A history of head radiation exposure or exposure to radiation during childhood or adolescence; family history; patient age <14 or >70 years; nodules in males; nodules found to have increased significantly within a short period of time on review – these are all high risk factors for cancer.
I. Women + stress are prone to thyroid nodules
Hello, Director Wu, and welcome to the show. In this issue, we would like to talk about the topic of cancerous thyroid nodules, first of all, can you introduce what is a thyroid nodule?
Dr. Wu Yijun: Thyroid nodules refer to the local abnormal growth of thyroid cells, forming a kind of scattered lesion. When it can be felt by hand and confirmed by ultrasound, we call it a thyroid nodule. If the nodule can be felt by hand but not detected by ultrasound, we cannot call it a nodule. In other cases, when the nodule is not palpable by hand but is detected by ultrasound, we call it an accidental nodule.
It is important to remember that not all thyroid nodules can be palpated by hand. This is related to the size of the nodule, its hard and soft texture, its location, and the experience of the doctor. Usually, nodules that are more superficially located, over 1 cm in size, and hard in texture are easy to palpate. However, nodules that are palpated will eventually require ultrasound confirmation. At present, the incidence of thyroid nodules in the general population is very high.
They are more prevalent in women
What is the pattern of thyroid nodules?
Dr. Wu Yijun: First of all, thyroid nodules are more common in women, with a 3:1 ratio between women and men, which may be related to the difference in estrogen and progesterone between men and women.
The thyroid tissue contains receptors for estrogen and progesterone. The level of estrogen and progesterone receptors in women is significantly higher than that in men. Moreover, the endocrine hormone changes in women during their lifetime are relatively large, such as pregnancy, breastfeeding, and the decline of ovarian function after menopause, which can affect estrogen and progesterone secretion. For the thyroid gland, the greater the hormonal fluctuations, the greater the impact on the thyroid gland, and the more likely it is to cause nodules.
In addition, the incidence of inflammatory diseases and autoimmune diseases of the thyroid gland is significantly higher in women than in men. Changes in inflammatory and autoimmune cells can stimulate thyroid tissue to proliferate, resulting in nodules.
Second, the incidence of thyroid nodules is higher in coastal areas than inland. This is because residents of coastal areas are easily and chronically exposed to foods high in iodine content. This may cause an excess of iodine, which stimulates thyroid hyperplasia and thus induces nodules.
People who are more stressed have a higher chance of developing thyroid nodules, don’t they?
Dr. Wu Yijun: Nowadays, people’s life is fast-paced and stressful, which can easily cause mental tension, lack of sleep and irregular diet. All of these can cause endocrine disorders in the human body. When the endocrine disorder is not adjustable, it will easily cause thyroid malfunction and lead to thyroid nodules.
Ultrasound hypoechoic, basically confirming the presence of nodules
Does “hypoechoic thyroid nodule recommended for review” mean there is a thyroid nodule?
Dr. Yijun Wu: Yes, the ultrasound reveals a hypoechoic nodule, which basically confirms the presence of a nodule in the thyroid gland. At this point, all the doctor has to do is determine whether the nodule is benign or malignant.
During the examination, the doctor asks the patient to swallow saliva, and not being able to swallow proves that there is a nodule, right?
Dr. Wu Yijun: Swallowing saliva is very important in the physical examination of the thyroid gland. Its main purpose is to let the doctor sense whether there are nodules in the thyroid gland, as well as the location, texture and mobility of the nodules. However, you cannot say that if you cannot swallow, you have a nodule or that it is caused by a nodule.
What else should I look for if a nodule is present?
Is it necessary to do thyroid function tests when ultrasound shows nodules?
Dr. Yijun Wu: Yes. All patients with thyroid nodules should have a serum thyroid stimulating hormone and thyroxine test, and may also need to have thyroid peroxidase antibodies and thyroglobulin measured.
Generally, elevated thyroxine levels are followed by decreased thyrotropin, often suggesting hyperthyroidism, or high-functioning adenoma, and these are essentially benign nodules. In contrast, thyrotropin is mostly normal or low in patients with malignant nodules.
Do I need an X-ray to confirm a thyroid nodule?
