Thyroid Mass: Evaluation and Management
by Dr. Christopher Chang, last modified on
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It is not uncommon for a patient to be informed by their doctor that they have a mass in their thyroid gland. Alternatively, patients may be concerned whether there MIGHT be a mass in the thyroid gland due to a lump sensation in the neck.
To be clear, what will NOT be discussed in this article is when dealing with multi-nodular goiters or thyroid problems (thyroiditis, hypothyroid, hyperthyroid, etc).
Before getting into what should be done, first a little anatomy lesson. I promise, it will be just enough anatomy in order to understand treatment.
If you look at the picture of the woman, the arrow points to the thyroid gland which is shaped like a butterfly and overlies with windpipe (trachea). Triangle arrow-heads point to nerves (yellow) which is found under the thyroid gland and is what makes the vocal cords move.
If you turn the thyroid gland around and look at it from behind, there are 4 little glands known as parathyroid glands. These special glands secrete a hormone which regulates the level of calcium in the blood.
More on why these structures are important below (under risks of thyroid surgery).
If a thyroid mass is suspected, the study of choice to evaluate further is an ultrasound. With the ultrasound, the mass is characterized with special attention to features that are suggestive (but not diagnostic) of cancer. Such findings that increase likelihood of cancer include:
- central vascularity
- irregular margins
- incomplete halo
- tall > wide
- documented increase in size
The most common thyroid cancer is papillary thyroid cancer and has an excellent "cure" rate as far as cancers go. Less common are follicular and medullary thyroid cancers. The most rare and almost universally fatal type is anaplastic thyroid carcionoma. There are other cancer types that can be found in the thyroid, but are technically not considered "thyroid cancer" (lymphoma, squamous cell carcinoma, sarcoma, etc).
Ultrasound characteristics that argue against thyroid cancer include:
- large, coarse calcification
- peripheral vascularity
- spongiform appearance
- comet-tail shadowing
Any nodules found on a thyroid ultrasound is given a TR or TI-RADS score which goes from 1-5. A nodule with a TR1 or TR2 score is considered benign with a near zero risk of cancer. TR3-5 nodules have risk of cancer that progressively increases. For more information on TR scoring and risk of cancer, click here.
Additional studies may be ordered by the physician to evaluate thyroid masses including CT scan of the neck with contrast, thyroid bloodwork, radionuclide thyroid uptake scan, etc.
However, a key test to determine the presence of cancer is a needle biopsy (FNA or fine-needle aspiration) of the mass which can be performed blindly by finger palpation guidance or under ultrasound guidance. Patients MUST be aware, however, that this test is NOT perfect. Just because the needle biopsy report comes back "No Cancer" does not mean that thyroid cancer is not present. It's possible that at the time of biopsy, the needle did not pick up cancer cells. To explain, imagine sticking a needle into an apple containing a worm... it's possible that the needle might miss the worm and declare the apple safe to eat.
Indeed, in certain situations, a needle biopsy is at best no better than flip of a coin in determining whether cancer is present (it is wrong 50% of the time!). So why do it? Because if it DOES show cancer, than thyroid surgery should strongly be considered. If the needle biopsy does not show cancer, further thought needs to be taken on what next to do. Ultimately, surgery may still be pursued if concern or suspicion for cancer is high in spite of the normal biopsy report (because the biopsy might be wrong).
As such, depending on study results and degree of suspicion for cancer while taking into account the level of patient concern, one of the following courses of action might be pursued:
- Thyroid surgery (Thyroidectomy)
- Monitor every few months
- Repeat Studies/Needle Biopsy
- Get a second opinion
Patients should be aware that there is a lot of controversy on how to manage thyroid masses in the absence of a definitive diagnosis of cancer. As such, if a patient sees 3 different physicians regarding a thyroid mass, they really may get 3 different opinions on what next to do.
On that note, what type of physician specialist manages thyroid masses?
- General surgeon
- Endocrine surgeon
- Otolaryngology, head and neck surgeon
Thyroid Surgery (Thyroidectomy)
There are several different flavors of thyroid surgery, but be aware that no approach is considered a clear winner and each approach has strong advocates.
- Standard Open Incision: 2-3 inch horizontal incision made in the neck over the thyroid. Direct visualization used to remove the thyroid. (Watch Video)
- Pros: Wide exposure
- Cons: Large neck incision
- Endoscopic: 1/2 - 1 inch horizontal incision made in the neck over the thyroid. Depending on the surgeon, the incision can be made in the armpit avoiding any neck incision (Watch Video). Video endoscopy is used to visualize the thyroid for removal.
- Pros: Limited field of view, possible no neck incision
- Cons: Small neck incision, not all patients are candidates
- daVinci Robotic Surgery:
NO neck incisions. Rather, the incision is typically made in the armpit. Several robotic arms are than tunneled from the armpit incision up to the neck where the thyroid is located. Under endoscopic robotic visualization, the surgeon directs the robotic arms to remove the thyroid. (Watch Video)
- Pros: No neck incision
- Cons: Not covered by insurance, much longer surgical time, more painful recovery, very few hospitals have a daVinci robotic system (and even fewer surgeons know how to perform), not all patients are candidates. Of more importance, the robotics company no longer supports use of daVinci for thyroid surgery.
