• Nalaka de Silva

Thyroid Mass

Updated: Jun 19, 2019

Please note that the following is a general guideline only.


Outline

When a patient with a thyroid mass presents,

-The first step is to see if it is goitre or a thyroid nodule.

-The second step is to determine the risk of cancer within

-The third step is to see if the patient is hyperthyroid or not

-Fourth is to determine if there are compressive symptoms- if so URGENT referral


The examination should assist determine the above four features


Investigations should be directed according to the findings.





History

Is this a long-standing mass, is the whole thyroid large or a nodule?

Is it an endemic goitre

Is it a toxic goitre



Is this a nodule the patient is presenting with

Is there is a risk of cancer

Extremes in age (very young or older)

Radiation exposure

Family Hx of thyroid cancer


Hyper or Hypothyroid symptoms

Rare for a nodule to be cancerous if hyper hyperfunctioning

Are the symptoms of acute onset or a longer standing



Are there compressive symptoms

Breathing?

Swallowing? if significant URGENT referral





Examination





First confirm its the thyroid (moves with swallowing)

Determine if this is a goiter or a nodule











look for cancer

Any hard masses- Hard= risk of cancer (individual nodule or within a goitre)

Any neck nodes (nodes= cancer)



look for compressive features

if venous congestion positive Pemberton's test

Stridor-URGENT Referral



Look for hyperthyroid features

Look for hypothyroid features





Investigations


-The first line of test:TFT- Hyperthyroid


If hyperthyroid determine the cause (Graves, Toxic nodular goiter/ thyroiditis)

Endocrine review

Anti thyroid medications


-If hyperthyroid also do TC99

what we want to know is...is it a hot nodule (low risk) or a hot gland with a cold nodule (High risk of cancer)

If cold nodule need US and FNA (as below)


If Euthyroid and a nodule/ or a euthyroid goitre

US-? suspicious features in nodules (i.e. calcification etc)

if so FNA the risky nodules




Treatment Outline

If US FNA says benign- 95% it benign, need to repeat US +/- FNA in 6 months

If FNA is cancer- Total thyroidectomy plus post op radioactive I if high risk

If inconclusive / follicular cells need hemithyroid- if cancer completion total T















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