Thyroid Nodule Removal: Introduction

Thyroid nodules are growths that occur in the thyroid gland forming a lump or bump within the otherwise smooth thyroid tissue. Thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Many people are unaware they have thyroid nodules. When people hear they have a thyroid nodule they worry about cancer and the need for nodule removal. Thyroid cancer only accounts for approximately 5-15% of all thyroid nodules, but people understandably get concerned about the need for biopsy and ultrasound scans. Some folks need thyroid nodule removal to treat these abnormal growths or lumps in the thyroid gland. Thyroid nodule surgery involves removing half or the whole thyroid gland in almost all instances.

Below I will discuss the Top 4 Facts About Thyroid Nodule Removal that you need to know.

Top 4 Facts About Thyroid Nodule Removal

#1 Thyroid Nodule Removal Fact: Thyroid Nodules with Cancer Require Surgery

Most thyroid nodules are benign, but some are cancerous (Figure 1 below). Thyroid cancer only accounts for approximately 5% (10%-15% at most) of all thyroid nodules. Thyroid removal (surgery) is the mainstay of treating thyroid cancer. This involves removing half (thyroid lobectomy) or the whole thyroid (total thyroidectomy). Removal of just the nodule is not a proper or curative surgery for a cancerous thyroid nodule. Thyroid surgery done for thyroid nodules with cancer is often no different than thyroid nodule removal done for non-cancerous growths in the thyroid. Thyroid nodule removal done correctly in experienced and skilled hands is crucial for curing thyroid cancer.

Numerous studies have shown that up to 20%- 30% of thyroid nodules with cancer have spread to lymph nodes (most often to the lymph nodes directly behind and around the half of the thyroid containing the nodule) at the time of diagnosis and surgery. Many times, thyroid nodule removal can cure the cancer by only removing half (or a lobe) of the thyroid along with the lymph nodes behind and around that half of the thyroid. Only expert thyroid cancer surgeons should be performing thyroid surgery because the risk to the patients, including the nerves to the voice box and glands that control calcium, are significantly higher in the hands of surgeons that do not perform these types of surgery frequently.

In other instances, total thyroid removal is needed to treat thyroid nodules with cancer that are large, located in both halves of the thyroid, or when thyroid cancer has spread to lymph nodes in the neck. Again, removal of the lymph nodes behind and around the thyroid in the middle of the neck, at a minimum, is important to ensure the cancer is completely cured. Complete thyroid removal is riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage.

Expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind. Thyroid cancers that are improperly evaluated and treated incompletely will recur at a 20%-30% rate. Thus, thyroid nodule removal for cancer, particularly involving the entire thyroid, should only be done by high-volume, experienced surgeons at busy centers such as ours. Hospital for Endocrine Surgery

For more information about thyroid surgery for cancer, visit our website at www.thyroidcancer.com and check out our blogs on thyroid removal for thyroid cancer at www.thyroidectomy-for-thyroid-cancer, and www.3-best-thyroid-operations-for-thyroid-cancer.

Figure 1: Ultrasound image of a cancerous thyroid nodule

#2 Thyroid Nodule Removal Fact: What Size Thyroid Nodule Should Be Removed?

Thyroid nodules are often diagnosed as benign by needle biopsy during a patient evaluation. Although these nodules are benign, almost all of them will enlarge or grow over time. Thus, size alone is one reason for thyroid nodule removal. Any nodule that is 4 cm or larger should be removed with thyroid surgery. Many patients are told that thyroid nodule removal is not needed if they are not experiencing symptoms and the nodule is benign. This is false. Consensus guidelines recommend thyroid nodule removal for ones that are 4 cm or bigger.

Nodules that are 4 cm or larger are easily seen and felt in almost all cases (unfavorable cosmetic appearance). Additionally, as these nodules progress and grow, the needle biopsies are less reliable from a volume sampling standpoint (a small amount of cells from a large nodule may miss cancer located elsewhere in the tumor). Finally, monitoring large nodules instead of undergoing thyroid nodule removal will eventually lead to a symptomatic nodule or goiter (enlarged thyroid) that is problematic. This is because the nodules can grow to extend under the collar bone into the chest (Figure 2 below), behind the voice box, or wrap around the wind pipe and/or esophagus, thus displacing or narrowing these structures and causing symptoms (difficulty swallowing, breathing, etc.).

