Thyroid Nodules | The Children's Hospital of Philadelphia

Pediatric Thyroid Center

Thyroid Nodules

Before you begin reading about thyroid nodules, please read a description of the thyroid gland for a basic understanding of its structure and function.

What is a thyroid nodule?

A thyroid nodule is a firm lump in the thyroid gland. Depending on the size and location, the nodule may or may not be visible or palpable (touched or felt) on exam. A thyroid nodule may be cancerous or benign (not cancerous). The majority of thyroid nodules in both children and adults are benign.

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What causes thyroid nodules in children and adolescents?

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While we don’t fully understand why children and adolescents develop thyroid nodules, there are several factors that increase the risk of being diagnosed with a thyroid nodule. These include:

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How are thyroid nodules diagnosed?

Historically, thyroid nodules in children have been most frequently discovered on physical exam by a parent, teacher, dentist, primary care provider, patient or friend. With the increased use of radiologic studies, more nodules are discovered incidentally (by chance) during an unrelated radiologic exam, such as a head and neck CT scan, MRI or ultrasound.

If your child's doctor suspects a thyroid nodule, a complete evaluation may include:

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For the majority of children, enlarged lymph nodes are due to infection (recent cold, sore throat or ear infection), dental issues (losing teeth, teeth coming in or cavities) or, in teenagers, acne. Often, primary care physicians will treat the suspected infection with one course of antibiotics. This is a reasonable plan; however, if the lymph nodes do not reduce in size over six to eight weeks, appear to be getting larger or more become visible or palpable, your child's doctor may order a thyroid and neck ultrasound.

If a thyroid nodule is found associated with these lymph nodes, your child may be referred to a program that specializes in the diagnosis and treatment of thyroid disorders, such as the Pediatric Thyroid Center at CHOP. In addition to a connection between thyroid nodules and enlarged lymph nodes, enlarged lymph nodes are a common finding with autoimmune thyroid disease, both hypothyroidism and hyperthyroidism.

Depending on the history, physical exam and ultrasound findings, a fine-needle aspiration (FNA) biopsy may be recommended in order to collect cells to examine under the microscope. During an FNA, a very thin needle is used to extract a sample of cells from a thyroid nodule(s) and/or lymph nodes to be analyzed.

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How are thyroid nodules treated at CHOP?

Benign thyroid nodules

The use of fine-needle aspiration (FNA) biopsy has allowed benign (not cancerous) nodules to be followed without surgery in children and adolescents. Most benign nodules remain stable in size, even over long periods of time. We may recommend a re-biopsy and/or surgical removal of nodules that increase in size.

Indeterminate thyroid nodules

For cells that fall in the indeterminate categories, including follicular lesions of undetermined significance (FLUS), follicular neoplasms (FN), and suspicious for malignancy, the final diagnosis can only be established by close examination of the entire nodule under the microscope. Therefore, surgical removal of the nodule is necessary. In adults, there are several tests that can help determine if the indeterminate cells are benign (not cancerous) or malignant (cancerous), but none of these tests has been studied to determine its usefulness in children or adolescents.

The risk of malignancy within the "indeterminate" category increases as follows:

The most common diagnoses in the indeterminate category are:

Follicular adenoma (FA) and follicular thyroid carcinoma (FTC)

The cell features between follicular adenoma (FA) and follicular thyroid carcinoma (FTC) are nearly the same, so a fine-needle aspiration biopsy will not help provide a final answer. The only way to find out if the nodule is a follicular adenoma (non-cancerous nodule) or follicular thyroid carcinoma (cancerous nodule) is to take out the entire nodule for examination. This is performed though a lobectomy, which is the surgical removal of half the thyroid gland. If the cells are not cancerous, clinical follow-up will be arranged. For the majority of patients who undergo lobectomy, the remaining thyroid tissue will produce an adequate amount of thyroid hormone, and thyroid hormone replacement therapy will not be necessary. For patients found to have FTC (cancerous nodule), a second surgery, called "completion thyroidectomy," to remove the entire thyroid gland will be recommended. 

Follicular variant of papillary thyroid cancer (fvPTC)

For follicular variant of papillary thyroid cancer (fvPTC), the cells from a fine-needle aspiration biopsy often look "suspicious," but these lesions may have less concerning features and be initially classified as follicular lesions of undetermined significance (FLUS) or follicular neoplasms (FN). This is one of several reasons why surgical removal of a nodule, even those classified as FLUS, is recommended. The surgery to remove a thyroid nodule is called a lobectomy, which is the removal of half of the thyroid gland. The nodule is then examined and an exact diagnosis is made.

For patients who have had only half of the thyroid removed (lobectomy) and are subsequently diagnosed with FTC or fvPTC, a second surgery will be performed to remove the remaining thyroid tissue. This procedure is called a total thyroidectomy.

Suspicious for malignancy

For results that are described as "suspicious for malignancy," surgical removal of the entire thyroid (total thyroidectomy) is the most conservative approach, as approximately 60 to 75 percent of these nodules will ultimately be diagnosed as thyroid cancer. 

See differentiated thyroid cancer for a complete discussion of evaluation and treatment.

Malignant nodules

When the results of the FNA show malignant cells, the next step is to arrange for surgical removal of the entire thyroid gland, a procedure called total thyroidectomy. The most common diagnosis in this category is papillary thyroid cancer (PTC).

See differentiated thyroid cancer for a complete discussion of evaluation and treatment.

When the FNA sample is insufficient

Even under the best conditions, with a highly skilled provider performing the procedure, the FNA sample may be “inadequate” for evaluation. The options after an inadequate sample are obtained include:

 

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