Thyroid nodules are very common and benign in most cases. “There are no more hot flashes,” she said. Zhang F. Thyroid nodule location on ultrasonography a predictor of malignancy (poster 1204). “It can also prevent cosmetic problems or possible future discomfort.”, Lisa Orloff MD, Professor of Otolaryngology, “I was awake for the whole procedure,” she said. “We can now wait longer (2-4 years) with less frequent intervals of surveillance. Some 40% of the patients had multiple nodules.1. Malignancy was observed most often in the superior region of the thyroid gland with 22% of nodules found in the upper lobes as compared to 14% in the middle pole, and just 5% in the inferior poles.1 Using a multiple logistic regression model to adjust for the number of thyroid nodules, age, sex, BMI, and laterality, a strong association between nodule location and presence of cancer was confirmed. Some nodules can become toxic, like O’Brien’s, secreting unwanted hormones that can cause a variety of symptoms, including a racing heart, difficulty sleeping, anxiety and irritability. Serum Markers. Stanford Health Care seeks to heal humanity through science and compassion, one patient at a time, through its commitment to care, educate and discover. “They told me they needed to take my thyroid out,” she said. Patients usually return home or … Thyroid nodules can be detected by ultrasonography in up to 68% of the general population. Treatment for nontoxic goiter will depend on the size, location, and presence of symptoms (respiratory or causing patient discomfort). Abnormalities detected by ultrasound, nodules are particularly common in the thyroid gland. LA was more effective in patients with spongiform nodules as compared to mixed (P≤0.01) and compact (P≤0.001) nodules. In 33 solid nodules, volume decreased from 26.4±24.5 ml to 17.9±22.0 ml, with a reduction of −26.8%. Access your health information from any device with MyHealth. Pattern 2. Although the vast majority of thyroid nodules are benign (noncancerous), a small proportion of thyroid nodules do contain thyroid cancer. First, the hot flashes began to lessen in both intensity and frequency. If the doctor recommends removal of your thyroid (thyroidectomy), you may not even have to worry about a scar on your neck. “Growth is not associated with thyroid cancer,”3,4 said Dr. Lee. Follow-up with ultrasonography seems to be an efficacious method even for spongiform nodules larger than 2 cm. 1B —Sonographic criteria for benign thyroid nodules described by Bonavita et al. AACE 27th Annual Scientific & Clinical Congress, Addressing the Complexity of Thyroid Disease Management During Pregnancy, Clinical Takeaways: Microvascular Risk, Metabolic Disease, Continuous Glucose Monitoring, Laterality of nodule location: left, isthmus, right, Polarity of nodule location: superior lobe, middle, lower, Results of fine needle aspiration (FNA) biopsy (1, 2 or more benign findings? For more information, visit: https://www.stanfordhealthcare.org. “Stay connected to your scans to better advise your patient,” said Dr. Lee. Also peripheral flow is also an indicator of benign nodules, it is internal flow that is worrisome. Difficulty swallowing. In fact, no follow-up is necessary for nodules smaller than 1 cm according to the American College of Radiology guidelines.”5 If there is any tracheal obstruction with symptoms, refer for surgery. Pure cysts over 1.5–2 cm are rare, comprising <2% of all thyroid nodules, but if present, these are reported to always be benign (Fig. Even a benign growth on your thyroid gland can cause symptoms. Another important tip for clinicians. “But the irritability started to interfere with my marriage and my patience with my two kids. Learn about potential causes of thyroid nodules, from benign tissue overgrowth to cancer. With Fan Zhang, MD, PhD, and Stephanie L. Lee, MD, PhD. Endocrine Web is a Remedy Health Media, LLC web property. Over the next eight years, after her neck injury was long forgotten, those nodules grew into a goiter-sized lump that protruded from her neck and caused a range of symptoms, including explosive anger, fatigue, muscle weakness and hot flashes. If all nodules are similar on sonography, biopsy the largest one; however, it’s more important to identify the highest risk nodule (ie, diffuse goiter, indistinct margins) to biopsy rather than the largest one. Surgery. Thyroid nodules were assessed for the following characteristics: Nodules were evenly distributed between the right lobe (47 percent) and left lobe (50.5 percent), with the rest of the nodules located in the isthmus (2 percent). They