Thyroid nodules or masses are a common clinical problem in thyroid surgery, yet not all surgeons are able to study them in depth and provide the most appropriate and effective treatment for their patients.
In fact, the diagnosis of a thyroid nodule or mass is not an easy one. It may be a tumor or a non-tumor disease, benign or malignant, and the clinical diagnosis determines the treatment plan, which varies from one disorder to another, and may require surgery or medical treatment. So, how to make a reasonable and accurate diagnosis of thyroid nodules or lumps? How do you treat a nodule or lump after diagnosis? What is the best way to perform thyroid surgery? How to follow up after surgery? These are the topics that thyroid surgeons should study properly.
I. Diagnosis of thyroid nodules or lumps
The diagnosis of a thyroid mass is not a simple matter! It is definitely not something that can be resolved by simple palpation. Of course, an experienced clinician’s examination and palpation can often make the initial diagnosis, but certain routine tests are needed to provide the clinician with additional diagnostic information.
The worst situation is to mistake a malignant tumor for a benign tumor, which leads to inappropriate treatment, delayed treatment, and even adverse consequences.
In fact, as far as the characterization of thyroid masses is concerned, several tests are helpful.
Physician palpation.
Hard texture, rough surface, fixation, and unclear borders are often signs of malignancy, and the possibility of malignancy should be considered even more when the ipsilateral cervical lymph nodes are palpably enlarged. Thyroiditis, especially Hashimoto’s thyroiditis, sometimes presents as a hard mass, but often with a history of acute upper respiratory tract infection and significant tenderness. Multiple nodules are present at the same time, and most cases are nodular goiter if they are not hard.
Indirect laryngoscopy or electronic laryngoscopy.
Vocal fold mobility should be part of the routine examination. Vocal fold paralysis is almost always a malignant tumor and may of course be due to injury to the recurrent laryngeal nerve from previous surgery. Benign thyroid nodules rarely show vocal cord paralysis, and I have not seen it in more than a decade of practice!
Ultrasound.
Ultrasound of the thyroid gland is up to about 85% accurate in the qualitative diagnosis of thyroid nodules. Calcification, poorly defined borders, substantial nodules, and enlarged paratracheoesophageal lymph nodes or lateral cervical lymph nodes are important indications for the diagnosis of malignant thyroid tumors by ultrasound.
CT.
The qualitative diagnosis of thyroid mass is even inferior to color ultrasound, however, it can clearly and visually show the location and surrounding relationship of the mass, and should be used as a routine examination for patients with huge masses and suspected malignant thyroid tumors. More importantly, CT plain scan provides too little information to be meaningful, and plain scan + enhancement should be used as a routine.
Fine needle aspiration cytology.
It is the most reliable basis for preoperative qualitative diagnosis as a routine test in most of Europe and America, however, in China, except for a few hospitals with high cytology level, the reliability of diagnosis is not high, which is the reason why our hospital is obviously different from NCCN guidelines when preparing the Guidelines for the Treatment of Thyroid Nodules and Thyroid Cancer
Thyroid function.
It is possible to understand both the function of the thyroid gland and to help in the identification of nail infection. Of course, it is not significant to check T3 and T4 alone, but TSH, TG and TM are more significant.
Thyroid nuclear scan.
Once considered a diagnostic routine, however, after intensive research, scholars have found that the nuclear scan has little value in identifying benign and malignant, however, it can provide some assistance in the functional status of the thyroid gland and is of high value in the diagnosis of metastases with iodine absorption.
In fact, after a comprehensive and careful clinical examination, thyroid ultrasound, and the five tests of thyroid function, the judgment of benign and malignant is already tentatively formed. We suggest that the above examinations should be used as a routine examination for patients with thyroid masses.
When we relax the diagnostic indications of nail cancer appropriately, the possibility of missing the diagnosis of malignant thyroid tumor becomes very small. The head and neck department of our hospital treats about 250 cases of thyroid tumors annually, including about 60 cases of nail cancer, and the possibility of missing the diagnosis is only about 1%.
