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Ask the Expert: When Small Nodules Cause Big Problems

Drs. Wojtek Mydlarz and Nicole Schmitt Nicole Schmitt, MD and Wojtek Mydlarz, MD
Board-certified Otolaryngologists at Suburban Hospital

If you or a loved one has had trouble swallowing and been diagnosed with a thyroid nodule, being confused and frightened is understandable. But what are thyroid nodules, and what do they mean for your long-term health? Board-certified otolaryngologists, Wojtek Mydlarz, M.D. and Nicole Schmitt, M.D. answer questions on signs, symptoms and treatments for thyroid nodules, what the difference between thyroid cancer and thyroid nodules are and much more.

While I was in the emergency room for something else, they ran scans on me and found a nodule on my thyroid. What is a thyroid nodule?

Simply put, thyroid nodules are lumps that commonly arise within an otherwise normal thyroid gland. Some are actually cysts, which are filled with fluid rather than tissue. Over 50 percent of people will develop a thyroid nodule by the time they are 60 years old. Although the vast majority of thyroid nodules are benign (noncancerous), a small proportion do contain thyroid cancer. In order to diagnose and treat thyroid cancer at the earliest stage, most thyroid nodules need some type of evaluation. —Dr. Mydlarz

My mother is having trouble swallowing and thinks she has a thyroid nodule. What are the symptoms and how are they discovered?

Most thyroid nodules are completely asymptomatic, which means they show no symptoms. Rarely, very large nodules can manifest as a lump or asymmetry in the neck, and these large nodules can cause some difficulty swallowing or difficulty breathing when lying flat. This happens when the nodule is particularly large or low in the neck, pressing on the esophagus or windpipe. Sometimes a thyroid nodule that produces excess thyroid hormones, called a “toxic nodule,” can actually cause symptoms of hyperthyroidism such as weight loss, heart palpitations, and intolerance of heat. However, most nodules do not produce excess thyroid hormone. The majority of nodules are identified incidentally on various types of x-rays and scans done for other reasons. —Dr. Schmitt

If I have a thyroid nodule, what are the next steps I should take? Is there further testing needed and how urgent is the matter?

Once the nodule is discovered, your doctor will try to determine whether the rest of your thyroid is healthy or whether the entire thyroid gland has been affected by a more general condition and is overactive (hyperthyroidism) or underactive (hypothyroidism).

Again, there is no reason to worry as most nodules are benign (noncancerous) and the evaluation can be done in a relaxed yet methodical fashion.

Your physician will feel your neck to see whether the entire thyroid gland is enlarged and whether a single or multiple nodules may be present. The initial laboratory tests may include measurement of thyroid hormone function (thyroxine or T4 tests) and thyroid-stimulating hormone (TSH) in your blood to determine whether your thyroid is functioning normally. Since it’s usually not possible to determine whether a thyroid nodule is cancerous or what it looks like by physical examination and blood tests alone, the evaluation also includes a thyroid ultrasonography. A biopsy may also be performed to test the nodule and see what it may look like under the microscope. —Dr. Mydlarz

A coworker of mine was explaining his treatment process for thyroid nodules. Is every case treated the same? How is treatment determined?

For nodules that are not suspicious for cancer, observation with regular ultrasound tests is sufficient. If a thyroid nodule is suspicious for cancer or confirmed to be cancer based on biopsy results, or if it is large enough to be causing trouble with breathing or swallowing, then treatment is recommended.

In most cases, treatment consists of surgery to remove half or all of the thyroid. In cases where the nodule is small or not confirmed to be cancer, only half of the thyroid is removed. Usually, the nodule will turn out to be benign and the patient will still retain the other half of their thyroid, which is sufficient for producing the necessary levels of thyroid hormone.

In other cases, if the nodule is confirmed to be thyroid cancer either on biopsy or after removing that half of the thyroid, the remaining half of the thyroid gland is then also removed. In more advanced cases involving large thyroid cancers or more aggressive subtypes, additional therapy such as removal of the lymph nodes in the neck or a treatment called radioactive iodine may be required. —Dr. Schmitt

My wife just got diagnosed with a thyroid nodule. Does that mean she has thyroid cancer? How often do the nodules turn out to be cancer?

The vast majority of thyroid nodules are benign. Those that are large or have a suspicious appearance on ultrasound examination are more likely to contain thyroid cancer, in which case a needle biopsy is recommended. Risk factors associated with thyroid cancer include: male gender, age under 20 or over 70 and a history of radiation exposure. Symptoms such as the rapid development of trouble swallowing, a hoarse voice, or the presence of large lymph nodes (bumps in the neck) may also indicate that a thyroid nodule contains cancer. —Dr. Schmitt

My daughter is only 20 and might have thyroid cancer. How serious is this? Is it treatable or curable?

Thyroid cancer is highly treatable and curable. The prognosis is excellent, especially for younger patients and those with small cancers. The 10-year survival for such patients is 100 percent and death from thyroid cancer anytime thereafter is extremely rare.

For patients who are over 45, or those with larger or more aggressive tumors, the prognosis still remains very good but the risk of cancer recurrence is higher. I encourage you to talk to your doctors about your individual profile of cancer and expected prognosis. It will be necessary to have lifelong monitoring, even after successful treatment. —Dr. Mydlarz

Do thyroid nodules always need to be treated or removed or is that only necessary when they are malignant?