may be obvious to the naked eye or can be found incidentally by Thyroid Nodules •Prevalence depends on population and method of detection –U.S. Stanford Health Care delivers clinical innovation across its inpatient services, specialty health centers, physician offices, virtual care offerings and health plan programs. So I started going to see doctors. Finally, it did. TSH measurement should be part of the initial workup in every patient with a thyroid nodule and be used as a guide for further management (Fig. You can message your clinic, view lab results, schedule an appointment, and pay your bill. It has a right and left lobe, connected by the isthmus, which is like a bridge. population ages 30-60 yrs, 6.4% of women and 1.5% of men possess palpable thyroid nodules –Finnish population ages 19-60 yrs, 27% possess thyroid nodules via neck ultrasound –60% of the elderly (>70 yrs) possess nonpalpable thyroid nodules on autopsy Enlargement of the thyroid (goiter) and lumps within it (nodules) are both relatively common. “In fact, suspicious features on imaging offer the best indicator of a missed malignancy,” she said, with further evaluation needed when a nodule shows irregular margins on non-contrast CT scan that is located below the trachea,” she said. Treatment for a benign thyroid nodule may range from close monitoring to … Presented at the AACE 2018, the 27. . The investigators proposed that the reason for the increased risk of malignancy in the superior poles may be due to anatomy. The estimated risk of malignancy and the presence of symptoms, particularly compressive symptomatology are indicative of the need for further management. And I was hot, hot, hot. “While substantial evidence supports the use of rhTSH stimulated I-131 treatment rather than I-131 alone, this approach remains off-label in the US,” Dr. Lee said. The procedure, which was led by surgeon Lisa Orloff, MD, professor of otolaryngology, with Noel assisting, took less than an hour. pertaining to thyroid assessment and length of time needed for monitoring. Therefore, follow-up is not necessary for thyroid cancer, just for growth, according to Dr. Lee. Despite benign biopsy (Bethesda II) findings, those thyroid nodules with “high suspicion” should have a repeat ultrasound and FNA biopsy within one year for indeterminate nodules or those with some suspicion of malignancy,5 the recommendation is to repeat the biopsy or continue active surveillance for growth or detection of new suspicious feature at 12 to 24 months. ... to guide treatment when aspiration yields an indeterminate result. They are relatively common, and, in most cases, their cause is unknown, Noel said. Haugen, et al. “Medical management of goiters and benign cytology on ultrasound and molecular markers rule out malignancy with a risk of error of 1-3% with errors. ), Indeterminate cytology and benign molecular test findings. When cystic portion of nodule is subtracted, spongiform nodule, or type 1 nodule, remains. Treatment for simple, nontoxic goiter will depend on the presence of any symptoms, if any, size, location, any compression of trachea but when with concerns, management should be to monitor for growth and development of hyperthyroidism.7. conditional upon your acceptance of our user agreement. Earlier this year, O’Brien became the first patient at Stanford Health Care to undergo a nonsurgical treatment, recently approved by the Food & Drug Administration for benign thyroid nodules, called radio-frequency ablation. If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. To the point where I wanted to scream. “In addition, for non-suspicious nodules—such as those with an absence of hypoechogenicity, irregular margins, taller than wider shape, asymmetry, these warrant observation without biopsy as a reasonable option.”. It also allows for ultrasound-guided fine-needle aspiration of selected nodules. They can also become unsightly goiters, which are groupings of several nodules that bulge from the neck. If a doctor suspects that a thyroid nodule may be cancerous, they will recommend additional testing, such as blood tests and biopsies. “It’s based on radio-wave technology that has already been used in the U.S. to treat bone, lung, liver and kidney tumors,” Noel said. Most nodules (79 percent) were located in the inferior poles with just 7% in the middle pole. Those patients rarely have thyroid cancer, and 80% of nodules over five years are stable or smaller with growth a very poor predictor of malignancy,” she told EndocrineWeb. “There was some pressure, but not really any pain.”, Doctors, Clinics & Locations, Conditions & Treatments, View All Information for Patients & Visitors ». Further gradual shrinkage can be expected for up to 12 months from the time of the surgery. Table 1: Recommendations for Management of Benign Thyroid Nodules. You can do this by naturally increasing your free T3 levels with the use of supplements or other therapies, by reducing inflammation in your body, and by changing up your diet (to exclude foods such as dairy which can block thyroid function). Immediately, the size of the goiter on her neck was significantly smaller, she said. Ultrasound scan of 49-year-old man with colloid cyst shows cyst with colloid clot. Get the Android MyHealth app ». About 50% of people in the U.S. over the age of 60 have at least one nodule. “I’m usually a bubbly, happy person,” she said. “The trick is not to mistake spongiform nodules, which make up about 10% of thyroid nodules and are benign, with microcalcifications,” Dr. Lee said. As thyroid nodules are commonly incidental, there are numerous classification systems to … Use of this website is If the second biopsy returns a benign cytology, then a repeat ultrasound is no longer indicated;2 however, “in my patients, I would likely follow the nodule for growth around 18 to 24 months,” Dr. Lee said. Pulmonary function tests should be ordered to rule out asthma. She kept putting off the surgery hoping that a better option would emerge. The probe is activated via a foot pedal, triggering radio waves that send an electrical current through the probe; the heat then destroys tissue of the nodule. A benign thyroid nodule is a noncancerous mass that originates from within the thyroid gland just above the sternum. The doctor uses a very thin needle to withdraw cells from the thyroid nodule. As a rule multiple nodules are more apt to be benign as opposed to a single cold nodule in males. Lee SL. Isoechoic spongiform nodules, either confluent or with regular halo. Health Media & EndocrineWeb do not provide medical advice, diagnosis or treatment. Thyroid fine needle aspiration biopsy (FNAB): a simple procedure that is done in the doctor’s office to determine if a thyroid nodule is benign (non-cancerous) or cancer. Thyroid nodules may be solid, cystic (fluid filled), or a combination of both and can develop in any location within the thyroid gland. ‘A safe, less invasive way’ “I had kind of missed it.”. The size of your thyroid nodule is greater than 2.0 cm or 20 mm (a size greater than 1.0 cm or 10 mm may also be worrisome as well) Unexpected weight loss. Thyroid nodules are lumps in or on the thyroid gland. Presentation. Earlier this year, O’Brien became the first patient at Stanford Health Care to undergo a nonsurgical treatment, recently approved by the Food & Drug Administration for benign thyroid nodules, called radio-frequency ablation. The tech does the radiography, and the radiologist may read the findings but neither has ever met your patient so by viewing the scan yourself, you can more confidently respond to patients questions and address any concerns directly, she said. Symptoms such as throat clearing, difficulty swallowing, or a light cough following a change in position are often the first sign of malignancy,” Dr. Lee said. A rule of thumb, is “thyroid nodules that tend not to grow are usually those which are small (< 1 cm) or large (> 4 cm or > 30 mL). Stanford Head & Neck Cancer Program offers highly experienced doctors, personalized clinical care and treatment, and leading edge clinical research. Fig. Most nodules form due to an atypical thyroid condition or chronic disease. In assessing thyroid nodules for risk of malignancy, findings from a ground-breaking study utilizing ultrasound imaging offered compelling evidence that the location of nodule was predictive of malignancy,1 according to poster author, Fan Zhang, MD, PhD, a resident in internal medicine at Brookdale University Hospital and Medicine Center in Brooklyn, New York. The difference in nodules' reduction between solid and spongiform nodules was significant from 3 months (p = .04) and became even more significant up to 48 months (p = .001). For years she prayed for healing, then, last year, she joined a support group on Facebook for people with benign thyroid nodules where she learned about a new procedure called radio-frequency ablation. Determination of soft appearance according to colour map on ultrasound elastography and low strain ratio values of dominantly solid areas may be useful to avoid unnecessary biopsies. Treatment and prognosis. Hoang JK, Langer JE, Middleton MD. Most thyroid cancers are curable. American Thyroid Association Guidelines on Nodules and Cancer. Medications helped some, but the best available treatment option was the surgical removal of the thyroid, an important gland that secretes hormones controlling the body’s metabolism. 