Thyroid Nodules and Multinodular Goiter

Nodular pathology is the most common thyroid disease and affects more frequently women

thyroid clinical evaluation

Clinical evaluation is the first and most important steep in thyroid pathology.

than  men; about 6.4 % of those aged between 30 and 59 years old. In fact, its incidence is probably even higher ( in the autopsy findings rises to nearly 50% of cases ), but not diagnosed by the absence of symptoms. Its prevalence in the general population increases progressively with age and sometimes is accompanied by an enlargement of the gland ( goiter ) .

Goiter is often compensatory hypertrophy of the thyroid gland particularly frequent in areas with low iodine content in the diet.

It is a round lesion , single or multiple ( multinodular goiter ) , solid or cist ( sometimes mixed ) that can reach sometimes size that can determine compression on nearby organs .

The detection of Thyroid Nodules is done by palpation and / or visually (often during a clinical examination ) or during an ultrasound examination. Many small nodules are often completely asymptomatic and are diagnosed occasionally, large nodules as well as being visible (often see them for the first patient himself) and also create an aesthetic problem can lead to disorders compression on nearby organs such as the larynx and trachea ( dysphonia, dyspnea) and esophagus (dysphagia ) .

The nature of thyroid nodules are benign in most cases; particularly in women , only 5-6% has tumoral origin ( papillary carcinoma , the most frequent ) .

The diagnostic procedures are intended to distinguish malignant from benign thyroid nodules; describe its size and its structure, whether it belongs to a single or multinodular goiter , a chronic or subacute thyroiditis .

Pay attention to:

previous irradiation of the neck
volumetric increase of the lateral cervical lymph nodes
rapid growth
increase of consistency
compression disorders ( dysphonia, dysphagia)
previous cases of thyroid cancer in the family

Rapid appearance , with sharp pain and tension

Concomitant relief of symptoms of hyperthyroidism ( tachyarrhythmia etc.).

Normally the first professional to take care of the problem is the general practitioner; he will judge whether it is necessary to consult an Endocrinologist .

The investigations that are both instrumental and possibly laboratoristiche citomorfologiche .


Evaluation of thyroid function by determination of TSH ( a small pituitary hormone that controls the thyroid ) and thyroid hormones ( free fractions circulating ) FT3 , FT4 . The detection of increased thyroid hormones ( particularly FT3 ) may lay down for a hyperfunctioning nodule ( toxic adenoma ) and low values ​​( FT4 ) with increased TSH are more typical example of a chronic autoimmune thyroiditis with hypothyroidism. In pregnancy, the stimulation by chorionic gonadotropin (HCG) on the thyroid gland in the first weeks may result in a slight lowering of the physiological TSH ( down regulation ) not to be confused with situations of hyperthyroidism .
Determination of Calcitonin : useful to identify or exclude the presence of a medullary carcinoma of the thyroid .
Dosage antitireoglobulina antibody ( TgAb ) and antitireoperossidasi ( TPOAb ) : their identification and titration process helps to identify any chronic autoimmune ( thyroiditis Haschimoto ) .


Thyroid ultrasound has a very important role. Highlight the thyroid nodule , its size , its structure

thyroid ultrasound

Thyroid ultrasonography play and important diagnostic role in nodular pathology.

, and also describes the context in which it is glandular and may also describe the presence of enlarged lymph nodes ( lymph node enlargement ) locoregional ( neighbors) .
The echo – Doppler Article by information on the vascularization of the nodule : an intense vascularization may be suspect but is also present in hyperfunctioning adenomas completely benign .
The CT scan ( Computerized Axial Tomography ) and MRI ( Magnetic Resonance Imaging) are sometimes useful in analyzing the relationships of the Thyroid Gland with organs and vascular structures nearby as well as in the study of development in substernal goiters .
The thyroid scan through the study of the uptake of a radioactive isotope of iodine helps to distinguish independently functioning nodules (lumps warm ipercaptanti ) and those not working ( cold nodules ) or isocaptanti than the rest of the gland. This exam is absolutely contraindicated in pregnancy.


The fine-needle aspiration is a valuable investigation in the differential diagnosis between benign and malignant thyroid nodules . With a needle under ultrasound control and we proceed to the aspiration of the nodule and the cells are removed so It ‘ important that the sample ( sampling) is adequate for the purposes of cytology . Has no contraindication in pregnancy and as a rule all palpable nodules larger than 1 cm should undergo this procedure.
As part of these investigations , however, elements of alarm or concern (in a tumor ) are the identification of nodules structurally solid , mixed or ipocaptanti scintigraphic examination ( cold ), fine-needle aspiration will identify those really dangerous , fortunately a small minority .

TREATMENT depends on the benign or malignant thyroid nodules , by the concurrence of a goiter , the overall clinical condition of the patient, including ( as many of the women) a possible pregnancy. A large part (up to almost 50 %) of benign nodules undergoes spontaneous regression .
Benign nodules that have demonstrated a growth documented or aesthetic problems that damage or compression can be treated with the administration of levo- thyroxine ( LT4 ) : exogenous administration of thyroid hormones in fact suppresses the pituitary secretion of TSH and this leads in many cases a significant reduction in the size of the nodule , the attempt is always made with the minimum effective doses , requires a selection of patients to exclude contraindications (eg. cardiovascular disease , post-menopausal age the risk for osteoporosis) and usually in the absence of success is not persisted for more than a year . While the LT4 seems also useful in preventing the formation of additional nodules and still halt the growth was not demonstrated an ability to avoid the neoplastic transformation .
Cystic nodules of secure benignity may be treated with the aspiration ( often burdened by relapse) , the ultrasound-guided percutaneous alcoholization ( sclerosed walls and is effective in 80 to 95% of cases ) , the surgery.
Different and more complex is the attitude in cases of malignancy that holds obviously also the biological characteristics of the tumor ( histological type ) : surgical therapy is the first choice and ranges from lobectomy ( partial removal ) total removal of the thyroid ( thyroidectomy ) , using when necessary the adjuvant radioiodine therapy ( administration of radioactive iodine that destroys residual cells ) , chemotherapy , radiotherapy.

IN PREGNANCY, the finding of one or more thyroid nodules generates anxiety perhaps even greater than normal and there is no justification to wait to make a diagnosis , because most of the surveys can also be made during the gestational period also included fine-needle aspiration , is a absolute contraindication scintigraphy . When you need LT4 therapy can be conducted with the foresight to always start with suboptimal doses and increase them gradually . Nodules may be reasonable doubt keep a close watch and postpone further evaluation and treatment choices after delivery (in some cases it may be justified even though treatment with LT4 ) . Nodules whose cytology for malignancy is indicated lays surgery : the choice of operating time should take into account the potential risks for both mother and fetus and should be thoroughly discussed with the patient. The finding of a papillary carcinoma (the most common ) is not an indication of termination of pregnancy , these tumors are slow-growing and low tendency to metastasize , malignant forms are fortunately very rare. In many cases delay the intervention of a few months could allow an easier reproductive success (reaching gestational age safe for the fetus ) without affecting the viability of mom , this is how you can easily understand the decisions that have to be extremely delicate taken by specialist teams ( endocrinologists, obstetricians, neonatologists ) in each case and on which you absolutely can not generalize

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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