Overview
Most of the limited masses formed by abnormal proliferation of thyroid cells have no obvious symptoms, some may have neck lumps, hoarseness, etc. Most of them do not need treatment, and those with large nodules or malignant changes should be surgically removed, mainly relying on the diagnosis of thyroid ultrasound and thyroid function tests.
What are thyroid nodules?
Definition
Thyroid nodules are masses in the thyroid tissue that appear after abnormal proliferation of thyroid cells and are a common clinical condition.
Thyroid nodules can be single or multiple, and are mostly asymptomatic in the early stages.
Classification
Classification according to the nature of nodules
Benign nodules: most of them are regular in shape, not adherent to the surrounding tissues, and cannot be touched to the lymph nodes in the neck, e.g. multinodular goiter, Hashimoto’s thyroiditis.
Malignant nodules: irregular in shape, can be adhered to the surrounding tissues and accompanied by enlarged lymph nodes in the neck, such as primary thyroid cancer, metastatic thyroid cancer (primary cancer is breast cancer, kidney cancer, etc.).
Classification according to the texture of nodules
Solid nodules: the main type of adenoma and carcinoma.
Cystic nodules: may manifest as localized pain, and if left untreated, intracapsular hemorrhage may occur in severe cases.
Classification of nodules according to their ability to uptake radionuclides
Hot nodules: autonomous thyroid nodules with endocrine function, almost always benign.
Warm nodules: most often seen in normal functioning thyroid adenomas, nodular goiter.
Cold nodules: without endocrine function, single cold nodule has higher cancer rate. If there is hemorrhage or cystic degeneration within the nodule, it may also appear as a “cold nodule”.
Incidence
Thyroid nodules are present in about 2-7 out of 10 people, of which only 7%-15% are malignant and most are benign [1-3].
Questions you may be concerned about
Can I get the New Crown vaccine for thyroid nodules?
Most patients with thyroid nodules can be vaccinated with the New Crown vaccine. Some patients need to hold off on vaccination until their condition has stabilized.
If patients with thyroid nodules have obvious abnormalities of thyroid function, such as TSH>10μIU/ml and T3 and T4 lower than normal values in patients with combined hypothyroidism, it is recommended to withhold vaccination; and patients with combined uncontrolled hyperthyroidism or hyperthyroidism with protruding eyes, it is recommended to withhold vaccination.
Patients who are taking levothyroxine for hypothyroidism or the anti-thyroid drugs methimazole and propylthiouracil are not contraindicated for vaccination.
What department should I consult for thyroid nodules?
Thyroid nodules are usually treated in endocrinology or thyroid and breast surgery or general surgery.
If there is no discomfort and the thyroid nodule is found during physical examination, the nodule is usually small and there is no serious symptom, you can usually consult the endocrinology department for treatment first.
If you feel obvious swelling at the neck, or have difficulty swallowing, irritating cough, voice change, etc., or find that the nodule suddenly increases in size in a short period of time, you need to hang up with the Department of Thyroid and Breast Surgery and General Surgery, and according to the results of the puncture examination or ultrasound results to determine the need for surgery and other treatments.
What should I pay attention to in my diet for thyroid nodules?
Thyroid nodule patients should pay attention to the reasonable intake of iodine in their diet. For nodules with normal thyroid function, “moderate iodine diet” is preferred; if thyroid nodules are combined with hyperthyroidism, “limited iodine diet” is preferred, with the consumption of non-iodized salt and avoidance of seafood; for nodules combined with Hashimoto’s thyroiditis, “low iodine diet” is preferred. For nodules combined with Hashimoto’s thyroiditis, a “low iodine diet” is recommended, i.e. consuming iodized salt and restricting high iodine foods, such as kelp and seaweed. Thyroid nodules combined with hypothyroidism can consume iodized salt while eating more foods with high iodine content.
Is a grade 4a thyroid nodule cancer?
Grade 4a thyroid nodules are not necessarily cancerous. 2% to 10% of grade 4a thyroid nodules are malignant.
