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Overview — Thyroid cancer

It’s most common in people in their 30s and those over the age of 60. Women are 2 to 3 times more likely to develop it than men.

Thyroid cancer is usually treatable and in many cases can be cured completely, although it can sometimes come back after treatment.

Symptoms of thyroid cancer

Symptoms of thyroid cancer can include:

a painless lump or swelling in the front of the neck – although only 1 in 20 neck lumps are cancer
swollen glands in the neck
unexplained hoarseness that does not get better after a few weeks
a sore throat that does not get better
difficulty swallowing

When to get medical advice

See a GP if you have symptoms of thyroid cancer. The symptoms may be caused by less serious conditions, such as an enlarged thyroid (goitre), so it’s important to get them checked.

A GP will examine your neck and can organise a blood test to check how well your thyroid is working.

If they think you could have cancer or they’re not sure what’s causing your symptoms, you’ll be referred to a hospital specialist for more tests.

Types of thyroid cancer

There are 4 main types of thyroid cancer:

papillary carcinoma – the most common type, accounting for about 8 in 10 cases; it usually affects people under 40, particularly women
follicular carcinoma – accounts for up to 1 in 10 cases and tends to affect middle-aged adults, particularly women
medullary thyroid carcinoma – accounts for less than 1 in 10 cases; unlike the other types, it can run in families
anaplastic thyroid carcinoma – the rarest and most serious type, accounting for around 1 in 50 cases; it usually affects people over the age of 60

Papillary and follicular carcinomas are sometimes known as differentiated thyroid cancers. They tend to be easier to treat than the other types.

Causes of thyroid cancer

Thyroid cancer happens when there’s a change to the DNA inside thyroid cells which causes them to grow uncontrollably and produce a lump.

It’s not usually clear what causes this change, but there are a number of things that can increase your risk.

other thyroid conditions, such as an inflamed thyroid (thyroiditis) or goitre – but not an overactive thyroid or underactive thyroid
a family history of thyroid cancer – your risk is higher if a close relative has had thyroid cancer
radiation exposure in childhood – such as radiotherapy
obesity
a bowel condition called familial adenomatous polyposis (FAP)
acromegaly – a rare condition where the body produces too much growth hormone

Treatments for thyroid cancer

Treatment for thyroid cancer depends on the type of thyroid cancer you have and how far it has spread.

The main treatments are:

surgery – to remove part or all of the thyroid
radioactive iodine treatment – you swallow a radioactive substance that travels through your blood and kills the cancer cells
external radiotherapy – a machine is used to direct beams of radiation at the cancer cells to kill them
chemotherapy and targeted therapies – medicines used to kill cancer cells

After treatment, you’ll have follow-up appointments to check whether the cancer has come back.

Outlook for thyroid cancer

Around 9 in every 10 people are alive 5 years after a diagnosis of thyroid cancer. Many of these are cured and will have a normal lifespan.

But the outlook varies depending on the type of thyroid cancer and how early it was diagnosed. At present the outlook is:

more than 9 in 10 people with papillary carcinoma live at least 5 years after diagnosis
more than 9 in 10 people with follicular carcinoma live at least 5 years after diagnosis
more than 7 in 10 men, and around 9 in 10 women with medullary thyroid carcinoma live at least 5 years after diagnosis
around 1 in 10 people with anaplastic thyroid carcinoma live at least 5 years after diagnosis

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Up to 1 in 4 people treated for thyroid cancer are later diagnosed with cancer in another part of the body, such as the lungs or bones, but cancer can often be treated again if this happens.

Page last reviewed: 28 August 2019
Next review due: 28 August 2022

Thyroid Nodules & Thyroid Cancer

We deliver effective, minimally invasive treatments in a caring environment. Call 310-267-7838 to connect with an expert in endocrine surgery.

What Are Thyroid Nodules?

Thyroid nodules are lumps or growths of the thyroid, usually made up of normal thyroid tissue or fluid. Thyroid nodules are frequently discovered on routine physical examination or unintentionally on imaging tests.

