Clinical Evaluation

Careful clinical assessment with particular attention to clinical risk factors (Table 9-1) gives important indicators for the diagnosis and requirements for surgery. Most thyroid nodules are asymptomatic, presenting as a chance finding by the patient or during a medical examination. Pain is uncommon, but a malignant lesion may occasionally cause discomfort in the neck. With respect to single and multiple nodules, current evidence suggests that when a dominant nodule appears in a multinodular gland, the risks of malignancy are probably the same as those in a true solitary nodule.17 The development of a new single nodule (Fig. 9-1) or the rapid growth of an existing dominant nodule (Fig. 9-2) may suggest malignancy, but a malignant nodule can also be extremely slow growing, present for many years before a diagnosis is made. However, the sudden presentation of a painful swelling in the thyroid is almost pathognomonic of hemorrhage into a colloid nodule. This is important to recognize because spontaneous resolution will occur within a few weeks, obviating any need for medical intervention.

Children younger than 14 years of age who present with a solitary nodule have a 50% chance of malignancy,18-19 but some evidence suggests that this increased risk may be a consequence of exposure to ionizing radiation.20 Previous thyroid irradiation confers a risk of malignancy in a palpable nodule of 20% to 50%21-23; therefore, a history of neck irradiation clearly influences surgical management, lending support toward a more aggressive approach.

Geographic factors may play a role in papillary cancer, which has been found to have an increased incidence in iodine-rich regions.24 The incidence of follicular cancer is increased in iodine-deficient endemic goitrous areas.25

Although thyroid nodules are more frequently found in women, a solitary nodule in a male conveys a greater risk of malignancy. A family history of endocrine disease should suggest the diagnosis of medullary thyroid carcinoma. This rare tumor constitutes 7% of all thyroid malignancies but may be familial in more than 20% of cases as multiple endocrine neoplasia (MEN) type 2A or 2B syndrome or rarely as a non-MEN familial syndrome. Coexistent endocrine disease, particularly pheochromocytoma, must clearly be sought and adequately treated before any thyroid surgical intervention. Papillary carcinoma is also occasionally familial26 and has been described with familial adenosis polyposis (Gardner's syndrome)27 and ataxia-telangiectasia.28

The patient with a thyroid nodule is usually euthyroid, but features of thyroid dysfunction may help establish

TABLE 9-1. Clinical Risk Factors

Solitary vs. multiple nodules Age

Previous neck irradiation

Geographic

Family history

Nodule characteristics (size, consistency, fixation) Lymph nodes

Recurrent laryngeal nerve palsy Pressure symptoms the diagnosis. For example, hyperthyroidism in a patient presenting with a solitary nodule suggests a toxic autonomous nodule, whereas associated hypothyroidism may indicate nodular Hashimoto's disease or possibly lymphomatous change within a Hashimoto's goiter. Palpation determines whether the thyroid lesion is a true solitary nodule or a dominant nodule within a multinodular goiter, but in approximately 50% of cases a clinically solitary nodule is found to be part of a multinodular gland.29 This distinction has been given inappropriate attention in the past, and current evidence suggests similar malignancy rates in the two types of glands.30'31 This fact is particularly relevant in the multinodular goiter with a dominant nodule increasing rapidly in size, which clearly should be treated as a true solitary nodule. A hard, fixed nodule is likely to be malignant, but some papillary carcinomas present as cystic lesions, and follicular carcinoma can be hemorrhagic and soft. Conversely, a benign colloid nodule can be hard with dystrophic calcification; therefore, consistency is not a reliable feature. However, associated lymphadenopathy is strongly suggestive of malignancy, and the so-called lateral aberrant thyroid with cystic change within a cervical lymph node involved with papillary carcinoma can occasionally be mistaken for a branchial cyst.

Presentation with a recurrent laryngeal nerve palsy in the absence of respiratory disease or previous thyroid surgery is a strong indicator of malignancy with direct nerve invasion. Occasionally, nerve palsy can occur as a result of local pressure symptoms of benign colloid nodular disease.

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FIGURE 9-2. Dominant nodule within a multinodular goiter.

These coexistent pressure symptoms on the esophagus or trachea will independently be indications for surgery despite any consideration of potential malignant disease.

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