Webinar on thyroid nodules and goitre

Thyroid nodules and goitre (swellings) are common and increase in frequency as we age. So it is unsurprisingly one of the topics we are most frequently asked about. At our recent webinar, consultant endocrinologist and BTF trustee, Prof Mark Strachan, gave a very informative overview on this topic; outlining the different types of nodules and goitre and their causes, as well as their investigation and management.  

This is a transcript of some of the questions answered by Mark. You can view the full transcript on our website or we can send it to you on request.

Key

MS – Mark Strachan

JP – Julia Priestley

Q 1 I have got a multinodular goitre and Graves’ disease. It is usual for the goitre itself to increase and decrease in size?

Q 2 I have got a malignant (cancerous) nodule. Is it possible for this to come and go? Could it be shrinking?

Goitres definitely do increase and decrease in size in people with Graves’ disease. This is because in Graves’ disease some of the goitre is due to the fact your thyroid cells are bigger. They are making more thyroid hormone and you have more of them because of the antibody stimulation. However, a large part of the goitre in Graves’ disease is due to your thyroid becoming engorged with blood. This is because you are pumping so much blood around your body. So the goitre does wax and wane.

People with thyroid lumps, not caused by Graves’ disease, tell us they sometimes notice the lump changes in size. These comments come from people with both benign and cancerous lumps. Although it is very common for people to tell me this, I have to say it is always hard for me to understand how this may be the case. This is because a lump in your thyroid (a hyperplastic nodule or a cancer) should not really get smaller. There is no real mechanism where that may be the case.

Thyroid cancers usually get bigger with time but only very, very slowly as most thyroid cancers grow very, very slowly. However, these questions highlight a common symptom. I am not disputing it, but it is something I cannot readily explain.

I have been referred to both Ear, Nose and Throat (ENT) and endocrinology for my benign thyroid goitre which may need surgery. Which of the two disciplines would be better for me?

Well, obviously I am an endocrinologist so there is no question at all: - it is endocrinology!  In all seriousness though, I think it depends. Different parts of the country have got different pathways for how nodules and goitre are investigated and managed.

Usually, an endocrinologist will see people where a goitre is associated with abnormal thyroid hormone levels because there is usually an underlying medical cause that, certainly initially, needs medical treatment. Usually, you are referred to a surgeon if thyroid hormone levels are normal and where the main treatment option is surgery, or otherwise, just observation.

It is unusual to be referred to two different clinics simultaneously and I do not quite understand why that would happen. I understand that you might not want to go to two different appointments so it might be worth clarifying with your GP what the rationale is for referring you to two different services because that does seem unnecessary.

How widely is Radio Frequency Ablation (RFA) used and when might it be used to treat a thyroid nodule?

RFA is basically putting a probe into the nodule and passing a high energy pulse into the nodule. In theory, it can cause the nodule to shrink down.

RFA is available in many parts of the world; usually in high income, high resource settings. It would be fair to say there are many RFA advocates, but there is not a lot published about it. Currently NICE is doing a technology appraisal on RFA to establish whether this is a treatment worthwhile the NHS investing in.

The reason I am saying this is if you have a lump in your thyroid that has been shown to be benign, for most people that lump does not need any treatment. It might need treatment from a cosmetic point of view or if it is giving symptoms. The reality is that most lumps do not cause symptoms.

So you might ask what is the place of RFA for a benign lump, as most benign lumps do not require any treatment at all?

On the other side of the coin, if you have thyroid cancer the evidence is you should have an operation to remove the lump. There are no large scale studies that show RFA is beneficial in thyroid cancer.

There are some centres that will use RFA if you have a lymph node involved but, again, these are relatively small case series. At the moment, RFA is a therapy that is available in some centres but I think it is looking for a place, I would say, as the evidence for it is not absolutely robust.

I have had two Fine Needle Aspiration Cytologies (FNAC) for thyroid nodules. A couple of weeks after both procedures it felt like I had a lump in my throat. Can the modules be made worse by being poked around?

