What if My Primary Physician Tells Me I have a Single Thyroid Nodule?

First of all do not panic. 31% of the time the palpation is NOT accurate. 16% of the time there is no nodule at all! The referral to the radiologist for an USGFNA may result in a biopsy even if there is no nodule present, as they are only doing what the physician orders. Ask for a referral to an endocrinologist that does their own high frequency Ultrasound. Check www.thyroidologists.com for a clinical thyroidologist near you. Also, 15% of patients with a worrisome single nodule will actually have a multinodular goiter. The thyroidologist ultrasonographer will confirm if there is a nodule, detect additional nodules, that may need FNA biopsy, and identify the ultrasound characteristics of the nodules. The present guidelines tell us that not all nodules need biopsy, especially <10 mm nodules. If the nodule is <10 mm there must be abnormal lymph nodes found, or radiation history or family history of thyroid cancer.
>10 mm nodules there are solid, hypoechoic or have micro-calcifications, need FNA biopsy. >1.0-1.5cm cm nodules that are solid and either iso,or hypoechoic need FNA biopsy. If they want to biopsy all your nodules or the ones that are not listed here, ask for a second opinion BEFORE you let them do the biopsy. >1.5-2.0 cm complex nodule, with another suspicious feature, such as vascularity, irregular margins,,micro-calcifications need a biopsy.
>2 cm Predominantly cystic without suspicious US features should be biopsied.

What about multiple nodules?
DO NOT allow them to Biopsy all the nodules. Prioritize based of Ultrasound findings. If there are multiple similar, coalescent nodules without suspicious features, they can biopsy the largest one.

Thyroid Ultrasound In summary,
Palpable Nodule
1. Assess if it is the same nodule seen on ultrasound, and look for suspicious findings. Review the ultrasound for other non-palpable nodules and their suspicious findings and select for USGFNA biopsy if indicated.

Non-palpable nodules seen on ultrasound.
1. Assess for need for Biopsy by suspicious findings, or history of radiation or family history.

Multiple Nodules
1. Select the nodules for biopsy based on suspicious findings or size.

All Nodules
1.Assess the lymph nodes for clues to the presence of thyroid cancer.

Always ask to see the actual diagnostic ultrasound and the report before allowing a biopsy to be done.

Good Luck,

Dr.G.

Reference:
Frontiers in Thyroid Cancer
ATA Guidelines in Clinical Practice
July 11-12 2008
Boston Mass.

What do I Need to do Before my Thyroid Cancer Surgery?

If you are told you have a positive cancer FNA biopsy result on a thyroid nodule, or they say it is suspicious for cancer, what do you neeed to be done BEFORE the surgery?
First, if you are not seeing a thyroidologist, or an endcrinologist with an interest in thyroid cancer, request a referral.
The Pre-operative screening should include a cancer marker test, thyroglobulin.
A detailed thyroid ultrasound to determine if there is tumor on the other lobes.
The thyroidologist should do an ultrasound lymph node mapping of your neck. 20-80% of patients already have mets in the local nodes around the thyroid. If abnormal nodes are found, an USGFNA for cytology, and Thyroglobulin cancer marker washings should be done.
If positive the original surgery plan will be changed in at least 20-30% of the cases, to include the lateral neck area of the cancer nodes.
Now you can go to surgery, and have the definitive first surgery, and save yourself from the recurrence and need for a second surgery in 1-5 years.
Good Job,

Dr.G.

What is a Low Risk Thyroid Cancer, and Do I Need Radiation?

How do I know if I am very, low risk?
If you are <45 years old,
Get your pathology report from your surgery.
Look for these items:
Very Low Risk is a patient has a single < 1 cm cancer nodule.
No lymph node mets.
The cell type is not an aggressive type, such as Tall Cell.
There is no extension beyond the capsule of the thyroid gland.
Then there is no family history of thyroid cancer, and no radiation exposure.

What needs to be done to treat you?
You will only need lobectomy, as there is no benefit from total thyroidectomy.
Also there is no benefit from Radioiodine ablation therapy with any dose.
Death 0% Recurrence by 20 years 8%

How do I know if I am low risk?
If you are <45 years old.

Again get the pathology report.
Papillary Ca 1-4 cm without nodes or distant spread.
No local invasion outside of the thyroid gland.

Follicular CA <2 cm

Minimal capsule invasion, but no vascular invasion.
What needs to be done if I am low risk?
Total thyroidectomy is definitely needed.
Radioiodine therapy is controversial.
May be only on a select few rather than knee jerk use in everyone.
Careful discussion with a thyroidologist before you accept the radiation therapy.

<40 years old Death 0%
<40 years old <3 cm RAI Dubious

Remnant Ablation with RAI/131?
All high risk patients, but not all very low, or most of the young low risk patients.

Stage I Age <45 Size <2cm No LN NO Radiation Ablation Needed
Stage II Age >45 Size >2 cm + LN rhTSH Stimulated Remnant ablation


Good Luck,

Dr.G.