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Thyroid Tumours (Benign & Malignant) : A Primary Care Guide

The thyroid gland can develop various benign and malignant tumours, each with distinct epidemiological patterns and clinical characteristics. Understanding their frequency and features is crucial for primary care management.


Benign Thyroid Tumours: A Primary Care Guide

Primary care clinicians frequently encounter thyroid nodules, with most being benign and requiring careful but measured evaluation. Understanding the spectrum of benign thyroid tumours, their clinical features, and appropriate management strategies is essential for optimal patient care


Type Key Features Clinical Clues Imaging/Labs
Follicular Adenoma Most common benign neoplasm (2–4.3%) Solitary, painless neck lump; euthyroid; more common in women Round, encapsulated, hypoechoic; peripheral vascularity; indistinguishable from carcinoma on FNA
Toxic Adenoma Functional nodule causing hyperthyroidism; ~1% of adenomas Palpitations, weight loss, tremor; typically ≥3 cm ↓ TSH, ↑ T3/T4; "hot" on thyroid scan; suppressed surrounding uptake
Multinodular Goitre (MNG) Most common cause of thyroid nodules (~60%) Compressive symptoms (dysphagia, choking); may extend substernally Multiple nodules; dominant nodules need biopsy; monitor TSH annually
Thyroid Cyst Simple, fluid-filled lesion; usually benign Often asymptomatic; can cause discomfort if large Anechoic or complex cyst on US; aspirate if symptomatic
Hashimoto's Nodules Nodular thyroid in chronic lymphocytic thyroiditis Firm, irregular gland; hypothyroid symptoms Heterogeneous US; ↑ TPO antibodies; may mimic malignancy on FNA


Primary Care Management: Benign Thyroid Tumours

Initial Evaluation

  • History:

    • FHx of thyroid cancer, radiation exposure

    • Symptoms of hyper/hypothyroidism

    • Compressive symptoms: dysphagia, dyspnoea, hoarseness

  • Examination:

    • Assess nodule size, mobility, tenderness

    • Check for cervical lymphadenopathy

  • Investigations:

    • 🧪 TSH: Always first-line

    • 📸 Ultrasound: If nodule palpable or abnormal TSH


 Risk Stratification & Referral

Monitor in Primary Care:

  • Nodules <1 cm, U2 (benign), asymptomatic, normal TSH

  • No high-risk features (e.g. FHx, rapid growth, lymphadenopathy)

  • Repeat TSH every 6–12 months

  • No need for routine repeat US unless new symptoms arise


Refer to Endocrinology/ENT if:

  • Suspicious US (U3–U5) or >1 cm with high-risk features

  • Abnormal thyroid function with nodules

  • Painful, rapidly growing, or fixed nodules

  • Paediatric patients with nodules

  • Red flags: hoarseness, hard mass, lymphadenopathy


Management of Specific Conditions

  • Toxic Adenoma / Toxic MNG:

    • Radioactive iodine: First-line in most cases

    • Surgery: For large nodules or compressive symptoms

    • Antithyroid drugs: Symptom control (not curative)

  • Benign Nodules:

    • Watchful waiting if stable, asymptomatic

    • Surgery only if symptomatic (e.g. swallowing/breathing issues)

    • ❌ Levothyroxine suppression not recommended due to CV and bone risk


Introduction: Malignant Thyroid Tumours

Malignant thyroid tumours are relatively uncommon but clinically important due to their variable prognosis and potential for early detection in primary care. Most thyroid cancers are well-differentiated and have an excellent prognosis with appropriate treatment.


🔹 Papillary thyroid carcinoma (PTC)

  • Most common type (80–90%)

  • Slow-growing, often with lymph node spread

  • Incidence: ~6/100,000 (↑ in women)

🔹 Follicular thyroid carcinoma (FTC)

  • 10–22% in iodine-sufficient regions

  • More common in iodine-deficient areas

  • Tends to metastasise haematogenously

🔹 Medullary thyroid carcinoma (MTC)

  • 5–10% of cases

  • Arises from C-cells; may be sporadic or linked to MEN 2A/2B

  • Requires screening for RET mutations

🔹 Anaplastic thyroid carcinoma (ATC)

  • Rare (<1%) but highly aggressive

  • Poor prognosis; rapid local invasion and early metastasis

  • Typically affects older adults


📋 NICE Two-Week Wait Criteria for Suspected Thyroid Cancer


Category Criteria
Primary Referral Indication Unexplained thyroid lump → consider urgent referral under NICE NG12 pathway
High-Risk Features • Solitary nodule increasing in size (esp. age >65)
• History of neck irradiation
• Family history of thyroid or endocrine tumours (e.g. MEN)
• Hoarseness or voice change with thyroid mass
• Palpable cervical lymphadenopathy
Age-Based Triggers • All children with thyroid nodules
• Pre-pubertal or <16 years
• Adults ≥65 with new/enlarging nodule
Same-Day Emergency Referral • Stridor or airway compromise → immediate ENT referral (risk of obstruction)
Common Referral Triggers • Presumed thyroid lump (50%)
• Enlarging nodule (33%)
• Median wait to clinic: 10 days
Do NOT Require Urgent Referral • Nodules with thyroid dysfunction but no red flags
• Compressive symptoms without other concerning signs
• Multinodular goitre without suspicious dominant nodule
• Simple cysts or incidental nodules <1 cm
Assessment Essentials History: hoarseness, rapid growth, dysphagia, FHx, radiation
Exam: stridor, thyroid consistency, lymph nodes


Safety Netting and Patient Communication

Essential Patient Communication

  • Provide the two-week wait information leaflet

  • Clearly explain: referral is to exclude cancer, not confirm it

  • Confirm patient is available within 2 weeks for hospital appointment


🧾 Safety Netting

  • Routine referrals: advise return if new or worsening symptoms

  • Incidental nodules: monitor unless size or features change

  • Missed appointments: must be rebooked with clinical reassessment


Service Standards

  • All suspected thyroid cancer cases should be managed by a Thyroid Cancer MDT

  • Pre- and post-operative MDT discussions are mandatory

  • Core MDT members must attend ≥66% of meetings annually.



📚 References

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