History
Most patients with a thyroid nodule have an asymptomatic neck mass, usually discovered by a parent or a pediatrician on routine examination. Upon evaluation, close attention should be paid to the presence of symptoms, the course of development of the mass, family history, and exposure to x-rays.
Risk factors
A history of head and neck irradiation increases the risk of nodularity and malignancy. This correlation is well-documented. Although the use of head and neck irradiation for benign conditions has decreased, this factor remains important, especially in patients with prior malignancies.
A family history of thyroid disease, benign or malignant, can be found in a significant number of patients with thyroid cancer and may help determine which patients have an increased risk. However, family history of thyroid disease also increases risk for autoimmune thyroiditis, and malignancy should not be assumed automatically.
Characteristics of the nodule
The history of the mass should be reviewed carefully. Time of initial appearance, rate of growth, and any associated symptoms especially can assist the clinician in determining the malignancy potential of the mass.
Rapid growth is an indicator of malignancy. Therefore, further diagnostic tests should be expediently obtained.
Transient tenderness within the mass at any time may signify an inflammatory process. However, this same symptom may also be caused by tumor hemorrhage, necrosis, or cyst formation. This information can be used to assist the clinician in determining malignancy of the mass. [12]
Thyroid dysfunction
Although most patients are asymptomatic, some exhibit evidence of altered levels of thyroid hormones or nerve involvement.
Symptoms of hyperthyroidism include nervousness, heat intolerance, diarrhea, muscle weakness, and loss of weight and appetite.
Hypothyroidism may result in cold intolerance, constipation, fatigue, and weight gain, which, in children, is primarily caused by the accumulation of myxedematous fluid.
Signs and symptoms of local nerve involvement should trigger rapid investigation because it may be indicative of local invasiveness from malignancy. The most important of these signs are dysphagia and hoarseness.
Obtaining a thorough history can be helpful for assessing malignancy and determining the need for surgery and/or medical therapy.
Physical Examination
In patients with a thyroid mass, careful physical examination is a key step in evaluating malignancy. Most patients are asymptomatic, but exophthalmos rarely may be present in a person with a hyperfunctioning nodule. In one study, 55% of pediatric patients with thyroid cancer had no other symptoms than a neck mass, whereas 23% had only neck and cervical masses. Therefore, the lack of symptoms should not preclude thorough evaluation.
Careful examination of the neck reveals the nature, location, and tenderness of the mass; fixation of the thyroid to surrounding tissue; and the presence of other cervical masses, which can be metastases or lymphadenopathy.
Benign masses are usually movable, soft, and nontender. Malignancy is associated with a hard nodule, fixation to surrounding tissue, and regional lymphadenopathy. See the image below.
A 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
Suspicions of cancer rise in incidents of a true solitary thyroid nodule, especially if designated as cold on scintigraphy. Reported rapid growth or recurrent laryngeal nerve dysfunction found on examination may indicate malignancy and local infiltration.
Finally, if medullary carcinoma is suspected in conjunction with multiple endocrine neoplasia (MEN) 2B, multiple mucosal neuromas, marfanoid body habitus, and skeletal defects may also be evident.
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A 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
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Surgical specimen of a thyroid lobe with papillary carcinoma taken from a 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