Currently, the TIRADS classification standard is mostly used to evaluate the benignness and malignancy of thyroid nodules, and the grading is as follows:
Grade 1 is no nodule, and the malignancy rate is 0%;
Grade 2 is benign nodules with a 0% malignancy rate;
Grade 3 is a possibly benign nodule with a malignancy rate of <2%;
Grade 4 is categorized into 4A, 4B, and 4C, where 4A is lowly suggestive of malignancy with a malignancy rate of 2% to 10%, 4B is moderately suggestive of malignancy with a malignancy rate of 10% to 50%, and 4C is highly suggestive of malignancy with a malignancy rate of 50% to 90%;
Grade 5 is highly suggestive of malignant nodules with a malignancy rate of >90%;
Grade 6 is biopsy-proven malignant nodules.
Is Xia Ku Cao a cure for thyroid nodules?
Xia Gu Cao is useful in the treatment of thyroid nodules.
Thyroid nodules belong to the category of “gall tumors” in Chinese medicine, and Xia Gu Cao has the function of clearing heat and fire, dispersing lumps, and has a certain therapeutic effect on patients with thyroid nodules that are characterized by liver depression, phlegm, and fire gathering in the body, but it has no therapeutic effect on other types of thyroid nodules.
It should be noted that the dispersing effect of Xia Gu Cao on thyroid nodules is limited, and it is often needed to be used together with other medicines in clinical practice.
Causes
Causes
The exact cause of the disease is not known, but may be related to the following factors.
Radiation
The thyroid gland is more sensitive to radiation, and radiation exposure can cause thyroid cell lesions, especially in those who received a large dose of neck irradiation at a young age.
Genetic factors
Some thyroid nodules have a clear genetic predisposition. The most typical is malignant thyroid nodules, which show family inheritance in more than 25% of patients.
Abnormal iodine intake
Iodine deficiency has long been recognized to be associated with the development of thyroid nodules. The incidence of malignant thyroid nodules is higher in mountainous areas with severe iodine deficiency.
Sex hormones
There is a large gender difference in the incidence of thyroid nodules, with women having a significantly higher incidence than men. Sex hormones may play a role in the pathogenesis.
Other factors
Factors such as environmental pollution, alcohol and smoking, high work pressure, irregular life, unhealthy diet, lack of exercise, and obesity can lead to an increased risk of thyroid nodules [4-6].
Symptoms
Main Symptoms
Foreign body sensation in the neck
Thyroid nodules usually have no obvious symptoms, but may have a foreign body sensation or discomfort in the neck. As the nodule grows, it may compress or involve the surrounding tissues and produce corresponding symptoms.
Hoarseness
Some patients may experience hoarseness and dysarthria due to compression by the nodule when the recurrent laryngeal nerve is involved.
Sense of pressure
In some patients, nodal compression leads to hoarseness, a feeling of pressure, difficulty in breathing or swallowing, and other symptoms of compression.
Pain
Bleeding in the nodule can cause acute pain and enlargement of the nodule.
It may move up and down in response to swallowing motions, and occasional pain may occur.
Difficulty or pain in swallowing occurs when the esophagus is compressed.
A large retrosternal goiter can cause superior vena cava syndrome (Pemberton’s sign).
If thyroid cancer metastasizes, symptoms related to chest pain, dyspnea, bone pain, and neurological problems may occur.
Hemoptysis
Coughing and shortness of breath occur when the airways are compressed.
Hemoptysis occurs when the trachea is invaded.
Other symptoms
Palpitations, excessive sweating, hand tremors and weight loss in the presence of hyperthyroidism.
With hypothyroidism, there is chills and generalized weakness [6-8].
Consultation
Department of Medicine
Endocrinology
Prompt medical consultation is recommended when the following symptoms occur
Touching a lump in the front of the neck, self-consciousness that the neck has become thicker than before, hoarseness, difficulty in swallowing, etc.
Unexplained weight loss, hand tremor, easy to get hungry, fear of heat and excessive sweating, protruding eyeballs, etc.
Presence of unexplained weakness, poor concentration, chills, decreased sweating, etc.
