SOLITARY THYROID NODULE APPROACH

History The most common presentation for a thyroid nodule is?

A swelling noticed by the patient or by family and friends

But if its not apparent how will it present?

Pressure symptoms is 1 way like (dysphagia, dyspnea,

stridor, engorged neck veins or even ear pain and change

in voice)

Symptoms of hyper or hypothyroidism

(change in weight, heat or cold intolerance, change in

bowel habits, sweating,…….so on)

Take history like normal history of onset, change in size,

associated symptoms, pain

Our history should focus

on

•Any family history of thyroid disease

•Drug history

•And very important to ask about any history of

radiation ( keeping in mind risk of papillary carcinoma

is highly increased with radiation)

Now we exam our

patient

•Never forget to make sure is it thyroid? Or a neck

swelling?

• give the patient a sip of water if it moves upward on

swallowing its attached to the thyroid, by?

•Pretracheal fascia

•After confirming its of thyroid origin, we do our full

exam of a mass first inspect, then palpate (percuss

also), then auscultate)

•And never miss any extra thyroid signs, neurological

exam (reflexes, tremor)

•LYMPHNODES!!!

Extrathyroid? •Graves disease:

•Exophthalmos

•Lid retraction

•Inflamed eyes

•Double vision

•Pretibial myxedema (non pitting, reddening and thickening of skin)

•Lid lag

•Hypothyroid:

•Puffy face

•Myxedema (nonpitting)

•Dry skin, coarse hair

•Bradycardia

•Loss of lateral 1/3 of eyebrow

•Hoarseness, slurred speech

•Hyperthyroidism: tachycardia, palpitations and might even cause CHF

Before we continue

lets take a minute

•Goiters can be classified in different ways:

•Benign or malignant

•Simple or toxic

•Diffuse or nodular (multinodular or solitary)

Investigate •Thyroid function tests

•Measure free t3, t4, TSH

•In thyrotoxicosis? TSH totally suppressed

•In hypothyroidism? Elevated

•Some things to keep in mind is in pregnancy or

estrogen administration increases the level of thyroid

hormone (increase thyroid binding globulin) in blood so

it makes it harder to diagnose

•So we use the T3 radioactive uptake

investigate •TRH and TSH stimulation tests

•to determine the site of failure of production of thyroid hormone

•Calcitonin levels are of importance too especially in diagnosis of medullary carcinoma

•Lets not forget men2 syndrome

•Men2A (medullary carcinoma of the thyroid, pheochromocytoma, parathyroid hyperplasia or

adenomas)

•Men2B (medullay carcinoma, pheochromocytoma, and neuromas (mucosal and intestinal)

Back to investigations

•Thyroid antibodies

•1-anti thyrocyte peroxidase antibody and anti

thyroglobulin antibody (hashimoto thyroiditis)

•2-thyroid stimulating immunoglobulin (graves disease)

•And Radioisotope scanning (I123):

•To differentiate between hot and cold nodules

•If we have a solitary hot nodule it’s a toxic adenoma

•If its cold we have multiple options (malignancy,

benign, cyst)

•ultrasound and FNA

•FNA is best for discrete nodules

investigate •And we cant not mention MRI, CT, PET scan

•But they aren’t in the routine assessment of a thyroid

swelling

•Mostly for assessment of a known malignancy, extent

of a retrosternal mass, staging, or vascular invasion

(MRI)

•Now lets put things in a better way (more focused on a

solitary nodule)

First keep in mind

•Is benign or malignant?

•Benign like: cyst, follicular adenoma (either toxic or

simple), thyroditis

•Malignant like: medullary, follicular, papillary,

anaplastic, maybe lymphoma)

So like we said history

So you’ve asked about everything we already said, family history, radiation, symptoms of hyper or hypo thyroid,…

Now u should pay attention to some stuff that might suggest a malignancy

Rapidly progressive

Young less than 15, or old over 65

Pain doesn’t suggest malignancy but if present doesn’t exclude malignancy (medullary cancer can cause dull aching

pain)

Hoarseness is worrisome because it indicates malignant involvement of recurrent laryngeal nerve

If patient comes with painful thyroid you suspect subacute thyroiditis, so we ask about?

History of upper respiratory infection (virus) and fever

Pain in thyroid: Medullary cancer Bleeding in thyroid Cyst Subacute thyroditis

Physical exam

•On inspection or palpation we also have signs the

should suggest to us malignancy

•Firm

•Fixed

•Irregular margins

•Cervical lymphadenopathy

investigate •Like we said our first investigation Is TFT, and this will

direct us to what to do next

•If the patient has low TSH it indicates that the nodule is

secreting thyroid hormones on its own so we should

further investigate by radio isotype:

•If we get a hot nodule it’s a toxic adenoma (almost

never malignant)

•If its cold we should do ultrasound and FNA

•On the other hand if we have normal or elevated TSH

we don’t do radio isotype we go directly to ultrasound

and FNA

Last thing: ultrasound

•Ultrasound often reveals multinodular goiters rather

than solitary nodules, so to know the size and number

of nodules

•To know is it cystic or solid

•And make a guess on how malignant is it

•It can be used as guidance for FNA for accurate

sampling

•Might reveal features suggesting malignancy:

•Microcalcifications

•Irregular margins

•Intra nodular vascular spots

•Hypo echogenicity within the nodule

Management Mainly depends on the cytology results from FNA

Malignancy needs surgical intervention depending on

type of cancer

Benign lesions might be left alone and monitored if

asymptomatic or surgically removed if symptomatic

About 30% of FNA turn out to be cysts and we just drain

them, but re accumulation is common

We surgically remove cysts if its growing or painful