Dr. Yijun Wu: The most common clinical test is ultrasound. High-frequency ultrasound is the most convenient, effective and sensitive way to evaluate the thyroid gland, and it is radiation-free and non-invasive.
For huge goiters or nodules, X-rays may be used considering the compression or nudging of the trachea. However, CT examination is often the clinical choice. This is because the spatial sense and accuracy of CT is much better than that of ordinary X-rays.
Do we have to do fine needle aspiration?
Dr. Wu Yijun: The purpose of fine needle aspiration is to identify the benignity and malignancy of thyroid nodules.
Before the technology of fine needle aspiration was immature, we relied on ultrasound imaging to determine the nature of the nodule. At that time, there were often some patients who underwent surgery because of a suspected malignant nodule, while the postoperative pathology was benign.
Now, nodules suspected by ultrasound to have adverse images are further screened by the surgeon with a fine needle aspiration. This diagnosis from the level of cytology has improved the rate of confirming malignant tumors and allowed patients with clinical suspicion of cancer but benign puncture to avoid unnecessary surgery.
Second, what should be done if nodules are found?
Some nodules do not need to be treated
What kind of nodules can be observed and do not need treatment?
Dr. Wu Yijun: If the ultrasound indicates that the nodule has regular shape, clear boundary, uniform internal echogenicity, no fine calcification, no longitudinal to transverse ratio disorder and slow growth. This is mostly a benign nodule, so observation is sufficient and no treatment is needed.
If not treated, what should I pay attention to during the review?
Dr. Wu Yijun: In the early stage of diagnosis, the nodules should be reviewed once every 3-6 months. If the nodules are stable and have no malignant tendency, the review interval can be extended to once a year or more.
The main tests are thyroid ultrasound and thyroid function tests.
Which nodules should be treated?
What kind of nodules need intervention? need to be treated?
Dr. Wu Yijun: If the ultrasound indicates that the nodule is hypoechoic, irregular in shape, with unclear borders, multiple internal calcifications, aspect ratio greater than 1, rich internal blood flow, and rapid growth, it indicates an adverse tendency. This condition requires intervention.
If said ultrasound reveals the above problems, we will recommend fine needle aspiration. If the puncture result is benign, then we would recommend further observation; if the fine needle aspiration is clearly malignant or suspected to be malignant, surgery would be considered.
Some patients may have some uncertain diagnostic results because of the volume of the puncture specimen or their own disease, then we will recommend re-observation.
What kind of nodules are prone to cancer?
Dr. Yijun Wu: The chance of nodular goiter becoming cancerous is about 5%, and the chance of adenoma becoming cancerous is about 10%. As the diameter increases, the chance of adenoma becoming cancerous will also increase.
However, not all thyroid cancers develop from a benign nodule that is cancerous. It may also be born already cancerous. Today, very small nodules, only 0.4 to 0.5 cm in diameter, are found clinically, but once punctured, they are cancerous.
Therefore, we need to emphasize a few points for your attention, the following are the high risk factors for cancerous thyroid nodules.
1. History of head radiation exposure or exposure to radiation during childhood or adolescence;
2. Family history of thyroid cancer in the family;
3. Patients younger than 14 years of age or older than 70 years of age;
4. Men are more likely to have cancerous nodules than women;
5. Regular review reveals that the nodule increases significantly within a short period of time.
Beware! Nodules can become cancerous!
Why is the cancer rate higher in men?
Dr. Wu Yijun: As mentioned earlier, the incidence of nodules in women is higher than that in men because women themselves are easily affected by endocrine fluctuations and produce nodules.
Men’s endocrine is relatively stable compared to women, and basic inflammation and autoimmune diseases are a little lower than women. In this case men then grow nodules, the possibility of growing undesirable nodules is much higher.
What are the symptoms that indicate nodules are becoming cancerous?
Dr. Wu Yijun: The cancer process is difficult to explain clearly. In clinical practice, we often encounter patients who had a good physical examination last year, but when they are examined this year, the nodules become tumors. Some small nodules themselves do not cause obvious clinical symptoms to human body, but their nature is changed.