As you can see, the MAIN difference between the different types of surgical approaches is the incision (where and how long). Beyond that, the surgery itself is the same.
Assuming thyroid surgery is pursued regardless of how it is approached, there are two basic types: Removing the entire thyroid gland or removing part of it.
Normally, the initial approach is to remove the thyroid half containing the mass of concern. If cancer is found, the rest of the thyroid gland is removed. This "completion" thyroidectomy may occur at a later date, though sometimes, the decision to remove the entire thyroid can be made at time of the initial surgery. It really depends on the pathologist who can provide an intra-operative diagnosis based on a frozen section which unfortunately is not 100% accurate. To summarize, the steps for thyroid surgery is as follows:
If the entire thyroid gland is removed, thyroid hormone replacement (ie, synthroid) must be taken. If the entire thyroid gland is not removed, a patient may not be required to take such thyroid medication, though it depends on whether the residual thyroid gland is able to make enough thyroid hormone for the patient.
Risks of Thyroid Surgery
Bleeding is ALWAYS a risk of any type of surgery causing a hematoma to form. What makes this particular complication especially concerning after thyroid surgery is that it often occurs DAYS after surgery. Even more worrisome is that it could lead to death as the hematoma formation can cause significant airway swelling with resulting airway compression (remember that the thyroid is located over the windpipe). This complication unfortunately occurs not uncommonly... and often leads the patient to obtain emergency care in the local ER by a local surgeon to drain/remove the hematoma and stop the bleeding. A tracheostomy (a hole in the neck to the windpipe) may need to be performed at this time as well.
Given the thyroid is located over the windpipe, the surgeon may accidentally (or deliberately if thyroid cancer is invading the windpipe's wall) enter into the airway. Why may this be a problem? Well, it may cause air to leak into the neck causing it to suddenly swell up and potentially lead to a pneumothorax (collapsed lung) if severe enough. The scary thing is that this complication can also potentially occur days after the surgery though if it is going to happen, it usually occurs within hours after surgery, especially with coughing.
Beyond bleeding and airway complications, thyroid surgery has two unique risks associated with it, regardless of how the surgery is performed.
Remember the anatomy lesson at the top? There are two key structures that are at risk with thyroid surgery: the parathyroid gland and nerves that go to the vocal cords.
Lets talk about each one separately with its associated risk.
The 4 parathyroid glands are responsible for regulating the calcium levels in the blood. Without the four parathyroid glands, the calcium levels will drop precipitously leading to heart arrhythmias and potentially cardiac arrest resulting in death. You need parathyroid glands!!! With thyroid surgery, the surgeon may accidentally remove or cut-off the blood supply to the parathyroid glands leading to cardiac complications. A patient does not necessarily need all four to survive. It's also possible that the parathyroid glands may be "stunned" by the thyroid surgery and temporarily malfunction resulting in transient calcium level decrease which can be addressed with vitamin D and calcium pill supplementation.
The nerves that go to the vocal cord (arrowheads) travel between the thyroid gland and the trachea/esophagus. Known as the "recurrent laryngeal nerve," one or both nerves may get accidentally cut during thyroid surgery resulting in complete vocal cord paralysis. With vocal cord paralysis, the voice becomes very breathy with talking. Aspiration may also occur. Depending on whether one or both nerves are cut, treatment to address the resulting hoarse voice is different. Click to read more about the treatment of unilateral vocal cord paralysis or bilateral vocal cord paralysis.
Of particular importance to singers, there is also another nerve near the top of the thyroid gland called the "superior laryngeal nerve" which if cut during surgery, a patient can talk just fine... but when singing, there is loss of upper range and falsetto. Unfortunately, there is no good fix for this if it happens.
What to Expect after Thyroid Surgery
Assuming no complications, depending on the approach (open neck, endoscopic, daVinci) and surgeon, recovery times and pain are different. However, a general rule of thumb is pain is less with neck incisions than with armpit incisions. Why? Because a neck incision only requires dissection to be performed in the neck region versus incision made under the armpit which requires not only surgical dissection of the neck region, but also the chest wall given the neck is approached through the upper chest wall from the armpit.
However, all other things being equal, it is not unusual to be discharged home the same day of surgery if half a thyroid was removed. Hospitalization for 1-3 days may occur if the entire thyroid was removed due to increased concern with bleeding and calcium stability. It is not unusual to have surgical drains placed during the first several days to prevent a hematoma from forming. Routine wound care to the incision with bacitracin ointment application is required for 1-2 weeks. Thyroid replacement medication may be started if the entire thyroid was removed.
Final pathology results take about 1 week at which time a definitive diagnosis of cancer can be made if present and subsequent care can be pursued. Click here to see why it takes so long to get a final diagnosis.
Please note that Dr. Chang no longer performs thyroid surgeries.
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