Treatment of thyroid nodules and lumps
Not all thyroid nodules or masses require surgery. Surgery is not necessary for nail infection or nodular goiter with a maximum diameter of less than 1.5 cm, but the fact that many general surgeons operate on almost all thyroid nodules is very irresponsible.
Of course, those with an unclear diagnosis of goiter, those who have failed experimental endocrine therapy, or those who have formed significant nodules with calcification should undergo diagnostic surgery and be frozen intraoperatively, and the appropriate procedure should be performed based on the results. Nodular goiter masses larger than 1.5 cm, or if malignancy is not excluded, or if the mass is large and has symptoms of compression should be treated surgically.
There is no doubt that any thyroid tumor with malignant potential should be treated surgically.
In fact, many clinicians understand that surgery cannot treat nodular goiter disease per se. It can only remove the enlarged nodule, relieve the compression or prevent possible compression, and, of course, prevent malignancy. Therefore, we believe that non-surgical treatment of benign thyroid nodules is worth exploring, such as anhydrous alcohol intracapsular injection, physiologically required levothyroxine replacement therapy, etc., provided that there is a high degree of diagnostic certainty.
Third, how to do thyroid surgery
It is due to the difficulty of preoperative qualitative diagnosis of thyroid masses and the high demand for fine anatomy in thyroid surgery that makes thyroid surgery not as simple as one might think. It is irresponsible to pursue a quick surgery.
In 2007, the National Conference on Head and Neck Cancer officially put the fine dissection of the thyroid envelope on the agenda. We advocate the use of small surgical magnification to perform thyroid surgery with fine dissection of the thyroid envelope, revealing and protecting at least one parathyroid gland on each side of the thyroid gland, and revealing the recurrent laryngeal nerve as a routine.
It is obvious that total thyroidectomy for nodular goiter is excessive (except when the entire thyroid gland is involved), just like high-dose I131 treatment for hyperthyroidism and long-term thyroxine replacement therapy after hypothyroidism, but it is a puzzling fact that Europe and the United States are happy to do it. There has been a recent shift in the concept of conventional total thyroidectomy for unilateral thyroid cancer.
According to current evidence-based medical evidence suggesting that.
(i) normal thyroid tissue should be preserved as much as possible in nodular goiters with indications for surgery, and replacement therapy should be given postoperatively when the amount of preserved tissue is insufficient.
(ii) One side of thyroid differentiated carcinoma without lymph node enlargement in the neck should be routinely removed along with lymph nodes in VI area by lobectomy of one side + isthmus.
(iii) Modified neck dissection for thyroid cancer with enlarged lymph nodes in the neck on one side, with the same treatment of the thyroid gland as before.
④ Modified neck clearance should preserve the cervical plexus nerve as much as possible.
⑤ Special types of thyroid cancer should be treated according to their pathological nature.
When malignancy is suspected preoperatively, intraoperative freezing examination is performed and decision is made according to pathological results. When malignancy is highly suspected intraoperatively and the frozen pathology suggests benign tumor, it should be treated as malignant while preserving the parathyroid glands and the laryngeal recurrent nerve.
IV. What to do after surgery
After surgical removal of thyroid masses, not everything is fine, in most cases, further treatment is needed.
① Those with nodular goiter with too little residual thyroid tissue should be treated with replacement therapy, constant testing of TSH levels, and adjustment of medication to prevent residual thyroid tissue from forming nodules again.
②Patients with high-risk factors for nail cancer should undergo TSH suppression therapy after surgery, and try to suppress TSH levels below 1.0uIU/ml as long as tolerated, and use the medication for at least five years.
(③) If the differentiated type of thyroid cancer is not cleanly resected surgically, or there are lung metastasis or bone metastasis, internal radiation therapy with I131 is still needed after surgery.
Since the postoperative treatment of different thyroid diseases varies, clinicians must have a good grasp of the principles of treatment for different cases, establish follow-up files for each patient and instruct them to follow up closely after surgery, and as patients should also actively cooperate with doctors’ treatment and undergo examination according to the routine.