When to worry about thyroid nodules

Aug. 11, 2023
Doctor feels a thyroid nodule on a young woman's neck.
Photo: Getty Images.

Thyroid nodules, or lumps in the thyroid gland, are usually nothing to worry about. But every now and then, they signal a more serious issue, such as cancer.

“Thyroid nodules are very common in older adults,” said Dr. Jessica Devin, an endocrinologist with UCHealth Endocrinology Clinic in Steamboat Springs. “Nearly half of adults 60 years or older have some sort of nodule in their thyroid gland.”

It’s rare for thyroid nodules to cause issues, such as voice hoarseness or trouble swallowing, that would signal the need to get them checked out. Typically, they’re found through a routine physical examination.

“Usually, a provider feels a nodule during an annual exam, or they are picked up incidentally through imaging,” Devin said. For instance, a carotid ultrasound or a cervical spine MRI may also end up revealing thyroid nodules.

Are thyroid nodules common?

Thyroid nodules are more common in older adults and also in people with Hashimoto’s disease, an autoimmune condition that affects the thyroid gland.

“You can get them at any age, but a thyroid nodule in a younger individual is a red flag,” Devin said.

Once thyroid nodules are discovered, an endocrinologist can help with further diagnosis.

“There are two things we want to rule out,” Devin said. “First, we want to make sure you’re not making too much thyroid hormone. And the next thing to rule out is thyroid cancer.”

Assessing thyroid function is tackled through a simple blood test. If too much thyroid hormone is being produced, additional scans may be done, and medication may be prescribed to bring hormone levels into a normal range. In very rare cases, surgery may be needed.

If initial tests show thyroid function is normal, the next step is ultrasound imaging.

“Depending on the size of the nodule and what it looks like on an ultrasound – is it solid or cystic, are there things like calcifications or vascularity – we may recommend a biopsy,” Devin said.

A biopsy is done under ultrasound guidance and can result in six possible results.

Can a benign thyroid nodule become malignant?

“The vast majority of the time, it’s coming back benign,” Devin said. “But the biggest surprise for patients is the fact that you don’t always get an answer from a biopsy. That’s the hard part – you may not get a black-and-white answer.”

If the biopsy shows the nodules are benign, there’s no need for treatment, though some providers continue to follow up with patients. While there aren’t strict guidelines for how long to keep tabs on thyroid nodules, Devin typically follows up with an ultrasound one year later, then again two years after that.

About 5% of the time, the biopsy will come back cancerous. In that case, the first step is surgery to remove the mass. A third option is for the biopsy to come back as suspicious, in which case the mass is considered cancerous and removed as well.

Very rarely, a result will suggest that there wasn’t a big enough sample and that the biopsy should be re-done.

The other two possible results are “indeterminate” – one suggests there’s a 5 to 15% chance of cancer, while the other suggests a 25% chance of cancer. With those results, some facilities, including YVMC, send off part of the sample that was held back for genetic testing. If genetic markers associated with cancer are found, then there’s a 50% chance the mass is cancerous.

“It’s not going to be a definite ‘Yes, you’ve got it,’ but the genetic testing is meant to save patients from unnecessary surgery,” Devin said.

If a nodule is cancerous and surgery is needed, Devin first makes sure a patient’s entire neck has been imaged, as 30% of thyroid cancers have locally metastasized to lymph nodes.

Depending on the size or number of nodules, only half of the thyroid gland may need to be removed. In those cases, most patients don’t need thyroid replacement therapy.

While a cancer diagnosis is never a welcome one, patients can take heart that, in most cases, thyroid cancer can be treated.

“Thyroid cancer is super, super treatable,” Devin said. “Most of the time, it can be cured with surgery.”

This story was first published in Steamboat Pilot.

About the author

Susan Cunningham lives in the Colorado Rocky Mountains with her husband and two daughters. She enjoys science nearly as much as writing: she’s traveled to the bottom of the ocean via submarine to observe life at hydrothermal vents, camped out on an island of birds to study tern behavior, and now spends time in an office writing and analyzing data. She blogs about writing and science at susancunninghambooks.com.