Thyroid nodules

Question 1

What are thyroid nodules?

Answer 1

Abnormal growths within the thyroid gland

Question 2

Summarise the epidemiology of thyroid nodules

Answer 2

● 40% of the general population have a single nodule or multiple nodules
● More common in WOMEN
● Very small proportion of thyroid nodules will be malignant

Question 3

What are some causes of thyroid nodules?

Answer 3

● The vast majority of thyroid nodules are BENIGN, but a small proportion turn into thyroid cancer
● Most thyroid nodules are adenomatous and most are multiple
● The nodules are usually non-functioning

Question 4

What are the different types of thyroid nodules?

Answer 4

• Majority are benign, but small proportion turn into thyroid cancer
  1. Benign → thyroid adenoma, thyroid cyst, multinodular goitre, Hashimoto’s thyroiditis
  2. Malignant → thyroid carcinoma:
  a. Papillary Carcinoma ⇒ most common, 30-40 yrs old, metastasis to cervical lymph nodes (contrast to follicular). Very good prognosis.
  b. Follicular Carcinoma ⇒ 2nd most common, 30-60 yrs old (typically presents later in life than papillary), more common in areas of low iodine and in women, metastasis to lung and bones.
  c. Medullary Carcinoma ⇒ cancer of parafollicular cells, secrete calcitonin, part of MEN-2

Question 5

What are the presenting symptoms of thyroid nodules?

Answer 5

● Most are ASYMPTOMATIC
● Usually found on self-examination or clinical examination – nodular goitre rather than smooth
● A single isolated nodule is more likely to be malignant
● They can sometimes cause pain and will rarely compress the trachea or cause dysphagia

Question 6

What signs of thyroid nodules can be found on physical examination?

Answer 6

● Ask the patient to drink some water and see if the nodule moves when swallowing (thyroid nodules move up on swallowing)
● Check for regional lymphadenopathy (consider malignancy)

Question 7

What investigations are used to diagnose/ monitor thyroid nodules?

Answer 7

All thyroid nodules should be investigated for malignancy
1. 1st Line Imaging → Ultrasonography (help determine if nodule has features of malignancy)
2. TFTs
3. Fine Needle Aspiration Biopsy
4. Radioiodine Uptake Scan
- Diffuse Uptake throughout enlarged gland ⇒ Grave’s Disease
- Multinodular Gland with single hot nodule, patchy uptake ⇒ Toxic Multinodular Goitre
- Diffuse Uptake with single cold nodule ⇒ Thyroid Cancer
- No Uptake ⇒ de quervain’s (viral) thyroiditis

Question 8

How are thyroid nodules managed?

Answer 8

1. Thyroid surgery
2. Papillary + Follicular Carcinoma → total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels to detect early recurrent disease.
   - Hypocalcaemia is a potential complication of thyroid surgery that can occur due to damage or removal of the parathyroid glands, which regulate calcium levels in the body. It can cause tingling in the fingers and around the mouth, muscle cramps, and spasms.
3. Treatment of Hyperthyroidism → beta blockers, anti-thyroid drugs (carbimazole)