Emergency Department
When symptoms such as high fever, vomiting, convulsions, unconsciousness, coma, etc. occur, immediate medical attention is recommended.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for the doctor
In order to facilitate the doctor’s examination, try not to wear high-collared clothes or necklace jewelry.
If there is any weight change, suggest the time and result of weight measurement for the doctor’s reference.
In case of vomiting, you can use your cell phone to take a picture of the vomit and save it for the doctor’s reference.
Preparation Checklist for Doctor’s Visit
症状清单
Have you noticed a lump in the front of the neck or the neck has become thicker than before?
Is there any hoarseness of voice, difficulty in pronunciation, difficulty in swallowing?
Is there irritability, panic, hunger, fear of heat and sweating, protruding eyes?
Is there any fatigue, coldness, lack of concentration, decreased sweating?
Has there been any change in weight in the last six months?
病史清单
Are any blood relatives suffering from thyroid disease?
Are there any allergies to drugs, food or other substances?
Are there any diseases such as hypertension, diabetes, systemic lupus erythematosus, rheumatoid arthritis, etc.?
Are there any cases of exertion, nervousness, frequent anger, or stress?
检查清单
Laboratory tests: thyroid function, thyroid autoantibodies, blood test, liver function, kidney function.
Imaging tests: thyroid ultrasound, thyroid radionuclide scanning, eye CT, eye magnetic resonance imaging, heart ultrasound, pituitary magnetic resonance imaging
Other tests: electrocardiogram
用药清单
Thyroid hormone: levothyroxine sodium tablets
Imidazoles: methimazole, carbimazole
Thiouracil: propylthiouracil
Beta-blockers: propranolol, metoprolol
Iodine-containing drugs: amiodarone, compound iodine solution, iodine-containing contrast media
Glucocorticoids: hydrocortisone, prednisone acetate, methylprednisolone, dexamethasone
Symptom list
Particular attention needs to be paid to the time of onset of symptoms, specific manifestations, etc.
Is there any foreign body sensation or discomfort in the neck?
Is there a sudden increase in the size of the anterior neck mass? Is there any pain?
Is there difficulty in swallowing, dyspnea, hoarseness?
Is there palpitation, excessive sweating, emaciation? or fatigue, chills, etc.?
Medical History Checklist
Any history of radiation exposure to the neck?
Any previous thyroid disease? What kind of treatment has been received?
Any family members with thyroid disease?
Checklist
Test results from the past 6 months, which can be brought to the doctor’s office
Imaging tests: ultrasonography of the thyroid gland and lymph nodes in the neck, nuclear thyroid test, CT of the neck, etc.
Laboratory tests: blood routine, biochemical routine, thyroid function test, etc.
Pathologic examination: thyroid nodule biopsy results, etc.
Medication list
Medication used in the last 3 months, if available in a box or package, carry it with you to the doctor’s office. For example, levothyroxine tablets, methylthiouracil, etc.
Diagnosis
Basis of diagnosis
Medical history
Excessive or low iodine intake.
History of radiation exposure.
Family history of thyroid nodules.
Clinical manifestations
A distinct isolated nodule is the most important sign.
About 4/5 differentiated thyroid carcinomas and 2/3 undifferentiated carcinomas present as a single nodule.
A proportion of thyroid carcinomas present as multiple nodules.
Patients with cancer often have large, hard lymph nodes palpable in the lower 1/3 of the neck.
The doctor will perform a palpation examination of the patient’s neck.
The examination requires a swallowing motion as instructed by the doctor to determine if the nodes are mobile, as well as the boundaries and hardness of the nodes.
Laboratory Tests
Routine blood tests are of little diagnostic value for thyroid nodules.
Autonomous hyperfunctional thyroid adenomas have decreased TSH with elevated T3 and T4, and autonomous functional adenomas have decreased TSH and normal T3 and T4.
The presence of positive thyroid autoantibodies suggests the presence of Hashimoto’s thyroiditis, but because papillary thyroid carcinoma and thyroid lymphoma can coexist with Hashimoto’s thyroiditis, concomitant malignant disease cannot be excluded.
