Thyroid nodules – when to be concerned…

The thyroid gland is situated in the front of the neck like a shield of a warrior protecting the windpipe or trachea which lies behind it. Indeed the word thyroid is derived from the Greek word for shield. The butterfly-shaped gland produces a hormone called thyroxine which is involved in the regulation of a variety of bodily functions. In essence, it controls your ‘metabolic rate’, so patients with low levels of thyroxine feel tired, lethargic and gain weight.

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Whilst those with high levels – a condition called thyrotoxicosis – suffer from ex300 sleeplessness, weight loss, palpitations and tremors.

The thyroid gland is prone to developing small lumps within it which are called nodules. These may appear gradually or suddenly. Occasionally they may be painful. Figure 1 shows a gland with several large nodules – a common condition known as multinodular goitre. About 60% of women will have a thyroid nodule present if they were to have

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an ultrasound scan of the neck. The vast majority of these nodules

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are benign but may require treatment if they cause swallowing or breathing problems. However, 5-10% of nodules may harbour a cancer and therefore require surgical removal. Trying to decide which 200-101 nodules are sinister is challenging.

Figure 1: A large 15 cm multinodular goitre removed from a patient. This had no cancer in it but caused swallowing difficulties

To decide if a nodule has a cancer within it, surgeons frequently use ultrasound scans and then take a small sample of cells from the nodule with a needle. Ultrasound can identify worrying features which signify cancerous change. There are now newer advanced applications such

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as elastography which help identify malignant nodules (see Figure 2). The cells sampled from a needle biopsy are analysed by cytologist to help make a diagnosis (see Figure 3). More recently, special molecular diagnostic techniques which identify point mutations in genes can help in the identification of malignancy. These include mutations in the BRAF and RAS genes.



Figure 2: Ultrasound scan of the thyroid gland utilizing elastography to identify sinister changes


Figure 3: Cells taken from a nodule are examined under a microscope. This is called cytology and gives a quick and accurate diagnosis

Once a nodule is deemed to be of concern, surgery is often advised. Surgical removal of the thyroid gland is known as thyroidectomy. If the nodule is clearly cancerous, the entire gland is removed in an operation called total thyroidectomy. This is a common operation, first performed by Professor Theodor Billroth in the 1860s in Europe. If the nodule has worrisome features based on the ultrasound scan or biopsy, some surgeons may choose to remove just half the gland first in an operation known as hemithyroidectomy or thyroid lobectomy. The nodule may then be sent for further analysis before the surgeon proceeds with further surgery.

The technique of thyroidectomy has evolved substantially. Technology has made this surgery safer and more effective. Amongst the more notable improvements is the use of nerve integrity monitoring which reduces the risk of nerve damage during which may affects the patient’s voice. The harmonic scalpel is another instrument which reduces blood loss from surgery and is associated with less pain following surgery.

The scar following thyroid surgery often heals well. Whilst it may appear unsightly initially, most people heal well and the scar is often imperceptible several months after surgery (see Figure 4).


Figure 4: The scar following thyroid surgery after 6 months

In selected patients, it may be possible to remove the thyroid gland using keyhole surgery (See Figure 5) or robotic surgery (see Figure 6) through the armpit. This clearly avoids the neck incision and is favoured by some women. It is best to seek the opinion of a surgeon if you wish to have this type of surgery.

Figure 5: Endoscopic thyroid surgery through the armpit. The author learnt this technique from Prof Luong (right) who is a leading authority on this approach

Figure 6: Robotic thyroidectomy using the da Vinci S system



Most patients survive thyroid cancer. The well differentiated cancer sub-types such as papillary and follicular thyroid cancer have very good outcomes. Figure 7 is the survival graphs from

a 10 year review of thyroid cancer at the author’s institutional practice. The average follow up period was 42 months. Survival was poorer for the less favourable sub-types such as Medullary and Anaplastic thyroid cancer

Figure 7: Survival outcomes in a review of 152 thyroid cancers treated at Tan Tock Seng Hospital, Singapore where the author is a Visiting Consultant

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