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Thyroid Nodules

The thyroid is a butterfly shaped gland in the neck. It produces thyroid hormone, which helps control your body's energy use (metabolism). Occasionally some of the thyroid tissue can begin to grow and form a lump or nodule. Approximately 3-7% if the population has a thyroid nodule.


A nodule may be cystic (contains fluid) or solid (made of thyroid tissue). There may be one nodule or many and they can vary in size. Many people with a nodule do not have symptoms and are unaware of the nodule until the doctor discovers one on a routine physical exam.  However, some nodules may secrete more thyroid hormone than the body needs and cause symptoms of hyperthyroidism.  Rarely, nodules can become large enough to cause difficulty swallowing or changes in voice.  While the majority of thyroid nodules are non-cancerous, approximately 10% of nodules contain cancerous cells.  It is therefore important to have any lumps or nodules evaluated by a doctor.


Types of Thyroid Nodules
Thyroid Cysts:


  • A cyst is a closed sac filled with fluid or semi-solid material that is lined by a membrane of cells (called the cyst wall).  Cysts can be simple or complex.  A simple cyst contains a cavity of fluid surrounded by a ring of cells.  A complex cyst may contain both fluid and solid components.  Simple cysts are almost always benign; complex cysts have a higher risk of being cancerous.
  • Colloid nodules are made up of thyroid cells surrounding collections of stored thyroid hormone.

Inflammatory Nodule
These nodules result from inflammation in an area of the thyroid gland (thyroiditis).  These nodules may be painful or painless.  If left untreated, an inflammatory nodule may become an abscess.


Neoplasms (Tumors) are masses of abnormal tissue growth.  They can be malignant (cells may spread to other areas of the body) or benign

Benign Neoplasms:
Benign (non-cancerous) nodules are overgrowths of normal thyroid tissue.  They may grow in size but will not spread from the thyroid gland. 


  • Follicular adenoma is a mass of thyroid cells
  • Multinodular Goiter is the term used to describe multiple nodules throughout the thyroid that lead to an overall enlargement of the thyroid gland (goiter).  If the thyroid gland becomes too large, it may obstruct the airway or cause difficulty swallowing.

Malignant Thyroid Nodules  (Thyroid Cancer):
Approximately 10% of thyroid nodules are malignant (contain cancer cells).  
There are four types of thyroid cancer. 


  • Papillary thyroid cancer is the most common type
  • Follicular thyroid cancer
  • Medullary thyroid cancer
  • Anaplastic thyroid cancer. 

Additionally, cancers from other areas of the body may spread to the thyroid gland.


Risk Factors:
Risk factors for the development of nodules


  • A close family member (parent, sibling) with nodules
  • Increasing age
  • Female gender
  • Radiation to the head or neck
  • Some thyroid conditions (i.e. thyroiditis)

Risk factors for thyroid cancer


  • Age between 20 and 60
  • Diet low in iodine
  • Female Gender
  • Inheriting an abnormal gene
  • Previous radiation to the head and neck


Symptoms:
Most thyroid nodules cause no symptoms.

Other thyroid nodules cause symptoms such as:


  • A lump in the neck that can be seen or felt
  • Anxiety
  • Difficulty sleeping
  • Excessive sweating
  • Fast or irregular heartbeat
  • Heat intolerance
  • Nervousness
  • Weight loss, despite eating normally
  • Pain in the front of the neck

Although nodules are rarely cancerous, a nodule is more likely to be malignant if the following symptoms are present:


  • Breathing problems
  • Difficulty swallowing
  • Hoarseness or other voice change
  • Lump or swelling in the neck that may grow rapidly in size
  • Pain the front of the neck
  • Enlarged lymph nodes under your jaw or neck

Diagnostic Studies:
When suspecting a thyroid problem, your doctor will take a medical history and perform a physical examination.  If the doctor feels any lumps or nodules in your neck, he or she may perform additional tests to determine the type of nodule.  The main goal of diagnostic studies is to distinguish a begin nodule that does not need further treatment from a malignant nodule, which requires further treatment.