650-498-6000, “It’s definitely helped a lot,” O’Brien said three months after the procedure. At the time, she was 24 and had no idea what that even meant. “I’m still struggling with up and down mood swings, but I’m going on walks every night with my kids, pulling them in a wagon that my aunt bought them. risks of a procedure for a given patient. jetmech313. 7.3d). Thyroidologist: A thyroidologist or endocrinologist is best qualified to evaluate and advise you about your thyroid status and ultrasound findings and to determine whether a needle biopsy and/or referral to a thyroid surgeon is advisable. Given that most thyroid nodules are benign, the clinical challenge becomes one of discerning when to maintain surveillance of a nodule and when to stop,2 said Stephanie L. Lee, MD, PhD, professor of medicine and director of the Thyroid Health Center at Boston Medical Center in Boston, Massachusetts in a pre-conference symposium on Clinical thyroidology—Beyond the Basics, at AACE 2018 in Boston, Massachusetts. “I could see that notch in my neck,” she said, referring to her Adam’s apple. However, a minority of these nodules can be aggressive cancers that require treatment. When thyroid tissue grows abnormally, it creates a nodule, or lump. “This study demonstrates that nodules located in the upper pole present a higher malignancy risk factor and, therefore, location of thyroid nodules may need to be included in ultrasound classification guidelines to enhance the predictive value of malignancy, diagnostic accuracy and reliability as an indicator to perform FNA,” said Dr. Zang, in presenting his results.1. Thyroid nodules with benign findings at cytologic examination: Results of long-term follow-up with US. The results of a retrospective study of 219 patients who had undergone biopsy with fine needle aspiration suggested that thyroid nodules found in the superior pole appeared to confer a four-fold higher risk of cancer than other regions of the thyroid gland.1 Thirty-one patients with benign (Bethesda II) nodules were followed for observation but excluded from the final analysis. Cibas ES, Ali SZ. Jetmech. “But I was scared to take out something that should be there.”. Still, benign nodules can wreak havoc, she said. If the nodules are not cancerous, you and your doctor may decide that you don’t need to... Radioactive iodine. The Diagnosis, Meaning, and Treatment of Thyroid Nodules. The thyroid gland secretes thyroid hormones “The first question to ask the patient: where is the problem? In effect, we should operate with the understanding that risk of thyroid cancer in cytologically benign nodules— (eg, cysts, nodules > 1 cm, spongiform, or those with 2 benign cytology reports) with no suspicious characteristics 3-5%. ), Lack of growth defined as >50% change in volume or >20% increase in at least 2 dimensions of a solid nodule or solid portion of a cystic nodule (How many years…1, 2, 5? I’m a new mom.”. Unfavorable Outcomes in Solid and Spongiform Thyroid Nodules Treated with Laser Ablation. “It allows us a safe, less invasive way to intervene on a benign thyroid nodule that’s causing problems without the risks of surgery and the need for hormone therapy caused by its removal.”. Treatment for any of the above conditions may involve one or several of the following: surgery, radioactive iodine, antithyroid drug therapy or levothyroxine tablets. Another option is medication, but it must be taken long-term, so is not preferred. Thyroid nodules are growths that develop within the thyroid gland, which is located in your throat, just behind your Adam’s apple. The risk of malignancy in thyroid nodules increases as the serum TSH increases. Management of benign thyroid nodules and goiter. “Don’t biopsy the largest nodule, rather biopsy the most suspicious, she said. The procedure, which has been used for years to treat benign thyroid tumors in Korea, Italy, Brazil and a handful of other countries, involves inserting a thin, needle-like probe through the skin of the neck into the troublesome nodule, said Julia Noel, MD, assistant professor of otolaryngology at Stanford. O’Brien had two toxic nodules treated out of a total of five benign tumors on her thyroid. It has been suggested that 4-7% of the UK population have palpable nodules, with the American Thyroid Association stating that in an iodine-replete part of the world, such as the UK, 