With the popularity of medical checkups, the detection rate of thyroid nodules is gradually increasing. The prevalence of thyroid nodules detected by ultrasound is 20%-70%, but 90% of them are benign and do not require pharmacological intervention or surgical treatment. In particular, in local hospitals, for the sake of hospital efficiency, surgical excision is performed directly to treat thyroid nodules without the relevant tests or nodule evaluation.
In the case of thyroid nodules, we first determine whether they are functional or not, and secondly, we further identify the benignity or malignancy of the nodule. When we find a thyroid nodule, we first perform a thyroid function test. Most thyroid nodules are non-functional, while a small percentage of nodules are toxic adenomas, which can lead to hyperthyroidism. If the nodule is functional, it can be judged as benign. After the ultrasound, a nuclear scan can be performed to clarify the function of the nodule. After that, treatment can be either surgery or iodine 131. For non-functional nodules, our next focus is to identify benign and malignant.
1. The differentiation of benign and malignant thyroid nodules begins with the medical history. The following medical conditions increase the risk of nodule malignancy.
(1) History of head and neck radiation exposure or radioactive dust exposure during childhood;
(2) History of systemic radiation therapy;
(3) Prior or family history of differentiated thyroid cancer;
(4) Age less than 15 years or more than 70 years;
(5) Male patients. Secondly, the symptoms.
2. The following symptoms increase the risk of malignant nodules.
(1) Rapid nodule growth and diameter more than 2 cm;
(2) with persistent hoarseness and dysphonia, and vocal fold pathology (inflammation, polyps, etc.) can be excluded;
(3) With dysphagia or dyspnea;
(4) Irregular shape of the nodule and fixed adhesion to the surrounding tissue;
(5) with pathological enlargement of lymph nodes in the neck. Again, it is combined with ultrasound examination to further determine the benignity and malignancy of the nodule.
3, In ultrasound suggestive of nodule malignancy analysis features are.
(1) solid hypoechoic nodules;
(2) rich blood supply and disturbance of blood flow in the nodule;
(3) Irregular nodule morphology and margins, halo absence;
(4) Microcalcifications, pinpoint-like diffuse distribution or clusters of calcifications;
(5) abnormal ultrasound images of the cervical lymph nodes. Among them, the specificity of microcalcifications, irregular nodal margins and disturbance of blood flow in the nodes under ultrasound performance is high, but the specificity of a single item suggesting malignancy is poor, so when we cannot take one abnormality of ultrasound we are overly nervous and rush to surgery.
For after assessing the possibility of benign and malignant nodules through medical history, symptoms, and ultrasound findings, the next step is further treatment. First of all, for nodules considered benign, we suggest that patients should review the ultrasound regularly, once every six months or once a year, to dynamically observe the changes of the nodules. For benign nodules, the current medical evidence suggests that there are no medications to treat them, so patients are not advised to use medications indiscriminately to reduce the size of the nodules.
Among them, thyroid hormone suppression therapy may be able to shrink benign nodules, but it is more likely to rebound after stopping the medication and is only suitable for patients with relatively high TSH, so it is not routinely recommended clinically, but can be used for a short period of time for identifying benign and malignant nodules. In addition, radiofrequency ablation is gradually being used for the treatment of benign thyroid nodules, but routine pathological examination is recommended before treatment. In addition, for cystic nodules, which are 99% likely to be benign, alcohol injection sclerotherapy is an option if the nodule is relatively large.
During the follow-up of benign nodules, surgery may be considered in the following cases.
(1) Nodules >3 cm in diameter, with local pressure symptoms or significant cosmetic impact;
(2) Combined with hyperthyroidism, where medical treatment is ineffective;
(3) The mass is located in the posterior sternum or mediastinum;
(4) Progressive growth of nodules with clinical consideration of malignant tendency or combined with high risk factors for thyroid cancer;
(5) Those who strongly request surgery because of appearance or excessive ideological concerns affecting normal life.
If the above-mentioned conditions do not occur during follow-up, but nodules are found to be significantly growing, i.e., nodule volume increases by more than 50%, or at least 2 diameter lines increase by more than 20% (and more than 2 mm), fine needle aspiration of thyroid nodules is recommended. Second, for nodules that are clinically suspected to be benign or malignant and cannot be clearly diagnosed, thyroid fine needle aspiration may be considered at this time. Thyroid fine needle aspiration is the most sensitive and specific indicator of the benignity or malignancy of a nodule. For nodules with high suspicion of malignancy, surgical excision may be considered directly, but if the patient agrees and thyroid aspiration is available, we recommend that a pathological examination of the nodule be performed first, as the pathological findings can help guide the choice of surgical approach.
Surgical treatment of malignant thyroid nodules inevitably leads to hypothyroidism, as most of the thyroid gland is removed for malignant nodules. These patients often fail to visit the endocrinology department in time to assess their condition after surgery, leading to recurrence. After surgery, some patients need to undergo iodine 131 nail clearing therapy or focal clearance therapy, and most patients need to use thyroid hormones to suppress tumor recurrence, all of which need to be evaluated by regular endocrine follow-up.
The prevalence of thyroid nodules is high, but the malignancy is low, and malignant thyroid nodules can be cured with regular treatment. Here, I suggest that patients follow the following procedure for proper diagnosis and treatment of thyroid nodules: discovery of thyroid nodules – assessment of function and identification of benign and malignant by endocrinologists (the 3 5 principles, i.e. 5 points of medical history, 5 points of symptoms and 5 points of ultrasound) – Endocrinologist determines whether to perform fine needle aspiration – Referral to surgery for patients requiring surgery – Follow-up of endocrine after surgery.