Thyroid Nodules

Tutor 14
Definition Thyroid nodules are nodules
(raised areas of tissue or fluid)
which commonly arise within an
otherwise normal thyroid gland.
They may be hyperplastic or
tumorous, but only a small
percentage of thyroid tumors are
malignant. Small, asymptomatic
nodules are common, and often go
unnoticed. Nodules that grow larger
or produce symptoms may
eventually need medical care.
Etiology
Result of mutations in the
TSHR or in the gene of the α-
subunit of the G protein, leading
to constitutive activation of the
cAMP cascade and enhanced
response to TSH.
 Epidemiology

By palpation, their prevalence has been

estimated around 4%. It has been reported to be
as high as 68% with hi-resolution US.
By age 60, about one-half of all people
Autopsy data from patients with no history of have a thyroid nodule that can be found either
thyroid disease have indicated a prevalence of through examination or with imaging.
50%
Fortunately, over 90% of such nodules

Increasing age, female gender, iodine

are benign.
deficiency, and a history of head and neck The prevalence of thyroid cancer is
irradiation seem to consistently increase the risk similar in patients with single or multiple
of developing thyroid nodules. nodules.
Diagnosis
● Thyroid nodules are usually discovered by palpation of the neck during
routine physical examination. Most clinically palpable thyroid nodules are at
least 1 cm in diameter.
● Nodules can also be incidentally diagnosed during ultrasonography (US)
of the neck done for unrelated conditions.
● A normal or high TSH level should raise concerns for possible malignant
potential of a nodule, whereas a low TSH is an indicator of benignity in most
cases.
● Fine-needle aspiration (FNA) cytology is the cornerstone of thyroid
nodule evaluation in determining whether a nodule is benign or malignant.
 ● Surgery
● Suppressive Therapy w/ Levothyroxine

Treatment ● Radioiodine Therapy

● Percutaneous Ethanol Injection
● Laser Thermal Ablation (2B)
Surgery
All thyroid nodules confirmed to be
malignant and most found suspicious
by Fine Needle Aspiration (FNA)
biopsy should be referred for
surgical excision. The extent of the
surgical procedure required is a matter Benign thyroid nodules
of debate, with some authors do not require surgery, unless
advocating total or near-TT, and others they produce symptoms of
favoring a more limited approach with compression or
lobectomy of the affected side. hyperthyroidism.
Suppressive Therapy with Levothyroxine

Levothyroxine is the generic name for a

prescription medication used to treat hypothyroidism.
Brand names include Synthroid, Levoxyl, and
Levothroid. This drug is classified as a thyroid
medication for hypothyroidism.

Suppressive therapy is not indicated for hyperfunctioning

nodules. A controlled trial of suppressive therapy in nontoxic
multinodular goiters showed a better than 13% decrease in thyroid
volume in 58% of patients treated with LT4 compared with only 5%
of those given placebo
Radioiodine Therapy
The mechanism of action of RAI is physiological. Iodine is the precursor of
thyroxine. The radioactive form of iodine is taken up by iodide transporter of the
thyroid the same way as natural iodine and is similarly processed.

+ Effective in the treatment of nearly 90% of

single toxic adenomas
+ Also effective nearly 80% to 100% effective in
the treatment of toxic multinodular goiter,

+ Moreover, because the side effects are dose

dependent, they are rare following doses of
rhTSH of 0.1 mg or less.
Percutaneous Ethanol Injection
● High concentrated ethanol can be used to
destroy the undesired tissue.
● Local pain, risk of recurrent laryngeal nerve
damage, and the need for repeat treatments make
PEI unsuitable for routine treatment of solid
thyroid nodules.
● The use of percutaneous ethanol therapy in thyroid
diseases, especially in solid nodules, has been
limited due to the seepage of ethanol into
perinodular tissue, which is the cause of pain and
other complications, but remains as an effective
method of treating cystic ones.
Laser Thermal Ablation (2B)
● Ultrasound-guided laser thermal ablation (LTA) has emerged as an alternative
therapeutic option in the management of patients with benign hypofunctioning
thyroid nodules associated with compressive symptoms, who are poor
surgical candidates or who refuse such intervention.
● Laser is an acronym for Light Amplified Stimulated Emission of Radiation.
Laser technology directs collimated, monochromatic, coherent, and powerful
light energy to a well-delimited area of tissue in a predictable, precise, and
controlled manner
● This procedure has resulted in 45% to 60% reduction in nodule volume 6
months after treatment. The procedure requires considerable skill of the
operator and is currently performed only in a few specialized centers.
 Reference

Pauline M Camacho MD - Evidence-Based Endocrinology-LWW (2012)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575959/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688381/

https://synapse.koreamed.org/search.php?
where=aview&id=10.3348/kjr.2011.12.5.525&code=0068KJR&vmode=FULL

https://www.youtube.com/watch?v=09mM7bkevcE