5% of women and 1% of men will have them, as will 19-68% of randomly … Most nodules and swellings are not cancerous. The 2017 Bethesda System for Reporting Thyroid Cytopathology. Kim SY, Han KH, Mood HJ, et al. O’Brien said she suffered with symptoms of irritability, hot flashes and anxiety for about a year after the car crash before she finally realized the nodules in her neck were causing these symptoms. Stanford Medicine is renowned for breakthroughs in treating cancer, heart disease, brain disorders and surgical and medical conditions. Goiters that present with no tracheal compression or extension into the trachea need no intervention. Dr. Lee offered four factors to inform clinical decision-making: In doing an initial assessment of thyroid nodules, certain imaging features such as spongiform or cystic appearance suggest a benign nodule whereas solid composition, irregular margins, the presence of microcalcifications or solid formation would suggest the need for further cytological evaluation, 3,4 said Dr. Lee. ... Benign thyroid nodules requiring treatment are rare. Check with your doctor whether your prescription is … An estimated two-thirds of adults have nodules in the thyroid gland, with most either benign or resulting in a slow-growing cancer that is not life-threatening. Differentiating between benign and malignant thyroid nodules Neither Dr. Zhang nor Dr. Lee had any financial conflicts to report. In addition, a “ spongiform appearance ” has a very low (<3%) risk of malignancy . We can treat hot nodules either with radioactive iodine therapy, which is a single dose of oral medication that destroys the over-active thyroid cells in the nodule, or by surgically removing the side with the nodule. Ultrasound is the modality of choice for diagnostic assessment of thyroid nodules 4. Thyroid nodules are lumps that occur in the thyroid gland. A thyroid nodule is a lump that can develop in your thyroid gland. As for nodules with a very low level of suspicion, the value of surveillance ultrasound is limited at best,2 said Dr. Lee. Solitary thyroid nodule. Nontoxic goiter with symptoms such as globus sensation (increased pressure on trachea/esophagus, particularly on neck flexion), respiratory symptoms (shortness of breath, cough) dyspnea on exertion, or dysphasia or those with positional stridor, Pemberton’s sign, superior vena cava syndrome, or result in voice changes should be referred to surgery,4 Dr. Lee said. Importantly, size is a poor predictor for large nodules, particularly those that extend beyond the screen. The term thyroid nodule refers to an abnormal growth of thyroid cells that forms a lump within the thyroid gland. The goal of thyroid nodule management is to design an optimal, personalized, risk-based approach that minimizes testing and unnecessary clinical intervention so active surveillance with ongoing imaging is reserved for suspicious thyroid nodules, she said. A 5-Year Follow-up Retrospective Study Endocr Metab Immune Disord Drug Targets . The first was fully ablated, and the second reduced in size. However, should the patient complain of discomfort, cough, hoarseness, treatment for a non-toxic goiter is surgical removal, she said. Although certain imaging characteristics in thyroid nodules, including micro-calcifications, hypoechoic nodules, infiltrative margins, increased vascularity, and nodules that are taller than wider, have had some evidence for increased risk of malignancy the association between malignancy and location of thyroid nodules in the thyroid gland, said Dr. Zhang. Another caveat: rule out a substernal goiter (ie, thyroid extension inferior to the sternal notch), which should be referred for surgery.4. For example, venous drainage is slower, which might cause a delay in clearing normal byproducts of metabolism, said Dr. Zang. She found herself wearing blankets at night for the first time in years, even putting on a sweater when she went out for a walk. This information is not designed to replace a physician's independent judgment about the appropriateness or How does presence multiple nodes change the course of surveillance? Also, the overproduction of hormones has begun to level out. Thyroid nodule is a discrete lesion or abnormal growth of thyroid cells that forms a lump within the thyroid gland that can be delineated on imaging studies from the adjacent thyroid parenchyma 1).Thyroid nodule may be solitary, multiple, cystic, or solid 2).Approximately 23% of solitary thyroid nodules represent a dominant nodule within a multinodular goiter 3). Changes to your voice or hoarseness when you talk. Even it is malignant, treatment and prognosis is excellent with minimal effects. They need to be watched in case they grow and start pushing on important structures. Treatment options include: No treatment/"watchful waiting." 