By far, most thyroid lumps are benign. However, thyroid lumps and thyroid cancer is increasing worldwide and NZ is no exception. We are iodine deficient but that is not the sole cause.
Around 85% cancers are papillary carcinoma, around 12% are follicular carcinoma, 5% medullary, and fortunately only 1-2% are anaplastic. Papillary and follicular are what we call "differentiated thyroid cancers"
About 6% of all patients with differentiated thyroid cancer will die of their disease....94% are either cured or live with dormant or active disease. As doctors we try to minimise the number dying by early diagnosis and treatment.
Differentiated (papillary and follicular)
Age at diagnosis is the single most important factor.
Under 45yrs age
Over the age of 45 yrs
Papillary (PTC)
Follicular (FTC)
Medullary carcinoma (MTC)
Anaplastic
Insufficient material
Benign follicular lesion/ colloid nodule
Indeterminate i.e. cannot differentiate between benign follicular and follicular neoplasm
Atypical follicular pattern - consistent with follicular neoplasm
Suspicious of papillary thyroid carcinoma
The aim of investigation is to determine the risk of the patient coming to harm if the nodule is left...in other words, to determine which nodules should be removed.
All require TFT's, ultrasound. Most require FNA cytology.
Most thyroid nodules require a specialist opinion (endocrinologist or surgeon) regardless of the TFT's, ultrasound, FNA cytology.
TFTs (for more information see bloods)
Ultrasound
(for more information see imaging)
FNA cytology
Goitres are clinically significant when
The aim of investigation is to determine the risk of the patient coming to harm if the goitre is left...in other words, to determine which thyroids should be removed.
All require TFT's, ultrasound. Some require FNA cytology.
Most thyroid nodules require a specialist opinion (endocrinologist or surgeon) regardless of the TFT's, ultrasound, FNA cytology.
TFTs (for more information see "bloods")
Ultrasound
(for more information see "imaging")
Chest XRay
FNA cytology
Whole gland or just lump?
It is important to establish whether the whole parotid is swollen or whether it is a lump within the gland. Remember that 80% of parotid lumps will appear in the tail. The parotid tail is just behind the angle of the mandible and is in the upper part of the neck.
Whole gland swelling:
Parotid lump:
whole parotid swelling
In association with eating...
Not associated with eating
parotid lump
neoplasm likely
The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.
Multiple lumps of recent duration:
Blood tests
If blood tests do not indicate diagnosis then consider ultrasound to determine what tissue is involved and to determine whether FNA cytology required. However, also consider whether there is likely to be a delay and whether referral is preferable.
The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.
Consider whether this is best imaging modality before referral. Public radiology departments inundated with requests. There must be value added to the working diagnosis. Unless showing a calculus or fluid collection it is seldom diagnostic.
The aim of management is to diagnose every neck lump and therefore to determine which are detrimental to the patient and should be treated.
be careful here...there may be sampling error or may be secondary inflammation! If reactive cytology and lump persists then significant risk of false diagnosis. Always be prepared to reconsider working diagnosis.
if lump solid and clearly palpable US guidance not required. If difficult to palpate and/or cystic then consider US guided FNA