eMedicine Specialties > Pediatrics: General Medicine > Endocrinology
Solitary Thyroid Nodule: Treatment & Medication
Updated: Nov 26, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
After initial diagnosis and investigation of the thyroid nodule, medical and/or surgical therapy is decided.
- A presumed benign nodule, especially in an adolescent, may simply be observed. Close observation and follow-up care is essential. The patient should be closely monitored for change of size and the development of symptoms.
- Treatment of autoimmune thyroiditis involves hormone replacement to maintain a euthyroid state.
- Treat infection appropriately. Abscesses should be drained and antibiotics should be administered. In patients with immunocompromise, be aware of the remote possibility of local spread to mediastinal structures.
- A warm nodule without physical signs of malignancy is usually benign and may be observed with close follow-up for growth or change in the nodule.
- A hot toxic nodule may require medical therapy before surgical removal to allow for operative stability. The patient should receive suppressive doses of antithyroid medications. Once physiologic stability is obtained, the surgeon can proceed with removal of the gland or lobe.
- In the past, preoperative thyroid suppression was used to exclude benign disease. This no longer is recommended for several reasons (eg, the incidence of cancer in childhood thyroid nodules is high, and well-differentiated cancers may respond, delaying definitive diagnosis and treatment).
- Routine preoperative and postoperative care includes the maintenance of nutrition and hydration as well as the observation for signs of complications.
- The pediatrician or other primary care provider should closely cooperate with the surgeon to monitor for nerve injury or hypocalcemia. Calcium supplementation may be necessary in the individual with parathyroid compromise, whether temporarily or permanently.
- Closely monitor laboratory findings to determine the initial and ongoing requirements.
- Recurrent laryngeal nerve injuries may cause dysphagia, which can endanger nutrition. In such an individual, involve speech pathology early to optimize recovery.
- After thyroidectomy, thyroid hormone replacement is necessary.
- This therapy is continued for the child's lifetime.
- Thyroid hormone levels should be monitored periodically so that adequate therapy is maintained during growth and changing needs. If malignancy is diagnosed, radioablation therapy may be used for any residual disease.
- Long-term follow-up care remains vital in such individuals to screen for disease progression or late recurrence.
Surgical Care
The presence of a thyroid nodule in children presents somewhat of a dilemma, given the less-than-ideal reliability of diagnostic tests. However, the increased incidence of malignancy in pediatric nodules has led to a somewhat more aggressive approach than that used in adults.
- Indications for surgical excision
- Indications for surgery include physical examination findings consistent with malignancy, persistence of a nodule, progressive increase in size, or the presence of significant risk factors, including family history or history of irradiation exposure. All toxic nodules in children should be removed. If the presence of malignancy is still in question after diagnostic tests and procedures have been completed, perform surgical excision. Some authorities recommend the removal of all nonsuppressible thyroid nodules found in children younger than 13 years.
- In the presence of a small asymptomatic nodule, the surgeon may elect to perform a simple lobectomy with close follow-up observation. Complications with this surgery are generally low. In such an individual, full thyroid suppression also is recommended as lifetime postoperative therapy. Many adenomas contain mutations, causing them to be hyperresponsive to thyroid-stimulating hormone (TSH). The presence of such an adenoma may signify the presence of other cells bearing the same mutations.
- Total thyroidectomy
- With the presence of any metastases on diagnosis, including lymph node involvement, total thyroidectomy is the recommended treatment. This procedure has decreased the rates of local and metastatic recurrence.
- Postoperative radioablation is also more effective in this case because tissue to absorb the radioiodine is reduced.
- Because the rate of pulmonary metastasis is high, postoperative radioiodine scintigraphy is performed 6 weeks after surgery to exclude the presence of pulmonary tumors. Scintigraphy is only reliable after total or subtotal thyroidectomy because any remaining tissue may hide the presence of metastases.
- Total thyroidectomy should be performed in individuals with medullary thyroid cancer, preferably before evidence of disease is obvious. This malignancy is aggressive and metastasizes early.
- Prophylactic therapy, with removal of the gland in children with a family history and genetic markers, provides the best outcomes with this malignancy.
- If Graves disease is diagnosed, thyroidectomy (near-total to total) may be performed. Thyroid hormone replacement therapy may not be needed in this case if some tissue remains.
- Surgical technique
- During the procedure, both lobes of the thyroid should be closely examined, because contralateral tumor involvement is common.
- Lymph node exploration should include nodes in the jugulodigastric chain and along the recurrent laryngeal nerve in the tracheoesophageal groove.
- Dissection may also be needed in the superior mediastinum.