2). ... Spongiform … Pain or discomfort in the neck area. There was no overnight stay in the hospital, and she went home to recover that same day. Obesity-Focused Pharmacotherapy: Giving Your Patients What They Need, © 2021 Remedy Health Media, LLC ALL RIGHTS RESERVED. The other changes came a bit more slowly over the early weeks as she began to heal, she said. COVID-19 Updates: COVID-19 Resources » Vaccine Update » Updated Visitor Policy » What We're Doing to Keep You Safe ». A Closer Look at the Study Design and Methodology. For the patient with a benign thyroid nodule, what criteria will best inform the need to discontinue active surveillance? Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Thyroid Findings Committee. Get the iPhone MyHealth app » With the population aging, clinicians will likely find 50-75 million thyroid nodules of which 500,000 will be biopsied, and 90% will be benign and 95% will be benign and remain asymptomatic.2. The vast majority of nodules — more than 90% — are benign. Thyroid lesions found on CT or ultrasound scan for non-thyroid reasons are the most common endocrine incidentalomas. “The hot flashes are gone and the goiter on my neck is significantly smaller.”, Julia Elizabeth Noel MD, Thyroid and parathyroid surgeon, “This new treatment is a very good option for people, like Sarah, who have these hormone-secreting nodules called toxic nodules,” Noel said. Stanford Health Care is part of Stanford Medicine, a leading academic health system that includes the Stanford University School of Medicine, Stanford Health Care, and Stanford Children’s Health, with Lucile Packard Children's Hospital. For nodules deemed spongiform or pure cyst on ultrasound, less than 1 cm with no suspicious features, the new recommendation is not to biopsy at all, and do not require routine ultrasound surveillance.5,6, For multiple nodules, the recommendation is to follow the guidelines for ultrasound evaluation. Benign Thyroid Nodules: How Long Should We Follow? Enlargement of the lymph nodes in or around your neck. Thyroid nodules are very common and the vast majority are benign. Radioactive iodine may be considered to manage lesser symptoms and for those who are not candidates for surgery.8 Recent radiograph studies support the use of iodinated contrast dye. Chen AY, Bernet VJ, Carty SE, et al. Always consult your doctor about your medical conditions. Adam’s apple or larynx. Treatment of goiter with levothyroxine is no longer recommended as results have been mixed and there is significant risk of TSH suppression with adverse effects on bone, particularly in postmenopausal women, and increased risk for cardiovascular disease.7 Of note, diffuse goiters appeared to respond more favorably to treatment than discrete nodules. A rule of thumb, is “thyroid nodules that tend not to grow are usually those which are small (< 1 cm) or large (> 4 cm or > 30 mL).3,4 Also, spongiform characteristics predict a benign nodule (Bethesda II) in comparison to nodules with suspicious features, based on results of a four-year, retrospective study in which 10 nodules were found to be cancerous out of a total of 854 evaluated.4. Presented at the AACE pre-congress symposium, Clinical Thyroidology—Beyond the Basics, on May 16, 2018 in Boston, Massachusetts. Thyroid nodules can occur as a single lump or as multiple nodules, and they can be solid or fluid-filled. In order to diagnose and treat thyroid cancer at the earliest stage, most thyroid nodules Dr. Zhang and her colleagues examined clinic charts of patients—of which 86% were female— from July 2016 to June 2017.1 Demographics collected on the patients included: sex, ethnicity, body mass index. The two new strategies for clinical consideration: the location of malignancy in the thyroid gland and which thyroid nodules necessitate monitoring.1,2. When Sarah O’Brien injured her neck in a car accident in 2012, a doctor examining her medical scans happened to notice that she had nodules on her thyroid, a gland located just below the Adam’s apple on the front of the neck. In the evolving care of patients with thyroid nodules, two key recommendations were highlighted to promote improved detection and treatment of thyroid cancer during the AACE 2018, the 27th Annual AACE Scientific and Clinical Congress held from May 17 to 20, 2018, in Boston, Massachusetts.
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