Thyroid Mass

Incidental Finding of Thyroid Gland Nodule
Short Summary

30-year-old female was noted to have two right lobe of thyroid gland nodules on a neck ultrasound. A diagnosis of incidental finding of thyroid gland nodule in the setting of normal thyroid gland function was established. In the expert's opinion, the clinical presentation is consistent with a "cold" thyroid gland nodule. He recommends an ultrasound-guided fine needle biopsy, because the results of the cytology can guide the treatment and dictate the extent of surgery.

Patient's Questions

1. Diagnosis

2. Recommended examinations

3. Prognosis

4. Treatment
 

Medical Background

Clinical Presentation Summary:

30 year old female who was noted to have two right lobe of thyroid gland nodules on a neck ultrasound. One of the nodules measured 16 mm in diameter while the other measured 6 mm in diameter. Thyroid blood function tests were normal. The neck ultrasound was performed as part of the workup for parotid gland pleomorphic adenoma and upper cervical lymph nodes. The surgeon who evaluated the patient recommended 6 months observation period and to repeat the neck ultrasound at that time.

Diagnosis: 30 year old lady with an incidental finding of thyroid gland nodule in the setting of normal thyroid gland function.
 

Expert's Opinion

Recommendation:

The clinical presentation is consistent with a "cold" thyroid gland nodule. The possibility of malignancy is not excluded based on normal thyroid gland function. The workup of such thyroid gland nodules evolved over the past decade. Currently, an ultrasound-guided fine needle biopsy is recommended. The results of the cytology can guide the treatment: observation is recommended for a macrofollicular pattern or clear benign colloid pattern, while surgery is recommended for microfollicular pattern or clear evidence of carcinoma.

The extent of surgery is dictated by the histology as well: a hemithyroidectomy is reasonable if the needle biopsy was not diagnostic of carcinoma but showed a microfollicular pattern. In such a case, it is recommended to perform frozen section histopathology examination of the surgical specimen and proceed to total or subtotal thyroidectomy if cancer was found on the frozen section diagnosis. On the other hand, a total or subtotal thyroidectomy is recommended if the needle biopsy was consistent with carcinoma.

As far as observing the patient for 6 months is concerned, I do not recommend such an approach if the medical facility is equipped with the capability of performing ultrasound-guided fine needle biopsy and there are qualified cytopathologists who can interpret the needle biopsy specimen.

Papillary thyroid carcinoma, in case this was the diagnosis, has a good prognosis in this age group (young female, small size tumor, and absence of lymph node metastasis or lung metastasis). Observing the patient for 6 months is not likely to negatively impact prognosis. At the same time, I do not see the value of waiting 6 months. Does this mean further observation if the nodule was stable is size??

In summary, I recommend ultrasound-guided fine needle biopsy. Observation is reasonable if the biopsy showed a benign morphology. Surgery is needed if the biopsy showed carcinoma or a microfollicular pattern. A total or subtotal thyroidectomy is needed if the diagnosis of cancer was established. A hemithyroidectomy is reasonable if the biopsy could not rule out cancer but was not diagnostic of cancer (for instance, a microfollicular pattern). In such case, the hemithyroid specimen should undergo frozen section histopathology examination and the surgery should progress to a total or subtotal thyroidectomy if cancer was seen on frozen section examination
 

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