Yes, absolutely. It is not that the nodule is made worse. It is that the thyroid gland has got a very rich blood supply. It is almost inevitable when you do a FNAC that you will pierce little blood vessels within the thyroid. You cannot avoid doing that and so, in effect, you get bleeding around the nodules. In some people that bleeding is more than in others. This can cause swelling as it is just like a big bruise in the thyroid. With time it will re-absorb and go away.  

Can the surgical use of iodine cause goitre?

There is no evidence that iodine uptake scans nor surgical iodine cause nodules or goitre. If anything it is iodine deficiency that causes goitre or nodule, not excess iodine as such. In someone who has Graves’ disease and borderline overactivity, if they took a lot of iodine (i.e. seaweed) this could make their thyroid more overactive in the short term.

Other than that, no surgical iodine does not get absorbed into the skin in any meaningful amount. In iodine contrast medium used in x-rays the amount of iodine is trivial; much, much less than is in normal diet.

What is the follow-up for a U3 graded benign nodule?

U3 graded nodules are radiologically 'indeterminate' and would often, but not always, be biopsied. If the biopsy suggests the nodule is benign, then in some centres they discharge you and say you do not require any follow-up. In other centres, they would do a follow-up scan after a variable interval. But we need to question what the purpose of the follow-up scan is? If you are looking at growth (i.e. an increase in the size of the nodule over time), that may not in itself be a reliable marker of whether a nodule is benign or a cancer. Cancers can grow very slowly with time, so if the time interval between scans is short then growth may be missed. On the other side of the coin, benign nodules grow also - a 3cm benign nodule must have been a 1cm nodule at one point. So I think there is still a certain amount of uncertainty about what the optimum follow-up, if any, should be on a U3 graded nodule, which has been shown to be benign on biopsy.

JP There is some work going on nationally to develop a new consensus statement on the follow-up of thyroid nodules. This should give some clarity on this and it will be available over the coming months. The BTF is also producing a patient leaflet to accompany this and we will share it as soon as it is ready.

What would you say is the best treatment for multinodular goitre – Radioiodine (RAI) or surgery?

This really depends on two things: If it is a multinodular goitre and you have an overactive thyroid, you will need treatment.  If it is a multinodular goitre with normal thyroid function then that does not usually need treating at all if it is not causing symptoms and not bothering you from a cosmetic point of view.

If, for whatever reason, you need treatment, it is a very personal decision whether you opt for RAI or surgery. If you are having treatment for cosmetic reasons, then probably surgery is the better option because RAI is not very good at shrinking a multinodular goitre, particularly where thyroid hormone levels are normal. It can cause a bit of shrinkage, but it is not going to shrink away completely. Surgery, on the other hand, will remove it completely. However, there are theoretical risks of damage to the parathyroid glands and the small nerves that supply the voice box.

If you have an overactive thyroid then RAI is a really effective treatment and it has got the simplicity of being a capsule you swallow. However, the downside is the restrictions that are in place following RAI treatment for four to six weeks, depending on dose and your local centre’s policies.  This is where your personal circumstances come into play. For example, if you are a parent with young children then being isolated from them, or having restricted access to them for several weeks, is not going to be a great option for you and surgery may be preferable.  The only thing I would say is if you are having treatment for cosmetic and symptomatic reasons, surgery is probably better than RAI if your blood tests are normal.

JP If you feel you are being pushed towards one option it is always worth having a discussion with your healthcare professionals to see whether there is another option available for you.

MS You should never feel forced to have a treatment that you do not want to have and certainly, it is important to explore these with your healthcare professional.  It may be there are particular reasons why some treatments are not an option for you. For example, if a patient saw me with a multinodular goitre and normal blood tests, I would say the results are likely to be better with surgery rather than RAI.

I have Graves’ disease and have been on carbimazole for ten years. My thyroid became a little enlarged. How long does it take for the goitre to reduce in size? I am having RAI in three months.