- Care should be taken to avoid injury to the recurrent laryngeal nerve or to the parathyroids.
- Of the parathyroid glands, 1-2 may be preserved and transplanted into the sternocleidomastoid muscle or nondominant forearm if needed.
- Thyroidectomy for familial medullary thyroid carcinoma demands a total thyroidectomy with complete lymph node dissection of the entire central compartment, including the paratracheal nodes, delphian nodes, and superior mediastinal nodes.
- Adequate dissection should extend to both carotid sheaths and to the innominate artery.
- A surgical cure is possible for this disease if the tumor has not spread to jugular or lateral cervical nodes or to distant organs.
Consultations
If a thyroid nodule is discovered, several consultations are useful.
- The team approach involves the pediatrician, pediatric endocrinologist, and pediatric surgeon.
- A hematologist-oncologist should be involved in caring for the patient with diagnosed malignancy.
- In addition, the treatment facility should have available experienced radiologists and cytopathologists who are comfortable with thyroid disease and its diagnosis in children.
Diet
- No specific dietary recommendations for individuals with thyroid nodules are indicated.
- Supplementary dietary iodine may be useful, especially in persons with iodine deficiency or iodine 131 (131 I) exposure.
Activity
- Once an individual has recovered from surgery, no specific activity restrictions are necessary.
Medication
Possible medical therapy includes antithyroid medications, thyroid hormone replacement, and radioiodine ablation. Antithyroid therapy is used to physiologically stabilize the patient before surgical excision of a toxic nodule. Thyroid hormones are necessary postoperatively after thyroidectomy for replacement and suppression of thyroid-stimulating hormone (TSH). Radioiodine ablation may be employed to treat the presence of residual disease and sometimes for suppression of a toxic nodule. Its use requires the cooperation of an experienced specialist. In addition, calcium supplementation may be required in the case of parathyroid complications, whether temporarily or permanently.
Thyroid hormones
Replacement is indicated after thyroidectomy to maintain levels and to prevent TSH stimulation of any remaining cells.
Levothyroxine (Levothroid, Levoxyl, Synthroid, Unithroid)
DOC. Levothyroxine exerts its effect largely after it is deiodinated to tri-iodothyronine at its site of action. In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development.
Adult
12.5-50 mcg/d PO initially; may increase by 25-50 mcg/d q2-4wk; not to exceed 100-200 mcg/d
Pediatric
Neonate to 6 months: 25-50 mcg/d PO
6-12 months: 50-75 mcg/d PO
1-5 years: 75-100 mcg/d PO
6-12 years: 100-150 mcg/d PO
>12 years: 150 mcg/d PO
Cholestyramine, iron salts, sucralfate, or aluminum hydroxide may decrease thyroid hormone absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effects of anticoagulants increase when administered with thyroid hormone; activity of some beta-blockers may decrease when hypothyroidism is converted to euthyroidism
Documented hypersensitivity; uncorrected adrenal insufficiency
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in angina pectoris or cardiovascular disease; monitor thyroid status periodically
Liothyronine (Cytomel)
Synthetic form of natural thyroid hormone T3 converted from T4. Duration of activity is short and allows for quick dosage adjustments in event of overdosage. Active form influences growth and maturation of tissues.
Adult
25 mcg/d PO initially; may increase by 12.5-25 mcg/d q1-2wk; not to exceed 100 mcg/d
Pediatric
5 mcg/d PO initially; may increase by 5 mcg/d q3d to 20 mcg/d (infants), 50 mcg/d (1-3 y), or 100 mcg/d (>3 y)
Hepatic enzyme inducers (eg, phenytoin) may increase degradation; insulin, antidiabetic agents, theophylline, adrenocorticoids, digoxin, and anticoagulants may need dose adjustments; phenytoin IV may release thyroid hormone from thyroglobulin; effects of tricyclic antidepressants and sympathomimetics may be increased; cholestyramine, iron salts, sucralfate, or aluminum hydroxide may decrease absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; activity of some beta-blockers may decrease when hypothyroidism is converted to euthyroidism
Documented hypersensitivity; uncorrected adrenal insufficiency; acute MI uncomplicated by hypothyroidism; untreated thyrotoxicosis
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in elderly patients, renal insufficiency, hypertension, ischemia, angina, and other cardiovascular diseases; monitor thyroid status periodically
Antithyroid agents
These agents are used when treating hot nodules before surgery.
Methimazole (Tapazole)
Inhibits thyroid hormone by blocking oxidation of iodine in thyroid gland. However, it does not inhibit peripheral conversion of thyroid hormone. Gradually taper to minimum dose required to clinically maintain euthyroidism. Caution during pregnancy because it can cause fetal hypothyroidism and has been associated with fetal aplasia cutis.