On the whole, when the cancerous nodules compress the surrounding tissues and nerves, and certain symptoms appear, such as hoarseness, compression of trachea, or causing difficulty in swallowing, etc., it often indicates that the tumor is already in the middle and late stage.
Prevention of nodule cancer by starting from life
How to prevent thyroid nodules from becoming cancerous?
Dr. Wu Yijun: In terms of the three levels of tumor prevention, prevention is the first level, the second level is early detection, and the third level is early treatment. Thyroid cancer is one of the cancers that have done relatively well in secondary prevention.
For the prevention of thyroid cancer, the following points can be started.
First, try to stop nodules from occurring. You should pay attention to the iodine-appropriate diet in your life, and you should not consume high iodine food for a long time.
Secondly, exercise properly to enhance physical fitness, maintain body weight and avoid excessive obesity.
Third, maintain good living habits and do not put too much pressure on your mind.
Fourthly, in daily life, try to avoid the contact of radioactive substances and irradiation.
Why can obesity prevent nodules from becoming cancerous?
Dr. Wu Yijun: Recent data show that overweight and obese people have an increased chance of nodules becoming cancerous. Obesity itself is also an endocrine imbalance. This affects the endocrine organs and organs. The thyroid gland can also be affected.
Security checks in airplanes and subways have radioactive scans. It is inevitable that disease screening will also have radioactive scans. So how can people with nodules avoid it?
Dr. Yijun Wu: The thyroid gland is very sensitive to radiation, yet people inevitably come into contact with radioactive sources in their daily lives. Some radiation is very weak or unavoidable, but it should be well protected.
Third, how to deal with malignant nodules?
How to choose the surgery method?
If cancer occurs, how to treat it?
Dr. Wu Yijun: At present, surgery is the first choice for treating thyroid cancer. Surgery can completely remove the cancerous nodes and metastatic lymph nodes, and the effect is complete and sure.
How to choose between open thyroid surgery and minimally invasive surgery?
Dr. Wu Yijun: The most ideal result of thyroid cancer surgery is the complete removal of the tumor including metastatic lesions while protecting the function of important nerves and organs, which means the unification of radical and minimally invasive.
At present, the mainstream surgery is total excision of the thyroid gland + lymph node dissection, and the other is lobectomy of one side of the thyroid gland + lymph node dissection.
Whether to choose open surgery or minimally invasive surgery, in general, depends on the different stages of the disease.
If the tumor is in early stage, there is no obvious lymph node metastasis, and the patient has cosmetic requirements, he/she can choose to have scarless neck surgery. It is a kind of lumpectomy, and the surgical operation is more difficult than open surgery.
For some patients with larger tumors and lymph node metastasis, it is still recommended to choose open surgery.
Does the adhesion of surrounding tissues affect the choice of surgical procedure?
Dr. Wu Yijun: Yes, it does. The size of the tumor and the invasion of the surrounding tissues is an important factor in the staging of the tumor. It is also called “T” in clinical practice.
If the tumor breaks through the envelope and invades the surrounding tissues and organs, it may be T3 or T4, and such patients are recommended to have open surgery.
Endocrine therapy after surgery
Do I need other treatments after thyroid nodule surgery?
Dr. Wu Yijun: For malignant thyroid tumors, endocrine therapy is needed after surgery. There are two types, one is hormone level replacement therapy and the other is hormone suppression therapy.
Hormone replacement therapy is because the thyroid gland function decreases or is missing after all or part of the thyroid gland is removed. This is when thyroxine supplementation from outside the body is needed to help the body achieve normal metabolism.
Hormone suppression therapy is targeted at differentiated thyroid cancer. We will give either a full dose or an overdose of thyroxine. This suppresses the secretion of thyrotropin from the anterior pituitary gland and inhibits the growth of tiny cancerous tissues in the body for the purpose of tumor treatment.
After the lesion is removed, does it have any effect on the patient’s life?
Dr. Wu Yijun: It will have an impact. The effect of the surgery is immediate when the lobe of the gland is removed and the lymph nodes are cleared. However, it will inevitably cause harm to the body. One of them is the obvious hypothyroidism. The second is the complications of the surgery, such as damage to the recurrent laryngeal nerve, which causes hoarseness, and damage to the parathyroid glands, which causes hypoparathyroidism and hypocalcemia.