By the age 45, up to half of normal people have thyroid nodules that can be seen on an ultrasound. Fortunately, about 95% of thyroid nodules are benign. The focus of the evaluation at the UCLA Endocrine Center is to help you determine if your nodule contains cancer or not.

Thyroid Nodule s Symptoms ?

Most thyroid nodules do not cause any symptoms. Some thyroid nodules show up as a painless lump in the neck that you can feel or see. Thyroid nodules usually move up and down with swallowing.

When thyroid nodules become large (>4 cm or 1.5 in) they may cause symptoms by pressing on the airway or esophagus. These are also called “compressive symptoms.” Compressive symptoms include:

Discomfort with swallowing
Discomfort when lying down in certain positions
A tight feeling when wearing a collared shirt
Noisy breathing at night
Food getting stuck in the throat
Shortness of breath when exercising and difficulty breathing.

Sometimes thyroid nodules can produce excess thyroid hormone. Excess thyroid hormone, also called hyperthyroidism, can cause the following signs and symptoms:

Heat intolerance (feeling hot when others do not)
Fatigue
Anxiety or swings in emotions/mood
Weakness
Tremor
Palpitations or feeling of an irregular heartbeat
Increased sweating
Weight loss despite normal or increased appetite
Thinning hair

How Are Thyroid Nodules Evaluated?

At the UCLA Endocrine Center in Los Angeles, multiple layers of evaluation are designed to help you avoid invasive tests and surgery whenever possible. Consultation, ultrasound, and FNA can all be performed in a single visit.

Initial evaluation of a newly discovered thyroid nodule begins with:

Assessment by an endocrinologist or endocrine surgeon
Thyroid function tests (laboratory tests)
Neck ultrasound performed by your doctor

An ultrasound is a highly accurate tool to visualize your thyroid nodule. There is no associated radiation with ultrasounds and it is non-invasive. Ultrasounds are cost-effective as most patients really don’t need any other imaging because the ultrasounds are the best way to look at the thyroid, all present nodules, and the lymph nodes in the neck.

Not all thyroid nodules need a biopsy. For many thyroid nodules we see in our office, we choose not to biopsy because the ultrasound appearance is so reassuring. That is one way to avoid over treatment. For example, nodules that appear completely black on the inside (“anechoic”) are purely cystic, or filled with fluid. The chance of thyroid cancer for a cystic nodule is essentially zero and cystic nodules do not require biopsy. There are guidelines from the American Thyroid Association that will help your doctor determine which nodules to biopsy based on their size and how suspicious they look on the ultrasound.

There are certain factors that make a nodule suspicious for thyroid cancer. For example, nodules that do not have smooth borders or have little bright white spots (micro-calcifications) on the ultrasound would make your doctor suspicious that there is a thyroid cancer present. If the nodule appears suspicious on ultrasound and is larger than 1cm, the next step is to do a thyroid biopsy.

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Our cytopathologists evaluate over 1000 samples per year, so we are confident in the accuracy of our biopsies. When biopsy does not give a clear answer, we automatically use molecular profiling to refine the diagnosis.

How Is a Thyroid Biopsy Performed?

A thyroid biopsy, also called a fine needle aspiration (FNA), uses a small needle to take a little sample of the cells in the thyroid nodule. The possible outcomes from a biopsy are:

Non-diagnostic: Non-diagnostic is a technically failed biopsy. There were not enough cells taken during the biopsy so the cytologist was not able to determine anything. These usually need to be repeated.

Benign: Most thyroid nodule biopsies come back benign, meaning your doctor is highly re-assured that it’s not cancerous. Patients can almost always avoid surgery unless the nodule is large and pushing on adjacent structures like the airway.

Indeterminate: Indeterminate means there was enough cells taken during the biopsy, but the cytopathologist was not sure if it is benign or malignant. Indeterminate results occur in about 20% of thyroid biopsies. This is a gray zone and means that the risk of cancer is about 10-30%. These nodules require additional work-up such as a repeat biopsy, molecular marker test, or surgical removal.