Diagnostic tests may include:


  • Blood tests to measure thyroid hormone level.  These tests are usually normal
  • An ultrasound of the neck enables the doctor to see the size and location of nodules as well as identify any additional nodules which could not be felt on physical exam.  An ultrasound only shows an image of the nodule and cannot determine whether a nodule is benign or malignant.
  • Fine needle aspiration biopsy is the most important test performed to identify the type of nodule.  This procedure is done in the doctor’s office using a thin, hollow needle to remove a sample of cells or fluid from the nodule.  An ultrasound machine may be used to guide the placement of the needle.  The cells or fluid collected will be examined under a microscope by the pathologist. 
  • Magnetic resonance imaging (MRI) scan may be done to evaluate the size and location of nodules along with other structures in the neck.  MRI is reserved for large and malignant tumors.
  • Thyroid Scan is a test that is rarely performed today.  This test involves taking a small amount of radioactive iodine followed by thyroid imaging to determine if the nodule is taking up iodine (which it uses to make thyroid hormone).   This test cannot determine whether a nodule is benign or malignant.

Treatment
Treatment of benign thyroid nodules will be based on the type of nodule.


  • Follow-up
    • If the fine needle biopsy shows cystic fluid or colloid material, the doctor may prescribe follow-up at regular intervals.  This usually involves having a physical exam to determine if the nodule has enlarged and blood tests to determine if the nodule is producing any hormones.
  • Medical Therapy
    • Thyroid hormone suppression therapy may be prescribed to decrease the amount of thyroid hormone produced by the nodule and possibly decrease the growth of the nodule.

  • Surgical Therapy
    • If the needle biopsy shows that the nodule is solid and may represent a tumor, surgery is indicated.  Sometimes the fine needle biopsy cannot determine whether the nodule contains cancerous cells.  In these cases the doctor may surgically remove the entire nodule to examine its contents in the laboratory and make a diagnosis. 
    • In addition to the general risks of all operations, surgery involving the thyroid gland can cause temporary or permanent hoarseness and damage to the parathyroid glands (glands that regulate the body’s calcium levels), which are located very close to the thyroid gland.  New techniques are used during surgery to minimize these risks.  The nerves to the vocal cords are monitored to prevent damage that will cause hoarseness.  Sophisticated techniques are used to identify the parathyroid glands during surgery to prevent damage or removal.
    • If the thyroid gland is partially or fully removed, lifelong, daily thyroid hormone supplements will be required.

Treatment of malignant thyroid nodules:
If a diagnosis of thyroid cancer is made, your doctor will design a treatment plan that is specific for your needs and type of cancer.  The first treatment is often surgical removal of the thyroid gland.  Additional therapies include radioablation of the thyroid gland with administration of a small dose of radioactive iodine.  The treatment is fairly safe and simple.  In rare cases chemotherapy or radiation may be necessary.


Prognosis
Most benign thyroid nodules do not cause symptoms and are not life-threatening.  Occasionally, benign nodules can produce too much thyroid hormone, leading to hyperthyroidism or thyrotoxic crisis (a life-threatening sudden, severe worsening of symptoms leading to rapid heart beat, high body temperature and even delirium, which needs immediate medical attention)


The prognosis of thyroid cancer is very good.  When cancer is diagnosed, a doctor will determine the stage of the cancer in order to design a treatment plan and discuss the prognosis for recovery.  Staging of thyroid cancer is determined by several factors including:


  • Age (age < 40 carries a better prognosis)
  • Grade of tumor cells, determined by examining the cells under a microscope
  • Extent of tumor spread to areas outside of the thyroid gland
  • Size of tumor

Even after thyroid cancer treatment, it is possible for cancer to return.  It is necessary to follow up regularly with your doctor.


Sources:
Mayo Clinic. Thyroid Nodules
http://www.endocrine.niddk.nih.gov/pubs/Hyperthyroidism/Hyperthyroidism.pdf
National Cancer Institute.  Thyroid Cancer
http://www.cancer.gov/cancertopics/wyntk/thyroid/page5
NIDDK. Hyperthyroidism
http://www.endocrine.niddk.nih.gov/pubs/Hyperthyroidism/Hyperthyroidism.pdf
Medline Plus.  Thyroid Nodules
http://www.nlm.nih.gov/medlineplus/ency/article/007265.htm