After surgery, regular follow-up is required
Do patients need to be followed up after surgery?
Dr. Yijun Wu: Follow-up visits are necessary. The purpose of follow-up is to adjust the drug concentration, guide the medication and prevent complications. The second is to monitor tumor recurrence. We will divide the patients into low risk group, medium risk group and high risk group according to the risk of recurrence.
For patients in the low-risk group, the gap of follow-up can be extended appropriately.
Patients in the intermediate risk group or high risk group need to be reviewed about once in 3-6 months if their disease is stable after drug adjustment. If the patient is suspected to have signs of metastasis, including metastasis in lymph nodes and lungs, the interval should be shortened.
What is the difference between different follow-ups for patients with different risk levels?
Dr. Yijun Wu: For example, the same papillary carcinoma, one patient has 0.5 cm in diameter, underwent lobectomy and lymph node dissection on one side, and there is no metastasis in lymph nodes after surgery.
While another patient has a larger tumor that invades the surrounding muscles and has enlarged lymph node metastasis in the contralateral area.
The prognosis of these two patients is definitely different. The former has a good prognosis with low chances of metastasis and recurrence. The latter has a higher chance of distant metastasis or local recurrence.
Therefore, we classify and manage postoperative patients, and pay more attention to the follow-up of some patients with severe disease and late stage. The follow-up interval for these patients should be shortened. If a suspicious lesion is found, further examination, including puncture characterization, will be done at the first time to screen according to the site of metastasis.
For patients with mild disease, the follow-up interval can be longer. This will also allow them to relax and not be stressed.
After surgery, what are the areas of patients’ life that need special attention?
Dr. Yijun Wu: The first thing is to relax, live happily and reintegrate into society. Secondly, they should understand their disease status correctly, not be sloppy or worried, and cooperate with the doctor’s follow-up. Diet is recommended for patients on a low iodine diet. Firstly, thyroxine has been supplemented and there is no need to synthesize it with iodine. Secondly, excessive iodine intake may promote the growth of thyroid cells in the body.
Find the right doctor to cure thyroid nodules
The first step is to teach you to choose the right department
How do patients with thyroid nodules seek medical care?
Dr. Wu Yijun: Thyroid nodules are usually seen in the general surgery department of a hospital.
In our hospital, the Thyroid Disease Center is in charge of treatment. It is like a 4S store for thyroid diseases. From diagnosis, surgery and post-operative management, it is very convenient and professional for patients with thyroid disease to seek medical treatment.
What are the clinic hours of the center?
Dr. Wu Yijun: There is a general clinic every day and a specialist clinic every morning.
How long does it take to schedule surgery for patients who are confirmed to have surgery?
Dr. Yijun Wu: Generally there is a bed waiting time ranging from one to several weeks, during which time the pre-operative preparations, including the patient’s work and living arrangements, can be perfected. After the New Year and holidays, the time is relatively shorter.
Step 2 Get pre-operative tests done
How long should I stay in the hospital for the surgery?
Dr. Wu Yijun: Patients with thyroid tumor have better physical strength and basically like normal people, they can complete all the pre-surgical examinations in the outpatient clinic without hospitalization.
Generally, patients with perfect preoperative examination can be operated on the second day of hospitalization. After 1-2 days of surgery, they are discharged from the hospital.
From your personal professional expertise, which patients would you prefer to help?
Dr. Yijun Wu: As a thyroid specialist, my primary job is the diagnosis and treatment of thyroid disease. The first thing is to help patients determine whether their disease needs surgery or not. This is the directional grasp of treatment and is critical for patients, allowing those who need surgery to undergo it and those who can be observed to avoid it.
Second, helping those patients who need surgery to receive standardized surgical treatment so that they can get better surgical results and reduce recurrence.
How can patients find you more easily?
Dr. Yijun Wu: I have opened “”. More and more patients are inquiring every day. Some of my surgical patients go online to ask me questions. Patients can feel the convenience of online communication. This is one of the easiest ways to find me.
This article is published with the permission of Dr. Wu Yijun.