More broadly speaking, however, not all nodules require removal. This is provided that the nodule is not large (4 cm or greater; or >1.5 inches), overactive/toxic (causing hyperthyroidism), progressing in size, symptomatic, part of a goiter that is extending into the chest cavity (substernal goiter), or pushing on the windpipe (tracheal) or swallowing tube (esophagus). To reiterate, if one or more of those characteristics are present, then thyroid nodule removal for treatment is necessary. As discussed above, thyroid nodule removal involves taking half or the whole thyroid out for definitive diagnosis and cure.

To learn more about thyroid nodules, visit our blog at www.top-5-worries-about-thyroid-nodules.

#3 Thyroid Nodule Removal Fact: Multiple Nodules, Even if Benign, Can Necessitate Surgery

Multiple thyroid nodules, particularly when part of an enlarged thyroid (goiter), can require surgery. Even if a nodule, or 2-3 nodules, are benign on needle biopsy, an enlarged thyroid with numerous nodules (multinodular goiter) often requires thyroid nodule removal for a few reasons. First, it is very hard and impractical to monitor and needle biopsy more than 2-3 nodules. Second, multiple thyroid nodules and a goiter often produce symptoms eventually. The most common symptom or complaint of a multinodular goiter is the unsightly cosmetic appearance of a large lump in the neck or the symptoms produced by the actual size of the goiter. Symptoms related to the size of the goiter may include the sensation of a lump in the throat, difficulty swallowing, pressure or tightness in the neck, difficulty breathing, and even in extreme cases, voice changes or a completely hoarse voice. As noted above, thyroid nodules or a thyroid goiter that have grown under the collarbone and into the chest cavity (substernal goiter) always require thyroid surgery for removal.

These larger or substernal goiters and nodules can almost always (over 99% of the time) routinely be removed through an incision in the lower neck right above your collar bone. Skill and experience are key for these challenging thyroid surgeries. If your surgeon is telling you that they need to "split your chest" or "open your sternum", doublecheck to make sure that you have identified a highly- experienced thyroid surgeon. www.top-3-ways-to-find-best-thyroid-surgeon www.multinodular-goiter-substernal

Figure 2: CT scan image of a massive substernal goiter with multiple nodules indicated with orange arrows. The goiter surrounds the windpipe (trachea) which is identified with the blue arrow. The dark black areas on each side represent the lungs.

#4 Thyroid Nodule Removal Fact: Removal Provides the Definitive Diagnosis of the Nodule

Most of the time, a needle biopsy is performed prior to thyroid nodule removal to obtain a diagnosis and guide treatment. Patients should realize that thyroid nodule biopsies are only as good and reliable as the people performing them and the pathologists who are evaluating the cells. The results of a thyroid needle biopsy are categorized according to the Bethesda System for Reporting Thyroid Cytopathology for Thyroid Nodules.

The diagnostic categories are as follows:

1. Nondiagnostic or unsatisfactory
2. Benign (non-cancerous)
3. Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS)
4. Follicular neoplasm or suspicious for a follicular neoplasm
5. Suspicious for malignancy
6. Malignant (cancerous)

Many thyroid nodules cannot be diagnosed as cancerous until the entire nodule has been taken out during thyroid nodule removal where half or the whole thyroid is resected. Frequently, a needle biopsy before surgery does not yield a definitive diagnosis as to whether a thyroid nodule is cancerous or benign (non-cancerous). Even special molecular/genetic testing of thyroid cells from a biopsy often does not reveal whether a nodule is cancer or benign. In some large studies, up to 50% of thyroid cancers are not diagnosed until after thyroid nodule removal.

Clearly, a biopsy does not always tell the doctor whether thyroid cancer is present. Furthermore, biopsies are not always accurate, and large nodules can harbor cancer (10.4%- 22% of the time) that is not diagnosed with FNA (fine needle aspiration) biopsy before surgery. That is to say that needle biopsies are not perfect, particularly as the nodules get larger. Thyroid nodule removal can be indicated for a definitive diagnosis and cure.

Thyroid Nodule Removal: Summary

Thyroid nodules are very common. Thyroid nodule removal, involving surgical resection of half or the whole thyroid, is often necessary to diagnose and cure these nodules, particularly when they are cancerous. Large nodules (4 cm or greater), multiple nodules with or without a thyroid goiter (enlarged thyroid), and ones that are atypical or suspicious require thyroid nodule removal. Even benign nodules may need surgery depending on symptoms, growth, or size.

Expert evaluation and treatment for thyroid nodules are paramount. Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid nodule removal. To learn more and become a patient, please see our resources below.

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more about The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.