I have a Thyroid Nodule: What next?
Written by Rija Choudhry, edited by Dr. Kathryn Dinh
Receiving a diagnosis of a thyroid nodule can be an unsettling experience, whether it is found on exam or is an unexpected finding on CT scan or MRI. In this blog post, we'll guide you through the steps to take after discovering a thyroid nodule, addressing common questions and providing insights into what comes next in your medical journey.
The thyroid, a butterfly-shaped gland located at the base of your neck, plays a crucial role in regulating many bodily functions. However, sometimes this vital organ can develop nodules which require evaluation.
Thyroid nodules are lumps or abnormal growths that form within the thyroid gland. Such nodules are quite common, occurring in over half of people by age 60. While the vast majority are benign (non-cancerous), a small percentage can be malignant (cancerous). Therefore, it is essential for individuals to be aware of potential symptoms and seek timely medical evaluation once discovered.
Here's what you can expect in your initial evaluation:
Consultation with an Endocrinologist: Your healthcare provider may refer you to an endocrinologist, a specialist in thyroid conditions. They'll go over your medical history, do a physical exam, and talk about any previous tests you've had. If needed, they'll order more bloodwork and imaging.
Imaging: All thyroid nodules should be evaluated by a comprehensive neck ultrasound, even if found incidentally on a CT scan or MRI. A Thyroid ultrasound produces detailed images of the thyroid gland, assisting in the evaluation of nodules in terms of size, shape, and characteristics. These features aid your doctor in estimating the risk of malignancy (cancer) for each nodule seen. The ultrasound results play a crucial role in deciding whether a nodule requires further evaluation, such as a fine needle aspiration (FNA) biopsy, and appropriate timing for follow-up imaging.
Blood work: Thyroid function tests assess the thyroid's hormone production, providing insights into whether a nodule is associated with abnormal hormone levels. Your doctor will order a thyroid stimulating hormone (TSH) measurement in the blood, which will indicate potential hyperthyroidism or hypothyroidism. The results may influence treatment decisions.
When evaluating a thyroid nodule, healthcare professionals consider multiple factors to determine its nature and the appropriate course of action. The assessment typically revolves around three main aspects: symptoms related to size and compression, functional status (whether the nodule is producing too much hormone), and the risk of cancer within the nodule.
Size & Compression:
Size: Larger nodules may cause visible swelling in the neck, making the thyroid gland palpable during a physical examination. Imaging studies, such as ultrasound, help measure the size accurately.
Compression: Nodules, especially when they grow, can exert pressure on surrounding structures, leading to symptoms like difficulty swallowing, a feeling of fullness in the throat, or changes in voice. These symptoms are indicative of compression of the trachea or esophagus.
Function:
Thyroid nodules can be classified based on their functional status, which is determined by thyroid function tests and, less often, a special type of imaging called an uptake and scan. Hot Nodules are overactive and produce excessive amounts of thyroid hormones, leading to hyperthyroidism. Symptoms may include weight loss, rapid heartbeat, anxiety, and heat intolerance. Cold Nodules are non-functional and do not produce excess thyroid hormones. They may cause symptoms related to their size or compression but do not impact thyroid function. A hot nodule requires treatment.
Cancer Risk:
Assessing the risk of cancer is a critical aspect of evaluating thyroid nodules. While most nodules are benign, some may be malignant. Key considerations include:
Patient Characteristics: Younger individuals and males are generally at a higher risk of having malignant thyroid nodules. Additionally, family history of thyroid cancer is always considered.
Ultrasound Characteristics: Certain features seen on ultrasound, such as irregular borders or microcalcifications, may raise suspicion of malignancy.
If there is concern the nodule may be cancerous based on the characteristics, the next step is a fine needle aspiration. This is a simple, outpatient procedure to extract cells from the nodule for microscopic examination. FNA helps differentiate between nodules with benign versus malignant character but cannot diagnose cancer. Nodules found at increased risk of cancer are often surgically removed.
Follow-up
Follow-up recommendations for a thyroid nodule depend on various factors, including size, characteristics, and functional status. Consultation with an endocrinologist is recommended for personalized decision-making based on the specific features of the thyroid nodule. Here's a brief overview of the options for nodules without high concern of cancer.
Watchful Waiting: Small, stable, and non-functional nodules often require no immediate intervention. Some can be followed by physical exam only whereas others should have periodic thyroid ultrasounds to evaluate for changes.
Repeat Thyroid Ultrasound: Large nodules or small nodules with higher risk ultrasound features will require a repeat ultrasound in six to 12 months to monitor for changes in size, echogenicity, or features.
Hot nodules: If a nodule is making excess hormone, treatment is generally recommended to normalize thyroid function. Options include radioactive iodine, surgery to remove the nodule, or medications to control hormone production.
Summary
In summary, a comprehensive evaluation of a thyroid nodule involves considering the presence of symptoms related to size and compression, determining its functional status regarding hormone production, and assessing the potential risk of cancer. The combination of imaging studies, laboratory testing, FNA biopsy when necessary, and clinical assessment enables your endocrinologist to formulate an accurate diagnosis and develop an appropriate management plan tailored to the individual patient’s needs. Regular follow-up and ongoing communication between the patient and their physician are crucial in ensuring optimal care and addressing changes in the nodule over time.
