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(630) 938-6161
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25 N Winfield Rd Ste 505, Winfield, IL 60190-1295

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Call
(630) 938-6161
to Schedule a Consultation

25 N Winfield Rd Ste 505
Winfield IL 60190-1295

Thyroid Nodules

Work-up

When thyroid nodules are discovered,
the goal is to rule out:

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Cancer

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Cause for compressive symptoms

Pressure on the throat, difficulty swallowing / breathing.

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Hyperthyroidism

The presence of thyroid nodules does not cause hypothyroidism.

Central Neck Dissection

How to meet these goals?

Patient History of Symptoms

  • Hyperthyroidism, compressive symptoms.
  • Signs and symptoms suspicious for cancer:
    Pain, voice change, dysphagia (difficulty swallowing), odynophagia (pain with swallowing), dyspnea (difficulty breathing), shortness of breath, stridor (audible breathing, particularly on inhale), rapid growth of a palpable neck mass.

Family History

  • Having a first degree relative (mother, father, sister, brother, son, or daughter) with history of thyroid cancer increases your risk of having thyroid cancer.

    This does not automatically mean you will develop thyroid cancer as well, but the work up and consideration for FNA (biopsy) of thyroid nodules should be more aggressive than the general population.

  • Hereditary syndromes that increase your risk of having thyroid cancer.

    PTEN hamartoma tumor syndrome (Cowden’s disease), familial adenomatous polyposis (FAP), Carney complex, multiple endocrine neoplasia (MEN 2A and 2B), Werner syndrome / progeria.

Medical / Social History

Radiation exposure to the head and neck region, particularly in childhood, greatly increases your risk for developing thyroid cancer. Examples include:

  • Treatment of cancers in the head and neck region.
  • Total body radiation for bone marrow transplant.
  • Treatment of acne, tonsillitis, thymus, and birthmarks / skin lesions performed in the 1940’s through 1960’s.
  • Frequent CT scans and X-rays of the head and neck, especially during childhood.
  • Proximity to radiation.
  • Physical exam: palpation of thyroid gland and lymph nodes in the neck.
  • If voice or swallowing changes are noted – indirect mirror or flexible scope exam of the larynx (voice box and vocal cords) should be performed.
  • TSH (Thyroid Stimulating Hormone) should be obtained for any thyroid nodule >1.0 cm.
  • If TSH is suppressed (below the normal range) suggesting hyperthyroidism, further lab work (free T4 and Total T3) and radionuclide uptake scan are recommended.
    • Hot nodules should not be FNA’d (biopsied) due to low risk of malignancy and potential false positive results.
      • The exception being hot nodules with high-risk features on ultrasound.
  • Ultrasound is the preferred imaging test to evaluate the thyroid and thyroid nodules.
    • Provides the most detailed images, better than CT or MRI.
      • Measurements and descriptions from different types of imaging tests should not be compared for growth / changes.
        • e.g., Measurements from a CT should not be compared to ultrasound measurements.
    • Should include assessment of the thyroid and lymph nodes in the central and lateral neck compartments.
    • Reasons to obtain a thyroid ultrasound:
      • Any palpable thyroid nodule or goiter on exam.
      • To better assess any thyroid nodule incidentally discovered on a different imaging study (e.g. CT, MRI, PET, etc.).
      • To confirm the presence of a hot nodule seen on an uptake scan.
        • A diagnosis of hypothyroidism is not a reason to obtain a thyroid ultrasound.

When should a CT scan be considered?

  • With large thyroid nodules or goiters with possible extension into the chest (substernal goiter).
  • When the trachea (windpipe) is significantly shifted to one side.
  • When stridor (audible breathing) is present.
    • To assess for tracheal (windpipe) narrowing.
  • If there is concern that thyroid cancer is invading the trachea (windpipe), larynx (voice box), or esophagus (food pipe).
  • CT scan should ideally be performed with iodine contrast for better visualization.
    • Will not affect any potential need for future radioactive iodine treatment of thyroid cancers.

When should an MRI be considered?

  • MRI can be a safe alternative to CT:
    • In children and pregnant women to decrease radiation exposure risk.
    • Patients with severe allergies to iodine contrast.

Should PET scans be obtained to assess thyroid nodules?

  • PET scans are not recommended for work-up of thyroid nodules.
    • Well-differentiated thyroid cancers are generally not PET avid (sensitive) and subsequently may miss thyroid cancers.
    • There are also potential nonspecific, benign reasons for the thyroid to show up on a PET scan.

What about incidental thyroid findings on a PET scan obtained for a different reason?

  • Focal uptake in an identified thyroid nodule (confirmed on ultrasound) > 1.0 cm should justify FNA given increased risk for cancer regardless of ultrasound features.
    • The higher the SUV, the higher the risk for cancer.
  • Diffuse uptake of the thyroid without identifiable nodule is likely due to benign thyroiditis (inflammation) or normal thyroid metabolic function and does not warrant an FNA.

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