Thyroid Nodules

A lump in your thyroid gland!? Is that like a lump in your breast, your prostate, and a lymph gland? Left alone, it can be just as dangerous, but evaluated and cared for, even thyroid cancer can be cured and not take time off your life. Certainly, a rare tumor occasionally comes along, and yesterday was already too late, but almost all thyroid cancers are cured at rates of greater than 90%. Those that recur tend to recur in the neck, and distant spread is unusual. So do you just forget about a thyroid lump? Absolutely Not. The reason for good results is proper diagnosis and treatment.

A thyroid lump (nodule) is usually found by accident at the time of a periodic medical exam. The vast majority causes no symptoms. Sometimes the patient will see a lump in the mirror or feel fullness with swallowing. There is a difference of opinion about what test should be done first. There are some tests, which can exclude worry about a possible malignancy, but the number of nodules excluded as worrisome, even by the most favorable results, is quite small. Therefore many experts in the field consider Fine Needle Aspiration (FNA) biopsy as the best first test.

What characteristics are unfavorable? Since most benign nodules occur in women, maleness is an unfavorable characteristic. Being under 25 or over 55 years of age or having a single nodule rather than a multinodular thyroid gland are unfavorable. Hardness is difficult to quantify and considered not favorable. Lastly, a nuclear iodine scan which shows decreased function (cold) also favors a malignant process. But even all the bad characteristic–male, young or old age, single, hard, and cold, carries only a 20% chance of malignancy.

Before FNA was available as a diagnostic tool, all people with a suspicious nodule had surgery, but 80% of them would not have needed the operation had the technique been available. FNA now saves the majority of those patients the surgery. There is nothing wrong with surgical removal of a suspicious nodule, but now there is an alternative.

A small (fine) needle, smaller than one used to draw blood, is put into the nodule. A large syringe is used to create suction (aspiration) to remove cells from the nodule (biopsy). Several aspirations are done to get multiple samples and avoid sampling error. Slides are prepared and sent to the pathologist who is experienced and confident in reading these. Malignant nodules are removed. Follow up of benign nodules is also necessary.

Unfortunately, no test is perfect. While the vast majority of patients will receive a definitive answer, there will still be a small percentage where the results are equivocal. These patients may well receive a benign diagnosis at the time of surgery, but an equivocal result must be further investigated. Options beyond this point need to be individually discussed with your doctor.

Authored by: Richard D. Jablonski, M.D.

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