Thyroid Mass

Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Outline
When a patient with a thyroid mass presents, 
    -First step is to see if it is goiter or a thyroid nodule.
    -Second step is to determine the risk of cancer with in 
    -Third step is to see if the patient is hyperthyroid or not
    -Forth is to determine if there are compressive symptoms- if so URGENT referral 

The examination should assist determine above four features

Investigations should be directed according to the findings




History
Is this a long standing mass, is the whole thyroid large or a nodule?
Is it an endemic goiter
Is it a toxic goiter



Is this a nodule the patient is presenting with
Is there is a risk of cancer
      Extremes in age (very young or older)
      Radiation exposure
      Family Hx of thyroid cancer

Hyper or Hypothyroid symptoms
Rare for a nodule to be cancerous if hyper hyperfunctioning
Are the symptoms of acute onset or longer standing


Are there compressive symptoms
      Breathing ?
      swallowing? if significant URGENT referral




Examination

First confirm its the thyroid (moves with swallowing) 
Determine if this is a goiter or a nodule

look for cancer
Any hard masses- Hard= risk of cancer (individual nodule or within a goiter)
Any neck nodes (nodes= cancer)


look for compressive features
if venous congestion positive Pemberton's test
Stridor-URGENT Referral


Look for hyperthyroid features 
Look for hypothyroid features




Investigations

-First line of test:TFT- Hyperthyroid

If hyperthyroid determine the cause (Graves, Toxic nodular goiter/ thyroditis)
    Endocrine review
    Anti thyroid medications 

-If hyperthyroid also do TC99 
    what we want to know is...is it a hot nodule (low risk) or a hot gland with a    cold nodule (High risk of cancer)
    If cold nodule need US and FNA (as below)

If Euthyroid and a nodule/ or a euthyroid goiter
   US-? suspicious features in nodules (i.e. calcification etc)
   if so FNA the risky nodules



Treatment Outline
If US FNA says benign- 95% it benign, need to repeat US +/- FNA in 6 months
If FNA is cancer- Total thyroidectomy plus pots op radioactive I if high risk
If inconclusive / follicular cells need hemithyroid- if cancer completion total T