Screening and diagnosis
Although you sometimes may see or feel a lump (nodule) in
your thyroid yourself — usually just to the lower right or left of your
Adam's apple — it's more likely your doctor will discover a lump during
a routine medical exam. You're usually asked to swallow while your
doctor examines your thyroid because the thyroid moves up and down
during swallowing, making nodules easier to feel.
Sometimes a thyroid nodule is detected as an incidental
finding when you have an imaging test to evaluate another condition in
your head or neck. Nodules detected this way are usually too small to be
found during a physical exam.
To help determine whether a nodule is malignant, you may
have one or more of the following tests:
If your doctor suspects medullary cancer, you may have tests that
check for high levels of calcitonin in your blood. Other tests can
provide information about the function of your thyroid gland. For
example, you may have a test that measures thyroid-stimulating
hormone (TSH), a hormone made by the pituitary gland that regulates
This was once the primary way of assessing thyroid nodules. During
the test, a radioactive isotope is injected into the vein on the
inside of your elbow. You then lie on a table while a special camera
produces an image of your thyroid on a computer screen. The length
of the scan varies, depending on how long it takes the isotope to
reach your thyroid gland. The disadvantage of a thyroid scan is that
it can't distinguish between malignant and benign nodules. You're
also exposed to a small amount of radiation during the test.
Fine-needle aspiration (FNA) biopsy.
This test is generally considered the most sensitive for
distinguishing between benign and malignant thyroid nodules. During
the procedure, your doctor places a thin needle through your skin
and into a nodule and removes a sample of cells. Several passes are
usually needed to obtain tissue from different parts of the nodule.
If you have more than one nodule, your doctor is likely to take
samples from as many as possible. Sometimes your doctor may use
ultrasound to help guide the placement of the needle. The samples
are then sent to a laboratory and analyzed under a microscope. Only
a small percentage of biopsied nodules are malignant. This diagnosis
is based on the characteristics of individual cells and patterns in
clusters of cells that are different from normal thyroid tissue. In
some cases, a pathologist can determine specific types of cancer
from an FNA biopsy sample.
Occasionally, an FNA doesn't provide a definitive diagnosis. In that
case, your doctor may operate to remove the nodule, which is then
examined in a pathology laboratory.
If you receive a diagnosis of thyroid cancer, you're
likely to have tests to help determine whether the cancer has spread
(metastasized) — a process known as staging. The stage of cancer helps
your doctor determine the best course of treatment and the outlook for
your recovery. The staging tests you have may vary, depending on the
type of thyroid cancer.
Papillary and follicular cancers.
A radioactive iodine thyroid scan is commonly used to stage
papillary and follicular thyroid cancers. But unlike most tumors,
which are staged before treatment, your doctor is likely to remove
the primary tumor along with part or all of your thyroid gland
before the test. That's because normal thyroid tissue would absorb
most of the radioactive iodine from the scan, making metastatic
cells hard to detect. Prior to this surgery, your doctor may
recommend an ultrasound examination of your neck to determine if the
cancer has spread to your lymph nodes.
Medullary thyroid cancer.
Because thyroid C cells don't absorb iodine, thyroid scans aren't
used to stage medullary cancer. Instead, you may have imaging tests
such as computerized tomography (CT) or magnetic resonance imaging (MRI).
A CT scan uses split-second computer processing and X-ray beams to
produce detailed cross-sectional images of your internal organs.
This test exposes you to more radiation than conventional X-rays do,
but in most cases, the benefits outweigh the risks. MRI, on the
other hand, uses a powerful magnetic field and radio waves — not
X-rays — to produce images of your body. Sometimes you may have an
octreotide scan — a test that uses a radioactively tagged hormone to
check for the spread of medullary cancer.
If you have medullary cancer, make sure that everyone in
your immediate family — children, parents, siblings, aunts and uncles —
is screened for the disease. In the past, doctors used a screening test
that stimulated the thyroid gland to produce calcitonin. People with
high calcitonin levels were considered at risk of medullary cancer. Now,
DNA testing, which checks a blood sample for a genetic defect, is
considered a more accurate screening method.
If you have medullary thyroid cancer but don't test
positive for the RET gene, it's still important that your close family
members should have their calcitonin levels tested. This is generally
done using a calcium infusion test. Although the calcitonin level of
healthy people rises slightly after an injection of calcium, it's much
higher in people with medullary thyroid cancer.
The calcium infusion test usually takes between 15 and 20
minutes and is done on an outpatient basis. You'll have a small amount
of blood drawn before the injection of calcium and again at two, five,
10 and 15 minutes after the injection.
Thyroid tumors can lead to a number of complications,
Difficulty swallowing and breathing.
Some thyroid cancers, particularly fast-growing anaplastic tumors
and thyroid lymphomas, can cause hoarseness and difficulty breathing
or swallowing when they spread to or press on your windpipe or
The nerves that control your vocal cords lie next to your thyroid
gland. Aggressive thyroid cancers can irritate or damage these
nerves, leading to a hoarse voice.
Medullary thyroid cancer can cause severe diarrhea, which may be
related to calcitonin production. It's usually controlled with drugs
that reduce the activity of the intestine such as Lomotil or
Spread of cancer (metastasis).
The most serious complication of thyroid cancer is the spread of the
cancer to other tissues and organs. This is especially likely in
anaplastic cancer, which has often spread to the trachea or lungs by
the time it's diagnosed. Follicular and papillary cancers also may
spread to distant organs such as the lung, bone and liver.
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