Suspicious for Malignancy or Malignant: Results categorized in these two categories are a strong indicator that there is thyroid cancer present and usually require surgical removal.

Patients usually wait one week for the cytopathologist to examine the cellular characteristic of the biopsy sample. If your doctor is reassured that it’s benign based on the biopsy result, further work-up is stopped and serial ultrasound surveillance is recommended usually once a year.

What Is Molecular Profiling?

At UCLA, thyroid nodules with indeterminate biopsies are sent out for an additional molecular marker test. An “indeterminate” biopsy result is the gray zone where the risk of thyroid cancer is intermediate (10–30%) but cannot be ignored.

Sometimes the biopsy result is reported as “indeterminate.” This means the cells are not normal, but there are not definite signs of cancer. When biopsies are indeterminate, the risk of thyroid cancer is 15–30%.

In the past, to avoid missing a cancer, we recommended thyroid lobectomy (removal of half of the thyroid) to establish a definitive diagnosis. Now, we use molecular profiling. This refers to commercial DNA or RNA tests made specifically for indeterminate thyroid nodules. If the genetic profile appears benign, patients can avoid surgery and we simply watch the nodule over time with neck ultrasound.

Thyroid Molecular Markers Allow Patients to Avoid Surgery

We want to help patients find that perfect balance between under-treatment and over-treatment. The people-gram shows how molecular testing can help patients avoid unnecessary surgery.

Thyroid Molecular Markers (people-gram)

Left Path: Before the use of molecular markers, everyone with an indeterminate biopsy went to surgery. Of those who went to surgery, thyroid cancer was found in only 25% of those cases (red). 75% of the surgical patients turned out not to have needed surgery at all because their nodules were benign (green).

Right Path: Today, if you have an indeterminate biopsy, you also undergo molecular testing. 50% of patients (green) were categorized as benign from the molecular test and safely avoided surgery. Of the surgical patients who received a suspicious molecular test result (yellow), cancer was found in 50% of those patients (red).

It is very rare that patients end up having thyroid cancer because of a false negative test. Still, it is UCLA’s standard of care to have a safety net and follow every patient after molecular testing, regardless of their result. Those patients will get ultrasounds every 12 months to ensure that nodules do not grow or change in appearance.

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What Are the Possible Causes of a Thyroid Nodule?

Thyroid Adenoma

Thyroid adenomas come in different forms and have different names, but they are benign growths of normal thyroid tissue. These do not require treatment if they are not causing compressive symptoms. If they are not causing symptoms, most of these are watched with neck ultrasound.

Toxic Adenoma

Toxic adenomas are thyroid adenomas that secrete excess thyroid hormone.

Thyroid Cysts

Thyroid cysts are fluid-filled nodules within the thyroid. Pure thyroid cysts are usually benign (non-cancerous).

Goiter

Any enlargement of the thyroid gland is referred to as a “goiter.” Goiter can be caused by Hashimoto’s Thyroiditis (an autoimmune disease) and iodine deficiency. These do not require treatment unless the goiter is causing compressive or hyperthyroid symptoms.

Multinodular Goiter

A multinodular goiter is an enlarged thyroid gland containing multiple nodules. Most often, these nodules are benign. As above, these only require treatment if you are experiencing compressive or hyperthyroid symptoms, or if one or more of the nodules is suspicious for thyroid cancer.

Top 4 Facts About Thyroid Nodule Surgery

Thyroid nodules are growths that occur in the thyroid gland forming a lump or bump within the otherwise smooth thyroid surface. Thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Many people are unaware they have thyroid nodules. Some folks need thyroid nodule surgery to treat these abnormal growths or lumps in the thyroid gland. Thyroid nodule surgery involves removing half or the whole thyroid gland in almost all instances.

Here are the top 4 facts about thyroid nodule surgery

1) Thyroid Nodules with Cancer Require Surgery

2) Some Benign (Non-Cancerous) Nodules Need Surgery

3) Multiple Nodules Can Necessitate Surgery

4) Surgery Provides the Most Definitive Diagnosis of the Nodule

Let’s take a more detailed look at all four of these facts about thyroid nodule surgery.

