History

The history in patients with a thyroid nodule or a known follicular or Hürthle cell neoplasm is neither sensitive nor specific for a diagnosis of malignancy. However, the following clinical features are more suggestive of malignancy:

A palpable mass in the thyroid (most common clinical sign)
Symptoms of pressure (eg, dysphagia, dyspnea, coughing, choking spells, hoarseness)
Rapid growth or significant compressive symptoms
Pain

Other features of Hürthle cell carcinoma are as follows:

Hürthle cell carcinoma is more often multifocal and bilateral
Lymph node metastasis and symptoms confined to metastatic sites can be the first clinical presentation in a subgroup of cases
A history of head and neck external beam irradiation should alert the clinician to a possible malignancy; multifocal and bilateral disease is more common in such cases
A family history of thyroid cancer and endocrinopathies can also be present
Patients are usually euthyroid, but hyperthyroidism or hypothyroidism occurs in a small percentage of patients

Other benign thyroid and parathyroid disorders can be observed, as follows:

Graves disease
Colloid nodular disease
Lymphocytic thyroiditis
Thyroid hyperplasia
Parathyroid adenoma
Follicular adenomas

Physical Examination

The most common physical examination finding is a palpable single neck mass. (However, the contralateral lobe may harbor impalpable malignancy in such cases.) Less often, patients may have multiple palpable masses. Regional lymph nodes may sometimes be felt in the neck and locoregionally, although this is not as common as in papillary carcinoma.

The trachea can be compressed and deviated secondary to the mass effect of the tumor. Hoarseness can occur if vocal cord involvement is present. A hard, fixed thyroid nodule, cervical lymphadenopathy, and vocal cord paralysis are features that may indicate carcinoma.

Horner syndrome can be present in patients with involvement of the cervical sympathetic ganglia.

If the tumor extends into the upper mediastinum behind the sternum, the superior mediastinal syndrome may ensue, with facial swelling, and dilated veins can be observed.

Physical findings of metastases and pathologic bone fractures may also be found in long and flat bones.

Most patients with Hürthle cell cancer and Hürthle cell adenomas are euthyroid, but in rare cases, signs of thyrotoxicosis may be present; either massive tumor burden or functioning metastatic disease causes thyrotoxicosis.

Differential Diagnoses

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Media Gallery

Tumor, lymph node, metastases (TNM) staging system for papillary and follicular thyroid carcinoma.
Hürthle cell carcinoma. A monomorphous cell population of Hürthle cells arranged in loosely cohesive clusters and single cells. The cells are polyhedral and have abundant granular cytoplasm with well-defined cell borders. The nuclei are enlarged and have a central prominent macronucleolus.