Adult
Initial: 5 mg PO q8h
Maintenance: 5-15 mg/d PO
Severe hyperthyroidism: not to exceed 60 mg/d PO
Pediatric
Initial: 0.4 mg/kg/d PO divided tid
Maintenance: 0.2 mg/kg/d PO divided tid, not to exceed 30 mg/d
Because of long half-life, sometimes can be administered bid or qd
Inhibits vitamin K activity and may potentiate activity of PO anticoagulants
Documented hypersensitivity; women who are breastfeeding
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor PT during therapy; may cause hypoprothrombinemia and bleeding; once symptoms of hyperthyroidism have resolved, presence of elevated serum TSH suggests use of lower maintenance dose
Agranulocytosis may occur, monitor patients for symptoms (eg, sore throat, fever, bleeding, bruising, malaise, stomatitis) and, if suspected, discontinue drug immediately
Propylthiouracil (PTU)
Derivative of thiourea that inhibits organification of iodine by thyroid gland. Blocks oxidation of iodine in thyroid gland, thereby inhibiting thyroid hormone synthesis; inhibits conversion of T4 to T3 (an advantage over other agents). DOC in pregnancy-associated thyrotoxicosis but should be used in lowest effective dose because of risk of hypothyroidism to fetus.
Adult
Initial dose: 300 mg/d PO divided tid
Severe hyperthyroidism: 600-1200 mg/d PO divided tid
Maintenance dose: 100-150 mg PO divided tid
Pediatric
<6 years: Not established
6-10 years: 50-150 mg/d PO divided q8h initially
>10 years: 150-300 mg/d PO divided q8h initially
Alternatively, 5-7 mg/kg/d or 150-200 mg/m2/d PO divided q8h; subsequent dosing determined by response
Antivitamin K activity; may potentiate PO anticoagulants
Documented hypersensitivity; breastfeeding women
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor PT during therapy; may cause hypoprothrombinemia and bleeding; may cause agranulocytosis, monitor patients for symptoms (eg, sore throat, fever, bleeding, bruising, malaise, stomatitis) and, if suspected, discontinue drug immediately; once symptoms of hyperthyroidism have resolved, lower maintenance dose of PTU if serum TSH levels are elevated.
Beta-adrenergic receptor blocking agents
These agents are used to control symptoms from hyperthyroidism. Inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.
Propranolol (Inderal)
DOC in treating cardiac arrhythmias resulting from hyperthyroidism. Controls cardiac and psychomotor manifestations within minutes.
Adult
80-240 mg/d PO divided q6-8h; up to 480 mg/d have been used to control severe symptoms
1-3 mg/dose IV; not to exceed infusion rate of 1 mg/min IV; not to exceed 10-mg cumulative dose for control of symptoms
Pediatric
2 mg/kg/d PO divided q6h
0.05-0.15 mg/kg IV; give one-half dose slowly over at least 10 min and observe; may repeat in 2 min prn; not to exceed 1 mg/dose
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity; may increase toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines
Documented hypersensitivity; uncompensated congestive heart failure; bradycardia; cardiogenic shock; AV conduction abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; slowly withdraw drug and closely monitor
More on Solitary Thyroid Nodule |
| Overview: Solitary Thyroid Nodule |
| Differential Diagnoses & Workup: Solitary Thyroid Nodule |
 Treatment & Medication: Solitary Thyroid Nodule |
| Follow-up: Solitary Thyroid Nodule |
| Multimedia: Solitary Thyroid Nodule |
| References |
| « Previous Page | Next Page » |
References
Desjardins JG, Khan AH, Montupet P, et al. Management of thyroid nodules in children: a 20-year experience. J Pediatr Surg. Aug 1987;22(8):736-9. [Medline].
Hung W, Anderson KD, Chandra RS, et al. Solitary thyroid nodules in 71 children and adolescents. J Pediatr Surg. Nov 1992;27(11):1407-9. [Medline].
Hung W. Solitary thyroid nodules in 93 children and adolescents. a 35-years experience. Horm Res. 1999;52(1):15-8. [Medline].
Chiesa F. Thyroid disease in northern Italian children born around the time of the Chernobyl nuclear accident. Annals of Oncology. 2004;15:1842-6. [Medline].
Newman KD, Black T, Heller G, Azizkhan RG, Holcomb GW 3rd, Sklar C, et al. Differentiated thyroid cancer: determinants of disease progression in patients <21 years of age at diagnosis: a report from the Surgical Discipline Committee of the Children's Cancer Group. Ann Surg. Apr 1998;227(4):533-41. [Medline].
