Thyroid Nodules

*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

Today I’d like to welcome to the PodMd studio Dr Suren Jayaweera is an Australian trained endocrine and general surgeon, with a special interest in benign and malignant disease of the thyroid and parathyroid glands, endoscopic trans-axillary thyroid surgery and workup and management of adrenal disease. He also performs elective and emergency surgery for gallbladder disease and hernias.

Today I’d like to welcome to the PodMd studio Dr Seren Jayaweera is an Australian trained endocrine and general surgeon, with a special interest in benign and malignant disease of the thyroid and parathyroid glands, endoscopic trans-axillary thyroid surgery and workup and management of adrenal disease. He also performs elective and emergency surgery for gallbladder disease and hernias.
Today, we’ll be discussing the topic of thyroid nodules.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.

Question 1

The topic of today’s discussion is thyroid nodules

How would a patient with thyroid nodules typically present?

Nodules are sometimes discovered incidentally on imaging while investigating other conditions such as on ultrasounds for carotid disease or CTs for respiratory issues or sometimes they’re picked up by an observant GP. But nodules may present as a visible or palpable lump or with symptoms due to pressure on structures in the neck. … ah structures in the neck that can be compressed by nodules include the oesophagus, the trachea, and the recurrent laryngeal nerve. Resulting on dysphasia, dyspnea or voice changes. In addition, if a nodule is producing an esses and excess amount of thyroid hormone and we refer to these nodules as toxic nodules. Patients may exhibit symptoms of hyperthyroidism. So, commonly, these symptoms include heat intolerance, sweating and palpitations but patients may also experience, sleep disturbance, fatigue, diarrhea, menstrual irregularities, nervousness and irritability.

Question 2
What investigations should be carried out for these patients where the GP suspects thyroid nodules?

I believe that thyroid nodules- everybody should be investigated with an ultrasound. It’s a simple, non-invasive investigation that helps determine the malignant potential Ah, I believe that all thyroid nodules ah should be evaluated with an ultrasound. It’s a simple, non-invasive investigation that helps determine the malignant potential of thyroid nodules. More and more radiologists are moving toward the tirads classification system of thyroid nodules which helps determine whether a nodule needs a fine needle aspirate. Basically, this system looks at features that raises suspicion of malignancy such as irregular margins or presence of calcification within the nodules. I like to perform an ultrasound in my office so I can confirm what’s on the radiologist’s report as well as to perform a fine-needle aspirate if it’s necessary. In terms of blood test, all patients should have thyroid function tests to determine if a nodule might be hyperfunctioning and if the THC is suppressed by chemical hyperthyroidism, I would consider extra investigations looking for an underlying cause. And these might include, thyroid antibodies looking for hashimoto’s, thyroiditis, and anti-TSH receptor looking for antibodies, which if elevated may indicate Graves’ Disease.

Question 2

Ok, so tell me about Thyroid Nuclear scans?

I often see on ultrasound reports that a nodule should be further evaluated with a nuclear scan. I don’t feel that there is any real value of nuclear scans except in the cases where the patient is chemically hyperthyroid. In these situations, a nuclear scan is really useful to determine if the hyperthyroidism is due to a solitary toxic nodule or a more diffuse thyroid condition such as Graves’ Disease or a toxic, multi-nodular goitre.
Yeah, right, so when in this process of investigation should a GP be referring to you?
Well, the vast majority of thyroid nodules are benign and asymptomatic and don’t require surgical intervention. But if a GP has any concerns about a thyroid nodule, particularly if it’s causing pressure symptoms, or if there’s concern regarding its malignant potential or if it’s a toxic nodule, then further evaluation is warranted.
Are there any warning signs a GP or their patient can look out for?
I get concerned when I see a patient who presents with a hard nodule or if they have a change in their voice or if there’s a short history of symptoms or a rapid progression of symptoms. To me these, these warning signs may indicate ahh higher chance of malignancy.

Question 3

Well, we’ve discussed when to refer but who should GPs really be referring to?

It’s a, it’s a good question, because there’s a confusing array of specialists who deal with thyroid glands. There’s a confusing array of specialists who deal with thyroid gland and these range from general physicians, endocrinologists, general surgeons, ENT surgeons, breast surgeons who od thyroid surgeries as well. And, I think a good way of looking at it is to divide thyroid problems into structure versus functional problems. And if it’s a functional problem then certainly endocrinologists ahh are probably the first point of call. And structural problems so, thyroid nodules, multiple nodular goitres, um thyroid cancer, um then they’re primarily dealt with by surgeons. Thyroid nodules, however, can have both structural and functional components. Um and pretty much all of the aforementioned specialists are able to to ah work up thyroid nodules. That being said, we’re in a new era of specialist endocrine surgeons who have undertaken, often several years of specialist training focussing on just thyroid, parathyroid and adrenal problems. And a study published in the journal of surgery, last year shows clearly superior outcomes when the surgeon is performing at least 40 thyroid procedures per year. There are many endocrine surgery units around Melbourne consisting of surgeons who work closely with endocrinologists and perform 150-200 procedures per year. So, I would encourage GPs to seek out appropriately trained, high volume surgeons

Question 4

Right, I can see how that could be confusing for GPs. So, I know you will be talking further on thyroid surgery in another podcast, but can you tell use quickly now, what indication should a GP be looking out for in terms of surgery?

So, a nodule that is confirmed to be cancerous on fine-needle aspirate, a nodule that is indeterminate or suspicious of cancer either on the thyroid ultrasound or the fine-needle aspirate. Benign nodules that continue to grow over a period of time, a large nodule of goitre that is causing compression symptoms such as dysphasia, dyspnea or voice changes, a nodule or goitre that is descending into the chest cavity or a retro-sternal goitre. Ah or a toxic nodule or a nodule producing an excess of thyroid hormone. They’re all examples of nodules that would be appropriate for surgical intervention.

Question 5

Have there been any developments in treatment?

There have been some developments in thyroid surgery so advances in technology means that surgery is safer, with lower complications than ever before. Further to this, if we look at trends internationally- there’s been a gradual uptake in the use of remote access surgery which is moving scars away from the neck to less conspicuous places. And I’m really keen to talk about the trans-oral endoscopic program that we have at Monash, but maybe that’s a topic for another podcast.
What role will the GP play in the treatment or investigation or a toxic or benign nodule?
The GP is involved in every step of thyroid nodules, um I’ve had many patients who have been diagnosed by an observant GP so ah right at the outset. GPs are often involved in the detection of nodules in the first place, they’re involved in the preoperative work up, including bloods, and ultrasounds. And postoperatively, depending on the operation-  the link between the GP and the surgeon is vital for the combined management of the patient in particular with regards to management um thyroxine dosing, calcium supplementation and ongoing surveillance of contra-lateral lobes.

Thank you so much for a through looking into thyroid nodules today. Before we finish up could you give us three take home messages that sum up your discussion?

Thyroid nodules are incredibly common, and the vast majority do not require any intervention at all
Baseline workup involves; history, examination, an ultrasound and thyroid function tests. As well as, I always screen for parathyroid disease as well. So that would involve, calcium, parathyroid hormone and vitamin D levels
Refer to your preferred thyroid surgeon any nodule that is causing pressure symptoms, symptoms of thyroid disfunction or if there are any concerns about malignant potential

Thank you very much for coming in today, Suren

Thank you.