Top 4 Reasons to Worry About Thyroid Nodules

What are Thyroid Nodules?

Thyroid nodules are organized, usually well- defined growths that occur in the thyroid forming a lump or bump within the otherwise smooth thyroid gland. Thyroid nodules are common, occurring in at least 40% of women and 30% of men during their lifetime. Most thyroid nodules are benign, but some are cancerous. As best we know, thyroid cancer only accounts for approximately 5% of all thyroid nodules, but people understandably get concerned once they find out they have a nodule or tumor in their thyroid. Below are the top 4 reasons to worry about thyroid nodules.

#1 Reason to Worry About Thyroid Nodules: The nodule is a cancer

Certainly, thyroid cancer is the foremost reason to worry about a thyroid nodule.  As noted above, most thyroid nodules are benign, but some are cancerous. Thyroid cancer only accounts for approximately 5% (10% at most) of all thyroid nodules. Thyroid surgery is the mainstay of treating thyroid cancer. Thyroid surgery done for thyroid nodules with cancer is often no different than thyroid surgery done for non-cancerous nodules in the thyroid. Thyroid surgery done correctly in experienced and skilled hands is crucial for curing thyroid cancer.

Some large studies have shown that up to 50% of thyroid cancers cannot be diagnosed until surgery has been performed to remove the nodule completely. Additionally, numerous studies have shown that 20%- 30% of thyroid nodules with cancer have at least microscopic spread to lymph nodes at the time of diagnosis.  Many times, thyroid surgery can cure the cancer by only removing half (or a lobe) of the thyroid (thyroid lobectomy) and the lymph nodes behind that half of the thyroid. Again, expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind.

In other cases, total thyroid removal (total thyroidectomy) is needed to treat thyroid nodules with cancer that are large, located in both sides (lobes) of the thyroid, or when thyroid cancer has spread to lymph nodes in the neck. 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. Thus, thyroid surgery 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 and the three best thyroid operations for thyroid cancer.

#2 Reason to Worry About Thyroid Nodules: The needle biopsy was NOT benign

Thyroid nodules are often found when a doctor examines a patient's neck, but nodules are also frequently discovered when a patient gets an x-ray, CT scan, MRI, or ultrasound the neck or chest for some other reason. While most thyroid nodules are benign (roughly 95%), often times a fine- needle aspiration (FNA) biopsy is needed to obtain more information about how a thyroid nodule is behaving. This is called a “needle biopsy”. A needle biopsy is typically done for larger nodules (>1cm or 3/8 inch), symptomatic thyroid nodules, nodules that have suspicious features on ultrasound, nodules that are changing in appearance, and/or thyroid nodules that have increased in size. Unfortunately, as noted below, we do not always get a definitive answer as to whether the nodule is cancerous or benign when needle biopsy is done.

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

            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

Second or third thyroid biopsies do not erase or eliminate the results of previous biopsies of the same thyroid nodule. When a biopsy returns atypical or suspicious cells, additional molecular/genetic testing can be undertaken to gain more information regarding whether the thyroid nodule is cancerous or not. No further testing on benign, very suspicious, or cancerous thyroid nodules is necessary. The risk decreases if molecular testing is negative. If your nodule is very suspicious or cancerous, however, surgery is needed. Atypical or suspicious cells on biopsy are also worrisome, and many patients elect to have surgery to remove, diagnose, and cure those nodules. Nodules that are non-diagnostic also need surgery in some cases for a definitive diagnosis (and cure).

Biopsies are not perfect, however, and expert ultrasound can diagnose whether a thyroid nodule is benign, atypical/suspicious, or cancerous in most cases. Patients should also realize that thyroid biopsies are only as good and reliable as the people performing them and the pathologists who are evaluating the cells. Therefore, biopsies of thyroid nodules should be performed and evaluated by high-volume centers and clinicians when possible. Expert evaluation of thyroid nodules is paramount to obtaining the correct treatment plan.

#3 Reason to Worry About Thyroid Nodules: They are large

Thyroid nodules that are benign may be observed. This is provided that the nodule is not large (4 cm or greater; or >1.5 inches) or progressing in size, symptomatic, part of a goiter that is extending into the chest cavity, or pushing the windpipe (tracheal) or swallowing tube (esophagus). Like any other tumor, nodule, or growth in the body, surgery is sometimes needed to remove thyroid nodules if they reach 4 cm or larger in the biggest dimension. Additionally, should the thyroid nodule should increase in size or cause symptoms, surgery is most likely necessary. The natural course of thyroid nodules is to enlarge over time slowly. Typically, the rate of growth is not rapid. Finally, large nodules can harbor cancer (10.4%- 22% of the time) that is not diagnosed with FNA biopsy preoperatively secondary to the increase in volume of the nodule as it grows. This is another reason thyroid surgery is warranted for large nodules.

Check out our thyroid nodule size chart showing the likelihood that surgery will be required based on size.

Schedule a world-class evaluation of your thyroid nodule.

#4 Reason to Worry About Thyroid Nodules: They are numerous or toxic (hot)

Some folks have numerous thyroid nodules. The number itself is not always a problem, but monitoring 7, 10, 12 nodules can be very challenging compared to monitoring 2-3, particularly outside of a thyroid center of excellence. Nodules can enlarge, change appearance, exhibit suspicious features, and abut other nodules making it challenging to discern if there is one or 2. More nodules also makes it slightly more likely one will be symptomatic or a cancer can be present just from a statistical standpoint. Finally, needle biopsy of 10 nodules is not a practical, feasible, or comfortable option for patients with multiple thyroid nodules. As such, patients with numerous nodules are more likely to need thyroid surgery for one of the aforementioned reasons.

Additionally, there are some rare circumstances where a patient has a hot/toxic nodule. In this instance, a thyroid nodule begins functions on its own (goes rogue). The nodule makes thyroid hormone when the body does not need it. Therefore, a patient with a toxic nodule will have too much thyroid hormone (hyperthyroidism). This is a more dangerous clinical situation than having too little thyroid hormone for a couple of important reasons. First, your body can get overwhelmed by too much thyroid hormone causing you to be sick and need medical attention or hospitalization (thyroid storm). Secondly, too much thyroid hormone can cause the heart to beat dangerously fast and/or irregularly. This will also land a patient in the hospital. Hyperthyroidism can also cause other symptoms that will make a patient feel ill or symptomatic: hair loss, palpitations, tremors, anxiety, hair loss, weight loss, change in appetite, insomnia, and more. Toxic/hot nodules can be definitively cured with thyroid surgery to remove the affected half (or entirety) of the thyroid.

Summary

To conclude, thyroid nodules are very common, more so in women than men. While most thyroid nodules are benign, surgery is necessary in many cases, particularly for thyroid cancers. While thyroid cancer is certainly the primary reason to worry about a thyroid nodule, there are other reasons thyroid nodules can be problematic or worrisome as noted above. Finding an expert team to work-up, diagnose, and treat your thyroid nodule is essential. Inexperience in evaluation, biopsy, and surgery for thyroid nodules will lead to poor outcomes and complications. Entrust only the best when it comes to care and treatment of your thyroid nodules!

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.

Additional Resources

• Become our patient at www.thyroidcancer.com/become-a-patient
• More about the The Clayman Thyroid Center at www.thyroidcancer.com
• More about the Hospital for Endocrine Surgery