Thyroid Nodules and Thyroid Cancer
Thyroid nodules are extremely common and are present in roughly 60-70% of adults. Approximately 5% of these are cancer. Most of these will be small papillary thyroid cancers, where the survival is 98-99%. Thyroid nodules, and thyroid cancer, should be approached at least initially with these facts in mind.
Increase in diagnosis of thyroid cancer
There is an exponential increase in the diagnosis of thyroid cancer in high-income countries. This is due to patients having easy access to high frequency ultrasound, which is being performed often for unrelated conditions. Thyroid nodules are also found incidentally through other investigations such as CT, MRI and PET scans. Around 50% of thyroid cancers are estimated to be micro-papillary thyroid cancers (less than 1 cm in size), which would largely have gone undiagnosed and likely never have caused a clinical problem. Autopsy studies have shown that in some countries up to 30% of people have these small thyroid cancers that were never known of or identified. Importantly, with this exponential increase in the diagnosis of thyroid cancer, the mortality rate from thyroid cancer (which is very low) has remained the same.
Thyroid nodule investigation
Facts such as these have tempered the investigation of thyroid nodules. Currently, the movement is toward more conservative investigation of thyroid nodules and more conservative thyroid surgery. For example, nodules less than 1cm in size are not recommended for investigation with ultrasound-guided fine-needle aspiration (US-FNA). Furthermore, there is a movement toward ultrasound surveillance of confirmed, low-risk, small papillary thyroid cancers in properly selected patients who do not undergo any surgery at all. This is called active surveillance, for which there is now long term evidence from trials in Japan and New York, for example. There is a shift to streamline the patient process, limit over-treatment, reduce error and reduce patient morbidity.
The gold standard for the management and work up of thyroid nodules is set out in the ATA (American Thyroid Association) Guidelines. Surgeons should be up to date with these guidelines and manage patients accordingly.
Surgeon-performed ultrasound for thyroid nodules
The work up of thyroid nodules to rule out cancer includes ultrasound and US-FNA. Surgeon-performed ultrasound (where the specialist surgeon performs their own dedicated ultrasound on the patient in the office) has been shown to change the surgical management in nearly half of patients with thyroid cancer and is performed internationally by thyroid experts. It also allows the surgeon to perform immediate US-FNA on the same day as the consultation, and has been shown to streamline diagnosis while decreasing the number of appointments, travel, costs and stress for patients.
Finally, evidence has shown that patients have better outcomes and less complications when treated by high-volume thyroid surgeons.
Goiter – enlarged thyroid glands
A thyroid goiter is an enlarged thyroid gland. This can result from different causes, including iodine deficiency, autoimmune thyroid disease, genetic conditions and thyroid nodules. Most goiters are actually benign.
In many instances surgery is not indicated and patients do not need to have an operation unless it is causing a problem. Indications for surgery include swallowing or breathing problems (resulting from pressure from the enlarged goiter), or cosmetic issues related to its size. Rarely, it can be associated with cancer. Otherwise, goiters can be safely observed until they cause symptoms, if they ever do at all.
Most goiters can be successfully removed with a standard thyroid operation, involving a limited small incision in the lower neck. Very rarely, some goiters are so large they extend below the neck into the chest. These ‘retrosternal’ goiters can often still be removed via the neck. However, sometimes a mini-sternotomy may be required. This technique, as compared to conventional ‘full’ sternotomy, involves a smaller incision and has been associated with decreased pain, faster recovery and shorter hospital stay.