When Should A Thyroid Nodule Be Removed?

Endocrinologists generally advocated non-surgical solutions for patients with thyroid disease. However, not every patient is able to avoid surgery. It takes experience and training to know which patient needs surgery at which time and the extent of the surgical therapy that is necessary.

Thyroid nodules are generally benign. Given this, it is the unusual nodule that requires surgical removal. Nevertheless, there are some circumstances in which surgery is necessary. Determining when to operate and when to observe can sometimes be tricky and requires a close working relationship between the endocrinologist and the thyroid surgeon.

There are three general situations in which thyroid surgery is warranted: suspected malignancy, large thyroid glands (goiters) that are causing obstructive symptoms, and large thyroids that are cosmetically bothersome.

Suspicious For Malignancy

Surgery is always required for thyroid nodules that are suspected to be malignant. Patients with nodules that have been biopsied and show a clear-cut diagnosis of thyroid cancer (usually papillary carcinoma) will often undergo a total thyroidectomy with removal of lymph nodes at the time of the original surgery. Patients with follicular lesions on biopsy also need surgery. However, only 1 in 5 follicular nodules end up being malignant. For this reason, most patients with follicular lesions on biopsy will only have the half of the thyroid with the nodule removed. The surgeon will usually have a pathologist on standby to review the surgical specimen (frozen section). If it appears to be malignant, the entire thyroid gland will be removed. If it appears to be benign, the operation will be concluded. Frozen section evaluation of nodules is very good, but not 100% accurate. In some cases, the final pathology will determine the nodule that was considered benign on frozen section was malignant. In such cases it will usually be necessary for the surgeon to do another operation to remove the entire thyroid gland for the cancer to be optimally treated.

Large Goiters

Patients with large goiters often experience obstructive symptoms. Other goiters may grow so large that they are very unsightly and become a cosmetic problem for patients. These should be considered for surgical resection. Symptoms of an obstructive goiter may include difficulty swallowing, food getting stuck, or choking while eating or drinking. Some goiters may also affect breathing function or cause problems with snoring. In more severe cases, large goiters may block the drainage of blood flow from the face and head back to the heart. This is often intermittent and most symptomatic when the patient has their hands elevated above their head. This maneuver may result in the face becoming flushed (red or purple in color), and the patient feeling a fullness in their head and short of breath.

The selection of a thyroid surgeon is critical for a good outcome. Experience is the single most important consideration in selecting a thyroid surgeon. Your surgeon need to know his or her personal limits and have the training to do a thorough dissection of the lymph node compartments of the neck is essential. They should not be afraid to tell you when your case should be referred to a tertiary center. Your surgeon must have a close working relationship with your endocrinologist so surgical and medical care can be appropriately coordinated.

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