Elevated calcitonin is a specific marker for medullary thyroid carcinoma, and serum calcitonin should be measured if medullary thyroid carcinoma is suspected.
Serum carcinoembryonic antigen is elevated in most patients with medullary thyroid carcinoma, but sometimes it is also elevated in other thyroid malignancies.
Serum thyroglobulin is not helpful in determining the nature of thyroid nodules, and it is mainly used in clinical practice to determine the surgical outcome and recurrence of well-differentiated thyroid carcinomas.
If parathyroid cysts are suspected, the level of parathyroid hormone in the cystic fluid can be measured. Most of the cystic fluid in parathyroid cysts is pure watery fluid, and the level of parathyroid hormone in the cystic fluid is significantly elevated, which can be two to several thousand times of the normal serum level.
Imaging
Ultrasonography: Ultrasonography of the lymphatic drainage area of the thyroid gland can also assist in the diagnosis of lymph node metastasis in malignant lesions.
Nuclear imaging: It can show the location, size, and shape of the thyroid gland and also provide information about the function and blood supply of the thyroid nodules.
Special reminder: the function and blood supply status of the nodule is related to the benign or malignant nature of the lesion; the richer the blood supply, the higher the probability of the nodule being malignant.
Pathologic examination
Ultrasound-guided needle aspiration cytology: this examination is currently the “gold standard” for preoperative identification of benign and malignant thyroid, and its diagnostic sensitivity and specificity are over 90%.
Molecular diagnosis helps to minimize unnecessary surgery in patients with indeterminate cytology results, as approximately 75% of indeterminate nodules are benign on postoperative histopathology [6-11].
Differential diagnosis
The main concern is to differentiate between the benign and malignant nature of the nodule.
Thermal nodules
Most benign nodules are “hot nodules”.
In thyroid hormone-producing nodules, more isotopic markers are absorbed by the nodules than by normal thyroid tissue, so that they can be clearly distinguished with the help of markers.
Cold nodules
“Cold nodules may become cancerous.
Nodules that do not have a thyroid secretory function are called “cold nodules”.
Fine-needle aspiration cytology can be used to determine whether the nodule is benign or malignant.
Treatment
The aim of treatment is to remove the malignant lesion and relieve the pressure and other symptoms of the benign lesion. At the same time, thyroid hormone levels should be reasonably maintained.
Treatment principle: benign nodules with normal thyroid function can be examined regularly if there are no clinical symptoms, and can be treated surgically if symptoms such as compression occur. Benign nodules with abnormal thyroid function need medication. Malignant lesions should be treated with surgery according to the stage of the disease and the type of pathology.
General treatment
Benign nodules are regularly reviewed to observe changes in the nodules.
Regular physical examination and thyroid function tests should be performed by the doctor.
Daily attention should be paid to avoid radiation exposure.
For those with iodine deficiency, iodine-rich foods such as seaweed can be consumed.
Medication
Thyroid hormone suppression therapy can be used directly for those with benign lesions, or for those whose nodules increase in size during follow-up.
TSH can be suppressed below 0.1 Mμ/L.
The initial dose of levothyroxine is recommended to be 100-150 μg/d for 1 year.
If the nodule shrinks after 1 year, thyroxine is reduced for long-term use to suppress TSH at the low limit of normal.
Those whose nodules increase in size during treatment need to stop treatment and undergo surgery or puncture, and those who have no change in suppression therapy also stop treatment, only as a follow-up observation.
Caution is needed in the use of thyroxine suppression therapy in postmenopausal women, the elderly, those with heart disease and osteoporosis.
If the nodules cause hyperthyroidism, radioactive iodine therapy, such as compound iodine oral solution, may be used.
Taking antithyroid drugs to suppress thyroid hormone secretion: The commonly used antithyroid drugs are thiosemicarbazones.
Propylthiouracil (PTU) of the thiouracil group.
Methylthiouracil (MTU).
Methimazole.
Carbimazole.
Levothyroxine.
After surgical treatment, long-term levothyroxine may be needed to maintain thyroid levels.
