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Thyroid Nodules

Thyroid nodules are well defined growths which appear as solid, partially solid, or liquid masses within the normal thyroid tissue. They are common in both women and men particularly in the fifth decade. Most nodules are small and create no symptoms or problems. Some however are discovered when they have become large enough to push against and displace adjacent structures. Symptoms such as hoarseness, difficulty swallowing, and pain are common with large nodules. Some people have visible swelling and distortion of their lower anterior neck. Certain types of nodules behave differently over time. Most nodules are benign and create no problems, whereas some have independent function that result in elevated thyroid hormone levels. Some may be cancerous and require extensive surgery. Others simply continue to enlarge and multiply over many years creating a goiter. Patients with symptoms are generally referred for surgical evaluation to consider removing the abnormal thyroid tissue.

The proper evaluation of nodules is easily performed in a physician’s office. After a physical examination, laboratory studies should be taken to assess thyroid function. A neck ultrasound is the best screening evaluation of the thyroid gland. It allows for the determination of size, the assessment of the normal thyroid tissue, as well as the evaluation of abnormal growths. These growths may be solid, fluid filled, or a combination of solid and fluid. Ultrasound studies performed by an experienced radiologist, endocrinologist, or surgeon usually produce the most useful information and interpretation.

Most nodules do not require removal. Sometimes the nodular characteristics seen on ultrasound are distinct enough to predict benign behavior. Solid and indeterminate nodules require a fine needle biopsy performed under ultrasound guidance once they have reached a size usually greater than 15 mm. The cellular content identified on fine needle cytology will be inspected. The classification of the tissue will help the physician determine the next mode of therapy. Obviously malignant nodules will prompt surgical intervention, whereas benign nodules will be observed, unless symptomatic. Depending on the size and appearance, thyroid nodule surveillance can be performed on a yearly basis at most.

For the last 100 years enlarged and symptomatic benign nodules have been removed by removing the entire thyroid lobe. This safe but invasive procedure has been the standard of care, and is best performed by surgeons who perform this surgery often. The surgery requires not only the surgeon and their assistant, but also an anesthesiologist, and an OR team. The patient is observed for several hours after surgery or admitted to the hospital for airway observation. The thyroid function in the segment that is removed is lost, and if the entire thyroid gland is removed the patient will always require thyroid hormone supplementation.

Thyroid hormone was initially discovered in the United States over 100 years ago and the replacement therapy has been a standard care ever since. Today there are hundreds of thyroid replacement regimens available to patients. Finding the correct dosage for each patient is not difficult but can sometimes take many months and lab evaluations to get finely regulated.

Not until recently has the concept of thyroid tissue preservation been prioritized as a result of the excellent and safe outcomes of thyroid nodule specific therapies. In the last 20 years there has been targeted thyroid nodule based treatment performed in Korea and Europe which have progressed in efficacy. These therapies include applying percutaneous ethanol ablation, laser catheter ablation, and radiofrequency ablation to the individual nodules directly. All have been relatively successful; however, both laser and radiofrequency ablation have proven most effective for solid thyroid nodules. Multicenter studies for these solid nodule targeted therapies have been completed over the last 15 years demonstrate uniformly good results with minimal morbidity. In the United States the ethanol ablation was utilized primarily in patients not considered surgical candidates and now for treatment of large thyroid cysts. The Mayo clinic performed a trial of radiofrequency ablation with very favorable results in 2017. In January 2019 an NIH registered a study of the feasibility of radiofrequency ablation started in France. These results may be published in 2020.

The use of radiofrequency for overactive or toxic thyroid nodules has also been well established. Ablation of these very active tumors will destroy their function and normal thyroid function returns. Patients not only avoid surgery, they also avoid requiring daily thyroid hormone replacement. Long term studies demonstrate a long term benefit, all without an operation.

Thus far the results of radiofrequency ablation have proven better than laser therapy. The proposed advantages to thyroid radiofrequency ablation for benign nodules include no scar, no hospital admission, minimal recovery, outpatient procedure, local anesthesia, and no hypothyroidism. The determination for suitability for this procedure should be by a surgeon experienced in all aspects of thyroid treatment, including advanced neck ultrasound evaluation, ultrasound guided fine needle aspiration, thyroid surgery, and now targeted thyroid therapy.