Thyroid Nodule Surgery Fact #1: Thyroid Nodules with Cancer Require Surgery

Most thyroid nodules are benign, but some are cancerous. Thyroid cancer only accounts for approximately 5% (10%-15% at most) of all thyroid nodules. Thyroid surgery is the mainstay of treating thyroid cancer. Thyroid surgery done for thyroid nodules with cancer is often no different than thyroid nodule surgery done for non-cancerous growths in the thyroid. Thyroid nodule surgery done correctly in experienced and skilled hands is crucial for curing thyroid cancer.

Numerous studies have shown that up to 30% of thyroid nodules with cancer have spread to lymph nodes at the time of diagnosis and surgery. Many times, thyroid nodule surgery can cure the cancer by only removing half (or a lobe) of the thyroid (thyroid lobectomy). Again, expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind.

In other instances, total thyroid removal (total thyroidectomy) is needed to treat thyroid nodules with cancer that are large, located in both halves of the thyroid, or when thyroid cancer has spread to lymph nodes in the neck. Again, removal of the lymph nodes behind and around the thyroid in the middle of the neck, at a minimum, is important to ensure the cancer is completely cured. Complete thyroid removal is even riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage. Thus, thyroid nodule surgery involving total thyroid removal should only be done by high-volume, experienced surgeons at busy centers such as ours. Hospital for Endocrine Surgery

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For more information about thyroid surgery for cancer, visit our website at www.thyroidcancer.com and check out our blogs on thyroid removal for thyroid cancer at www.thyroidectomy-for-thyroid-cancer, and www.3-best-thyroid-operations-for-thyroid-cancer.

Figure 1: Ultrasound image of a cancerous thyroid nodule

Thyroid Nodule Surgery Fact #2: Some Benign (Non-Cancerous) Nodules Need Surgery

As noted above, thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Most nodules are benign, but some of these do require thyroid nodule surgery. Thyroid nodules are often diagnosed as benign by needle biopsy during a patient evaluation. Although these nodules are benign, almost all of them will enlarge or grow over time. Thus, size is one reason for benign thyroid nodule surgery. Any nodule that is 4 cm or larger should be removed with thyroid nodule surgery. Thyroid surgery is also very frequently needed for nodules that have atypical or suspicious cells on biopsy. This allows for a definitive diagnosis and cure.

Many thyroid nodules that are benign on biopsy may be observed. This is provided that the nodule is not overactive/toxic (causing hyperthyroidism), large (4 cm or greater; or >1.5 inches) or progressing in size, symptomatic, part of a goiter that is extending into the chest cavity, or pushing the windpipe (tracheal) or swallowing tube (esophagus). If one or more of those characteristics are present, then thyroid nodule surgery for treatment is necessary. Observation usually implies repeating thyroid blood tests, ultrasound, and physical examination in approximately 12-18 months (an ultrasound every 3 or 6 months is not indicated for benign nodules).

To learn more about thyroid nodules, visit our blog at www.top-5-worries-about-thyroid-nodules.

Thyroid Nodule Surgery Fact #3: Multiple Nodules Can Necessitate Surgery

Multiple thyroid nodules, particularly when part of an enlarged thyroid (goiter), can require surgery. Even if a nodule, or 2-3 nodules, are benign on needle biopsy, an enlarged thyroid with numerous nodules (multinodular goiter) often requires thyroid nodule surgery for a few reasons. First, it is very hard and impractical to monitor and needle biopsy more than 2-3 nodules. Second, multiple thyroid nodules and goiter often produce symptoms eventually. Symptomatic thyroid nodules require thyroid nodule surgery. The most common symptom or complaint of a multinodular goiter is the unsightly cosmetic appearance of a large lump in the neck or the symptoms produced by the actual size of the goiter. Symptoms related to the size of the goiter may include a sense of a lump in the throat, difficulty swallowing, difficulty breathing, and even in extreme cases, voice changes or a completely hoarse voice. Finally, thyroid nodules or a thyroid goiter that have grown under the collarbone and into the chest cavity (substernal goiter) always require thyroid removal.