Fowler CL, Pokorny WJ, Harberg FJ. Thyroid nodules in children: current profile of a changing disease. South Med J. Dec 1989;82(12):1472-8. [Medline].
Al-Shaikh A, Ngan B, Daneman A, Daneman D. Fine-needle aspiration biopsy in the management of thyroid nodules in children and adolescents. J Pediatr. Jan 2001;138(1):140-2. [Medline].
Lugo-Vicente H, Ortiz VN, Irizarry H, et al. Pediatric thyroid nodules: management in the era of fine needle aspiration. J Pediatr Surg. Aug 1998;33(8):1302-5. [Medline].
Millman B, Pellitteri PK. Nodular thyroid disease in children and adolescents. Otolaryngol Head Neck Surg. Jun 1997;116(6 Pt 1):604-9. [Medline].
Bentley AA, Gillespie C, Malis D. Evaluation and management of a solitary thyroid nodule in a child. Otolaryngol Clin North Am. Feb 2003;36(1):117-28. [Medline].
Bukhari MH. An updated audit of fine needle aspiration cytology procedure of solitary thyroid nodule. Diagn Cytopathol. 2008;36:104-12. [Medline].
Canadian Pediatric Thyroid Nodule (CaPTN) Study Group. The Canadian Pediatric Thyroid Nodule Study: an evaluation of current management practices. J Pediatr Surg. 2008;43:826-30. [Medline].
Cotran RS, Kumar V, Robbins SL. The thyroid. In: Robbins Pathologic Basis of Disease. 5th ed. 1994:1121-42.
Dreimane D, Varma SK. Common childhood thyroid disorders. Indian J Pediatr. Jan-Feb 1997;64(1):3-10. [Medline].
Fisher DA. The thyroid gland. In: Clinical Paediatric Endocrinology. 1989:309-37.
Flannery TK, Kirkland JL, Copeland KC, et al. Papillary thyroid cancer: a pediatric perspective. Pediatrics. Sep 1996;98(3 Pt 1):464-6. [Medline].
Herrmann MA, Hay ID, Bartelt DH Jr, et al. Cytogenetic and molecular genetic studies of follicular and papillary thyroid cancers. J Clin Invest. Nov 1991;88(5):1596-604. [Medline].
Loh KC, Greenspan FS, Gee L, et al. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients. J Clin Endocrinol Metab. Nov 1997;82(11):3553-62. [Medline].
Lugo-Vicente H, Ortiz VN. Pediatric thyroid nodules: insights in management. Bol Asoc Med P R. Apr-Jun 1998;90(4-6):74-8. [Medline].
Niedziela M. Pathogenesis, diagnosis and management of thyroid nodules in children. Endocr Relat Cancer. 2006;13:427-53. [Medline].
Sclafani AP, Valdes M, Cho H. Hashimoto's thyroiditis and carcinoma of the thyroid: optimal management. Laryngoscope. Aug 1993;103(8):845-9. [Medline].
Stezhko VA, Buglova EE, Danilova LI. A cohort study of thyroid cancer and other thyroid diseases after the Chornobyl accident: objectives, design and methods. Radiat Res. Apr 2004;161(4):481-92. [Medline].
Takahashi T, Fujimori K, Simon SL. Thyroid nodules, thyroid function and dietary iodine in the Marshall islands. Int J Epidemiol. Aug 1999;28(4):742-9. [Medline].
Walfish PG, Tseng KH. Thyroid physiology and pathology. In: Pediatric Endocrinology. 1989:367-448.
Yip FW, Reeve TS, Poole AG. Thyroid nodules in childhood and adolescence. Aust N Z J Surg. Oct 1994;64(10):676-8. [Medline].
Further Reading
Keywords
solitary thyroid nodule, follicular adenoma, thyroid nodule, hot nodule, warm nodule, cold nodule, nodulus, node, thyroid mass, thyroid cyst, thyroid cancer, cancer, papillary carcinoma, follicular carcinoma, medullary carcinoma, carcinoma, malignancy, unilateral agenesis, chronic lymphocytic thyroiditis, Hashimoto thyroiditis, hyperthyroidism, thyrotoxicosis, Graves disease, lymphadenopathy, multiple endocrine neoplasia, MEN, adrenal pheochromocytoma, cervical disease, medullary thyroid carcinoma, marfanoid body habitus, familial polyposis syndrome, Hodgkin lymphoma, bone marrow transplantation
