are infiltrative

Question 8

Thyroid cancers (4)

Answer 8

1% of cancers - 20th most common

Most common endocrine neoplasm

Increasing incidence (175% since 1990)
5 per 100,000 women
2 per 100,000 men

Question 9

Risk Factors (8)

Answer 9

FHx Thyroid cancer
Female
Age
Radiation/Radioiodine
Non-smoker
Obesity
prexisting thyroid disease
Genetics (MEN, Cowden, DICER)

Question 10

History taking - neck symptoms (5)

Answer 10

Lump size, pain, soft/hard, mobile

Duration / growth rate

Voice / Stridor

Swallow

Other lumps

Question 11

History taking - other (4)

Answer 11

Systemic symptoms? – Think excess thyroxine or PTH

PMHx – Metastatic spread to thyroid or neck

Thyroxine & rapidly enlarging mass? Consider thyroid lymphoma

Thyroid cancer in the family tree? Cancers or MEN syndromes?

Question 12

Examination- inspect (2)

Answer 12

Inspection= Eyes + Neck

Question 13

Examination- feel neck triangle (3)

Answer 13

Feel Neck Triangles / Lymph Nodes=

-Bony landmarks,
-Anterior vs Posterior
-Levels: 2,3,4 lateral nodes

Question 14

Examination- feel thyroid gland (6)

Answer 14

Feel Thyroid gland =
-Nodule/mass size & shape

-consistency

-mobility/fixity to other structures,

-pulsatility

-tenderness

-Thyroid symmetry, lower edge ?retrosternal, skin surface

Question 15

examination other (3)

Answer 15

Tongue protuberance - Thyroglossal duct cyst

Drinking water

Pemberton’s sign

Question 16

Blood tests

Answer 16

-TSH
-Calcium

Question 17

Thyroid imaging- US (6)

Answer 17

Ultrasound – nodule size, number, shape, background thyroid, nodes

U1 – Normal
U2 – Benign
U3 – Indeterminate / Equivocal
U4 – Suspicious
U5 – Malignant

Question 18

Imaging- Radioisotope scan (3)

Answer 18

If TSH suppressed (< 0.4 mlU/L

Hot nodule - Toxic adenoma

Cold nodule

Question 19

Imaging- CT (4)

Answer 19

Selected cases: Symptoms of
-extra-thyroidal extension (voice change)
-neck nodal disease on ultrasound
-suspicion of lung/bone/brain mets

Question 20

Thyroidectomy- surgery indications (6)

Answer 20

Thyrotoxicosis
eg. Graves’ disease, Toxic nodule, Toxic multinodular

Compression symptoms from >3cm nodule – swallowing / breathing

Indeterminate nodule for ?cancer diagnosis + treatment….

Question 21

Thyroidectomy- cancer (3)

Answer 21

Thyroid cancer & indeterminate nodule surgery

Lobectomy / Hemithyroidectomy if <4cm, or if diagnostic doubt (eg. Thy3 or Thy4)

Total thyroidectomy if Thy5 nodule >4cm, extrathyroidal extension, nodal disease or thyroid metastasis

Question 22

Complications of thyroid surgery (11)

Answer 22

Seroma
Superficial haematoma
Hypocalcaemia
Voice changes
Scar
Wound infection
Nerve injury
Chyle leak
Tracheal / Oesophageal / Blood vessel injuries
Stridor
Tracheostomy need

Question 23

What about benign nodules? (3)

Answer 23

Surgery - if compressive symptoms

Ultrasound Surveillance - if small & low cancer risk

Thyroid Ablation options (new) – Radiofrequency (solid), Ethanol (cystic), & other options