One important consideration is that even though a substernal goiter with multiple nodules may extend extensively below the sternum (collar bone) and go well into the chest, these can almost always routinely be removed through an incision in the lower neck right above your collar bone. Skill and experience are key for these challenging thyroid surgeries. If your surgeon is telling you that they need to «split your chest» or «open your sternum», doublecheck to make sure that you have identified a highly- experienced thyroid surgeon. www.top-3-ways-to-find-best-thyroid-surgeon www.multinodular-goiter-substernal

Figure 1: CT scan image of a massive substernal goiter with multiple nodules indicated with orange arrows. The goiter surrounds the windpipe (trachea) which is identified with the blue arrow. The dark black areas on each side represent the lungs.

Thyroid Nodule Surgery Fact #4: Surgery Provides the Most Definitive Diagnosis of the Nodule

Most of the time, a needle biopsy is performed prior to surgery to obtain a diagnosis to guide treatment. Patients should realize that thyroid biopsies are only as good and reliable as the people performing them and the pathologists who are evaluating the cells. The results of a thyroid needle biopsy are categorized according to the Bethesda System for Reporting Thyroid Cytopathology for Thyroid Nodules. The diagnostic categories are as follows:

Nondiagnostic or unsatisfactory
Benign
Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS)
Follicular neoplasm or suspicious for a follicular neoplasm
Suspicious for malignancy
Malignant

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Many thyroid nodules cannot be diagnosed as cancerous until the entire nodule has been removed during thyroid nodule surgery where half or the whole thyroid is taken out. Frequently, a needle biopsy before surgery does not yield a definitive diagnosis as to whether a thyroid nodule is cancerous or benign (non-cancerous). Even special molecular genetic testing of thyroid cells from a biopsy often does not reveal whether a nodule is cancer or benign. In some large studies, up to 50% of thyroid cancers are not diagnosed until after thyroid nodule surgery.

Clearly, a biopsy does not always tell the doctor whether thyroid cancer is present. Furthermore, biopsies are not always accurate, and large nodules can harbor cancer (10.4%- 22% of the time) that is not diagnosed with FNA biopsy (or needle biopsy) preoperatively. That is to say that needle biopsies are not perfect, particularly as the nodules get larger. Thyroid nodule surgery can be indicated for a definitive diagnosis and cure.

Summary

Thyroid nodules are very common. Thyroid nodule surgery, involving removal of half or the whole thyroid, is often necessary to diagnose and cure these nodules, particularly when they are cancerous. Large nodules, multiple nodules with or without thyroid goiter (enlarged thyroid), and ones that are atypical or suspicious often require thyroid nodule surgery. Even benign nodules may need surgery depending on symptoms, growth, or size.

Expert evaluation and treatment for thyroid nodules are paramount. Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid nodule surgery. To learn more and become a patient, please see our resources below.

Additional Resources

Become our patient by filling out the form at this link.
Learn more The Clayman Thyroid Center here.
Learn more about our sister surgeons at the Scarless Thyroid Surgery Center,Norman Parathyroid Center, and Carling Adrenal Center
Learn more about the Hospital for Endocrine Surgery.

Author

Dr. Nate Walsh

Dr Nate Walsh was raised in Tampa, FL for almost his entire life. He completed the Honors Program at the University of Florida then received his MD from the University of South Florida. Dr Walsh completed surgery training at the Medical College of Georgia and then completed a Head and Neck Endocrine Surgery fellowship at Augusta University Medical Center. Dr Walsh has a passion for cutting edge thyroid surgery and is an exquisitely talented and experienced thyroid surgeon and is highly sought for his expert care. He is married and has 3 children.

ThyroidCancer.com is an educational service of the Clayman Thyroid Center, the world’s leading thyroid surgery center operating exclusively at the new Hospital for Endocrine Surgery.