Benign (noncancerous) thyroid nodules are sometimes removed to confirm that they are benign. This is rare because the accuracy of needle biopsy is quite high, especially for smaller nodules. Benign nodules are removed if they are large enough to compress the esophagus or windpipe, which can cause difficulty with swallowing or with breathing while lying flat. —Dr. Schmitt

My husband was told he needs to have surgery for his thyroid cancer. Are there complications after surgery?

The primary therapy for all forms of thyroid cancer is surgery and the generally accepted approach at the present time is to remove the entire thyroid gland in what is called a total thyroidectomy. Some patients will have thyroid cancer present in the lymph nodes of the neck or upper chest. These lymph nodes are removed at the time of thyroid surgery or sometimes as a later procedure. After surgery, patients need to be on a thyroid hormone for the rest of their lives with close monitoring.

Some of the more common changes after surgery are scars, sore or scratchy throat, swelling and stiffness, healing fluid (seroma) or small blood collection (hematoma). These usually resolve with time and can be treated during follow up.

The most serious possible risks of thyroid surgery are more rare, but can include: bleeding that can cause progressive difficulty breathing and/or swallowing, and injury to the nerve that moves your vocal cords (recurrent laryngeal nerve) that can cause permanent change in voice quality (hoarseness). Rarely, patients will have breathing problems. This happens if both nerves are injured (there is one on each side) and from damage to the parrathyroid glands, which regulate calcium levels in the body, causing low blood calcium level (hypocalcemia). Overall the risk of any serious complication should be less than 2 percent, which is 1 in 50 patients.

The risk of complications should be discussed with each patient at length and prior to surgery. Patients should understand the reasons for the operation, the alternative methods of treatment and the potential risks and benefits of the operation. —Dr. Mydlarz

Are there any nonsurgical treatments for a thyroid nodule? What about thyroid cancer?

Thyroid nodules that are benign rarely require any type of treatment. For toxic nodules that produce excess thyroid hormone, medications can be used to suppress the excess thyroid hormone production to lessen the symptoms of hyperthyroidism; however, if these medications do not adequately suppress thyroid hormone production, surgery to remove the thyroid gland may be required.

For some cases of thyroid cancer, removal of the thyroid is followed by radioactive iodine therapy (RAI). Most iodine consumed in the diet is taken up by thyroid gland cells and RAI involves attaching a radioactive component to the iodine, which is then taken up by a residual or microscopic thyroid cancer cells, with limited impact on other normal cells and tissues in the body.

For patients with advanced thyroid cancer that has spread to other parts of the body, which fortunately is rare, new generation targeted drugs, given intravenously specifically act on thyroid cancer cells. These new drugs have shown promise in recent clinical trials. —Dr. Schmitt

My mom has thyroid nodules. Is there a genetic link and is there anything I can do to avoid a thyroid nodule?

We do not know what causes most thyroid nodules, but they are extremely common. By age 60, about one-half of all people have a thyroid nodule that can be found either through examination or with imaging. Fortunately, more than 90 percent of such nodules are benign (non-cancerous). Hashimoto’s thyroiditis, which is an autoimmune process that causes your body’s cells to damage the thyroid gland, is the most common cause of underactive gland function (hypothyroidism). It is associated with an increased risk of thyroid nodules. Low iodine levels (iodine deficiency), which is very uncommon in the United States, is also known to cause thyroid nodules. —Dr. Mydlarz

My doctor said my thyroid tests were normal, even though I have a nodule. How are these related?

In rare cases, toxic nodules produce excess thyroid hormone, causing symptoms of hyperthyroidism (overactive thyroid gland) as described above. However, most thyroid nodules do not produce an excess of thyroid hormone, so most people with thyroid nodules will have normal thyroid function on their blood tests. —Dr. Schmitt

About Dr. Mydlarz

Dr. Wojtek Mydlarz is an assistant professor in the Johns Hopkins Department of Otolaryngology–Head and Neck Surgery. He specializes in the treatment of benign and malignant tumors of the head and neck, including the upper aerodigestive tract, salivary glands, thyroid, skin and soft tissue. His research interests include evaluating both surgical and non-surgical treatment outcomes in head and neck cancer patients. He is also interested in the complex molecular biology of head and neck cancer and potential clinical applications of novel targeted cancer therapies.

He received his medical degree from The Johns Hopkins University School of Medicine in Baltimore and completed his internship and residency in Otolaryngology-Head and Neck Surgery at Johns Hopkins. Dr. Mydlarz received his specialized fellowship training in head and neck surgical oncology at the renowned MD Anderson Cancer Center in Houston, TX.

About Dr. Schmitt

Dr. Nicole Schmitt is a fellowship-trained head and neck cancer surgeon. Her clinical interests include surgical treatment and surveillance of patients with benign and malignant tumors of the head and neck, robotic surgery, benign and malignant thyroid and parathyroid disease and skin cancers of the head and neck. Dr. Schmitt’s research interests include the use of platinum-based chemotherapy drugs and immunotherapy for the treatment of head and neck cancer. She holds a joint appointment at the National Institutes of Health.

Dr. Schmitt earned her medical degree from the Washington University School of Medicine in St. Louis, Missouri and completed her residency training in otolaryngology at the University of Washington in Seattle. Dr. Schmitt also completed a research fellowship at the University of Washington in Seattle and a head and neck surgical oncology fellowship at the University of Pittsburgh.

Drs. Mydlarz and Schmitt see patients at the Johns Hopkins Health Care & Surgery Center located at 6420 Rockledge Drive, Suite 4920 in Bethesda. Call 301-896-3332 to make an appointment.