Thyroid Nodules: Risks, Surgery, and Post-Operative Care

Thyroid nodule with extrathyroidal extension?

Hello, doctor.
I previously underwent a thyroid ultrasound and fine needle aspiration biopsy, which revealed 1 to 2 nodules in each lobe.
In the middle part of the right lobe, there is a hypoechoic heterogeneous nodule with microcalcifications (0.79 x 0.67 x 0.69 cm, TR 7).
In the lower part, there is a severely heterogeneous hypoechoic nodule with microcalcifications, irregular margins, and extrathyroid extension (1.03 x 0.94 x 0.94 cm, TR 10).
The doctor mentioned that surgery is necessary.
Based on my condition, what is the likelihood of cancer? If traditional surgery is performed, will the surgeon proactively conduct a frozen section analysis on the problematic area during the operation (or does the patient need to request this beforehand)? How will the decision be made regarding total thyroidectomy versus partial removal? If a total thyroidectomy is performed, will the parathyroid glands also need to be removed? Additionally, I have osteoporosis (approximately -3.1) but am currently not on medication.
Will postoperative thyroid hormone supplementation have a significant impact? I kindly ask for your answers, thank you!

S, 50~59 year old female. Ask Date: 2021/11/03

Dr. Yuan Tianmin reply Breast and Thyroid

The questions you are asking are quite professional and important; however, I recommend that you discuss them with your attending physician.
Ultimately, he is the surgeon performing your operation and will be able to explain things to you in his own way.

Reply Date: 2021/11/03

More Info

Understanding thyroid nodules is crucial, especially when considering the risks associated with potential malignancy, surgical intervention, and post-operative care. Based on your description, you have multiple nodules, including one that is classified as TR 10, which indicates a high suspicion for malignancy. The presence of microcalcifications, irregular borders, and extrathyroidal extension are concerning features that often warrant surgical intervention.

Cancer Risk Assessment
The risk of cancer in thyroid nodules can vary significantly based on ultrasound characteristics and fine-needle aspiration biopsy (FNAB) results. In your case, the TR 10 classification suggests a high likelihood of malignancy, particularly given the features of the nodules you described. While not all TR 10 nodules are cancerous, the presence of these concerning features typically leads to a recommendation for surgery to ensure proper diagnosis and treatment.

Surgical Considerations
Regarding the surgical approach, it is common practice for surgeons to perform intraoperative frozen section analysis if there is a suspicion of malignancy. This allows the surgical team to assess the tissue in real-time during the procedure. If the frozen section indicates cancer, the surgeon may decide to perform a total thyroidectomy or a more extensive resection based on the findings. If the frozen section is benign, the surgeon may opt for a less extensive procedure, such as a lobectomy.

You do not need to specifically request a frozen section; it is generally part of the protocol when dealing with suspicious nodules. However, it is always a good idea to discuss your concerns and preferences with your surgeon beforehand to ensure that you are both on the same page regarding the surgical plan.

Impact on Parathyroid Glands
In terms of the parathyroid glands, if a total thyroidectomy is performed, there is a risk of damaging or removing these glands, which can lead to hypoparathyroidism. This condition can result in low calcium levels post-operatively, necessitating calcium and vitamin D supplementation. Surgeons typically try to preserve the parathyroid glands whenever possible, but this may not always be feasible depending on the extent of the disease.

Post-Operative Care and Thyroid Hormone Replacement
After surgery, especially if a total thyroidectomy is performed, you will need to take thyroid hormone replacement therapy (levothyroxine) for life. This is essential to maintain normal metabolic function, as your body will no longer produce thyroid hormones. The dosage will be adjusted based on your TSH levels, which will be monitored regularly.

Given your history of osteoporosis (with a T-score of -3.1), it is crucial to manage your thyroid hormone levels carefully. Excessive thyroid hormone can lead to bone loss, so your endocrinologist will work with you to find the optimal dose that maintains thyroid function without adversely affecting your bone health. Additionally, you may want to discuss osteoporosis management strategies, including dietary changes, calcium and vitamin D supplementation, and possibly medication, with your healthcare provider.

Conclusion
In summary, your situation indicates a significant risk of malignancy, and surgical intervention is warranted. The surgical team will likely perform a frozen section analysis to guide the extent of surgery. Post-operatively, you will require lifelong thyroid hormone replacement, and careful management will be necessary to protect your bone health. It is essential to maintain open communication with your healthcare team throughout this process to address any concerns and ensure optimal outcomes.

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