Thyroid Nodules and Enlargement: When to Consider Surgery

Thyroid issues

The patient has a history of thyroid nodules, first discovered at the age of 15 when family members noticed a swelling in the neck.
They have been returning for regular check-ups every six months to a year, believing it to be thyroid nodules for over a decade.
It was only in the last two years that they were informed of thyroid enlargement (this was mentioned during a consultation for ablation).
Perhaps due to not having a consistent physician, the patient has changed hospitals frequently for work and studies, and the neck swelling has progressively increased.
The patient recalls that the thyroid enlargement is about 4-5 cm, and the previously monitored nodules have also gradually grown to around 2 cm.

Recently, the patient consulted a new doctor who recommended a fine needle aspiration for a 1 cm nodule, noting that the size discrepancy might be due to different measurement techniques.
The doctor also mentioned the presence of calcification and suggested surgery, which had not been previously communicated by other doctors.
A biopsy performed six months ago showed no malignant components.

The patient recalls a previous doctor stating that even if the nodules were removed, the neck would still appear enlarged (this was during a consultation for ablation, but the external appearance would not change due to the enlargement).
Currently, there are no issues with tracheal compression or swallowing difficulties, but the enlargement is indeed gradually increasing.
The patient is seeking advice on whether surgery to remove the nodules or the entire thyroid gland is recommended.
Thyroid function tests over the past decade have been normal, but the issue of enlargement seems inevitable for surgical intervention.
In recent years, the patient has adopted a wait-and-see approach, reasoning that as long as swallowing and breathing are unaffected, they would leave it as is.
Thank you.

Lan, 30~39 year old female. Ask Date: 2022/03/24

Dr. Yuan Tianmin reply Breast and Thyroid

Based on your values, it does not seem that you require immediate surgical intervention.
Some of your conditions cannot be addressed through a consultation with a physician; it is advisable to seek guidance from a thyroid surgeon for more appropriate recommendations.

Reply Date: 2022/03/24

More Info

When it comes to thyroid nodules and enlargement, the decision to consider surgery is influenced by several factors, including the size of the nodules, their characteristics, and any associated symptoms. In your case, you have a long-standing history of thyroid nodules, which have gradually increased in size, and you are now facing a situation where the nodules are causing noticeable enlargement of your neck.
Thyroid nodules are quite common, and the majority are benign. However, certain characteristics can raise suspicion for malignancy, such as microcalcifications, irregular margins, and increased vascularity on imaging studies. The presence of calcifications, as mentioned in your case, can be a concerning feature that warrants further investigation. Fine-needle aspiration (FNA) biopsy is often recommended for nodules that are larger than 1 cm, especially if they exhibit suspicious features on ultrasound. This procedure can help determine whether the nodule is benign or malignant.

In your situation, the recommendation for surgery may stem from the combination of the size of the nodules, the presence of calcifications, and the gradual increase in size over the years. Even though your previous biopsies have shown no malignant cells, the ongoing enlargement and the potential for future complications, such as compression of the trachea or esophagus, are valid concerns.
Surgery may involve either a lobectomy (removal of one lobe of the thyroid) or a total thyroidectomy (removal of the entire thyroid gland). The choice between these options depends on several factors, including the size and characteristics of the nodules, your overall health, and your personal preferences. If the nodules are benign but causing significant cosmetic concerns or symptoms, surgery may still be considered to improve your quality of life.

It is also important to note that even after surgery, the appearance of your neck may not change significantly if the thyroid gland is still present or if there is residual tissue. However, if the nodules are removed, you may experience relief from any potential future complications associated with their growth.

In terms of your thyroid function, it is reassuring that your blood tests have remained normal over the years. However, after surgery, particularly if a total thyroidectomy is performed, you will require lifelong thyroid hormone replacement therapy to maintain normal metabolic function. This is typically done with levothyroxine, which is a synthetic form of the thyroid hormone thyroxine (T4).

Ultimately, the decision to proceed with surgery should be made in consultation with your healthcare provider, ideally an endocrinologist or a surgeon specializing in thyroid disorders. They can provide a thorough evaluation of your specific situation, discuss the risks and benefits of surgery, and help you make an informed decision that aligns with your health goals and concerns.

In summary, given your history of thyroid nodules, their gradual enlargement, and the presence of calcifications, surgery may be a reasonable option to consider. It is essential to have a detailed discussion with your healthcare team to weigh the potential benefits against the risks and to determine the best course of action for your individual circumstances.

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