In some people, the goitre will shrink back when their thyroid levels normalise with treatment. In others, however, it does not. I said earlier that RAI was not very good at shrinking a multinodular goitre but it is actually pretty good at shrinking a goitre in Graves’ disease. So you may find after RAI that your goitre does shrink back.

I have a benign multinodular goitre. Should it be monitored to check whether it is getting worse? Is it permanent?

Lumps in the thyroid are permanent. They rarely go away by themselves. The exception to that is if you have a cyst (fluid-filled sac) in your thyroid or a lump that is mixed solid and cystic. Sometimes the cyst can actually burst, for whatever reason, and the fluid just leaks away. This can cause the lump to shrink down. By and large, if you have a multinodular goitre, you will always have a multinodular goitre.

If you have had an ultrasound scan that says the goitre is benign and looks reassuring then any further scans may not be necessary for the reasons I gave earlier. Generally, we do recommend that you should have your thyroid blood tests done every one to two years to ensure your thyroid hormone levels are not changing. Obviously,  if you notice any change in the feel or the look of the goitre then by all means discuss this with your GP but it is not an absolute that this will need follow-up.

What types of nodule would ethanol ablation be suitable for?

What I said about RFA almost similarly applies to ethanol ablation with two caveats. If you have a large cyst, then ethanol ablation can be quite effective. Usually what happens is that the cyst is drained of fluid under ultrasound guidance then ethanol is injected back into it immediately. This can be effective in causing the walls of the cyst to stick together and it stops the cyst from recurring.

As far as ethanol ablation for solid nodules, again there is not a huge amount of good quality data about this. There is some published information about ethanol ablation for people with recurrent thyroid cancer in the neck and lymph glands. This involves injecting ethanol in the lymph gland with the cancer cells and, in theory, the ethanol destroys them. Again the quality of studies is variable, so most doctors would say definitive treatment for lymph glands with thyroid cancer cells usually requires an operation.

I am having my goitre surgically removed. What is the average recovery time?

If you are fit and well, then the recovery time is pretty quick – around two weeks.

My nodule has become a bit more noticeable in the past couple of weeks and I feel a bit off. Does this mean it has grown again?

It could mean that. More often than not, it does not though.

Thyroid nodules grow very slowly. You are usually talking millimetres of growth over a year or two years. If you have had an evaluation of the nodule and it looked very reassuring on the scan then it is very unlikely that that would suddenly grow very big.

Sometimes, for some reason, people do feel their nodule has got a bit bigger. When you scan them you actually find there is no change. As ever, if you are in any doubt you should speak to your GP about that.

My daughter was diagnosed with an underactive thyroid and goitre aged ten. She has never had her goitre checked in the past seven years. Should the GP be checking this?

Not necessarily. Goitre is very common in people with an underactive thyroid. Sometimes it goes away with levothyroxine treatment but sometimes it does not. Providing the goitre has not changed in size I would not say she specifically needs to be seen.

In effect, it is the same as someone with Graves’ disease presenting with a goitre. Most times we would not do a scan in somebody with Graves’ disease and a goitre because we know that the diagnosis is. Again, in your daughter’s case we know the diagnosis is autoimmune hypothyroidism (Hashimoto’s thyroiditis) and that is a sufficient explanation for the goitre.

Are there any particular issues you are seeing with patients over the pandemic, such as patients’ symptoms being missed due to difficulty accessing healthcare professionals?

The first thing to say is I do not think there is any particularly strong evidence to suggest Covid-19 affects the thyroid. There are some anecdotal reports, but no particularly strong evidence.

The issue around delayed diagnosis is as true of thyroid as it is of many other healthcare problems. There is now delayed diagnosis across a whole slew of healthcare problems.

I suppose with regards to any thyroid lumps, thankfully because they grow very, very slowly, a delay in diagnosis, even for a lump that turns out to be cancerous, usually does not make any difference.

As always, if people are concerned they have a lump in their thyroid then they should be pushing to get an assessment by their primary care clinician

JP – Yes, either go back to your GP and if you are waiting for a follow-up appointment you should contact the hospital department and let them know you are still waiting. Hopefully, this will move you up the list somehow.

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