Surgical Treatment
Total thyroidectomy
Removal of the entire thyroid gland and complete removal of the lesion.
There is a risk of injury to the nerves in the larynx and the tissues around the thyroid gland.
Post-operative hypothyroidism is likely to occur and long-term medication is required for replacement therapy.
Unilateral lobectomy
Remove the thyroid tissue on the diseased side and preserve the normal glandular tissue on one side.
Postoperative recovery is faster and associated complications are fewer.
It is suitable for early malignant lesions and benign nodules.
Microwave ablation
A minimally invasive procedure.
It can reduce and eliminate the size of benign nodules.
Not recommended for patients with malignant nodules.
Lumpectomy
Surgery of thyroid nodules with a laparoscope is minimally invasive.
It is contraindicated for larger nodules and advanced malignant thyroid tumors [6,11-15].
Traditional Chinese medicine (TCM) treatment
It can relieve the symptoms associated with thyroid nodules in patients.
There is no authoritative evidence that TCM can effectively treat thyroid nodules.
Prognosis
Cure
Thyroid nodules are not self-curable, but most thyroid nodules do not have symptoms, and if the benign nodules are small in size, they will not affect the patient’s life.
If the size of benign nodules is large, the treatment is more effective and does not affect daily life.
Thyroid cancer can be clinically cured with standardized treatment.
Harmfulness
It can lead to abnormal thyroid secretion function and symptoms such as hyperthyroidism and hypothyroidism.
Large nodules may affect the appearance.
Large nodules can lead to compression, swallowing and breathing difficulties.
Metastasis of thyroid cancer can be life-threatening.
Daily
Daily Management
Dietary management
Intake of sufficient calories
Enhance diet to ensure energy supply.
Control of iodine intake
Iodine is an important component in the synthesis of thyroxine. Giving patients appropriate amounts of iodine compounds can increase thyroxine storage and reduce its release, but excessive iodine intake can interfere with antithyroxine therapy and cause harm to the patient.
Work and rest management
Regularize your daily routine, get enough sleep and avoid exertion.
Keep your mood stable and do not be overly anxious or nervous.
Do not stay up late or smoke.
Avoid excessive alcohol consumption, smoking and other cancer risk factors to avoid triggering cancerous thyroid nodules.
Psychological support
Patients can regulate their own emotions and avoid excessive sadness and depression.
Colleagues, friends and family members should enlighten the patient and give spiritual encouragement and care.
Disease monitoring
Indicators for monitoring
Including changes in heart rate/pulse, measure the patient’s early morning heart rate and blood pressure, and pay close attention to changes in basal metabolism.
Patients receiving medication
Patients need to monitor the focus of thyroid hormone levels. It is recommended to wake up early in the morning and first look at the mirror to observe whether there is any abnormal edema in their neck.
At the same time, touch the skin surface of the nodule with your hand to sense if there is any pain and if there is any pressure in the throat.
If symptoms occur, you need to seek medical help promptly.
Post-surgery patients
Post-surgery patients need to focus on monitoring the surgical wound at home.
Observe whether there is any infection and whether the wound is pus-filled and broken.
Choose a cleaner living and working environment, away from dust and sources of infection.
Patients who need long-term medication after surgery
Patients, usually those who have had a massive removal of the thyroid gland, need to be concerned about wound infections during the recovery period after surgery.
After the recovery period, you need to monitor your thyroid hormone levels.
If you notice any uncomfortable symptoms such as generalized weakness, swollen lymph nodes or dizziness, you need to seek medical attention promptly.
Prevention
Stay away from radioactive sources and ionizing radiation
The possible cause of thyroid nodules is exposure to radiation sources, so you should avoid the effects of harmful substances in the environment on your body on a daily basis.
Avoid the use of drugs
Certain medications can affect metabolism, such as diet pills or nutritional supplements containing phytohormones.
Control the intake of iodine appropriately
Moderate intake of iodized salt and iodine-rich foods such as kelp and nori.
Those with symptoms of hyperthyroidism need to limit their iodine intake.