University Hospitals of Leicester NHS Trust

Department of Diabetes & Endocrinology

Leicester Royal Infirmary, Leicester, LE1 5WW

Goitre and Thyroid Nodules: About the Condition
Definition	· A goitre is any enlargement of the thyroid gland. · A thyroid nodule is a discrete area of enlargement within the thyroid. It may be visible, palpable or only seen on imaging.
Symptoms	· Patients may complain of a visible swelling in the neck or pressure symptoms in the neck on swallowing or in particular positions
Signs	· Thyroid enlargement may be visible and/or palpable · Consider: is goitre diffusely enlarged or nodular, symmetrical or asymmetrical, soft, firm or hard?
Investigations	· Investigation is indicated to elucidate symptoms and/or to exclude malignancy as a cause of goitre. However a majority of goitres of all types are benign.
Other factors	· Prior radiation exposure (therapeutic or accidental) significantly increases the risk of thyroid cancer and therefore index of suspicion required.

Goitre and Thyroid Nodules: When to Refer?
Referral Recommendations	· An asymptomatic, soft diffuse goitre may not require any further investigation or referral as long as thyroid function is normal. · Recent onset of proven or suspected nodular thyroid disease usually requires referral to exclude a malignancy (but most cases are benign) · Pressure symptoms may indicate referral to consider surgery · Longstanding known multinodular goitres do not normally need reinvestigation unless changing in size or causing pressure symptoms. · Multiple small (<1cm) nodules may be seen in up to 40% of the population on high-resolution ultrasound – this is not per-se a reason for referral. · Strongly positive thyroid antibodies suggest an autoimmune aetiology but are not per-se a reason for further investigation or referral.
Urgent Referral	· Urgent referral may be indicated: · Via 2-week-wait – if malignancy is strongly suspected (e.g. rapidly enlarging hard mass; vocal cord palsy; sudden change in voice; signs of local or distant metastasis) · For tracheal compression by any large goitre causing symptoms of stridor (but not simply because tracheal deviation or compression is described on imaging)
References or Guidelines	· UK Guidelines for the Management of Thyroid Cancer include guidelines for the management of thyroid nodules (to diagnose or exclude malignancy)
Which Clinic or Choose & Book Service?	· A “Joint Surgical-Endocrine Service - Endocrinology - LRI - RWE” referral will allow clinical assessment, ultrasound and if appropriate fine needle aspiration cytology to be performed in a single visit to a clinic run jointly by endocrinologists and endocrine surgeon. · An “Adult Endocrinology Service - Endocrinology - LRI - RWE” referral will book an appointment on any of medical lists in clinics at Leicester Royal Infirmary where endocrine patients are seen. Any imaging, FNA and referral to surgery will normally need to be organised at separate visits.

Goitre and Thyroid Nodules: What to do before a hospital appointment?
Additional Investigations	· Thyroid function tests if not already peformed · Thyroid peroxidase antibodies if not already performed · Ultrasound may have already been performed in order to diagnose the goitre – but if not already performed we can arrange as single visit in the appropriate clinic.
Treatment prior to specialty appointment	· None required
How to manage the patient if you do not refer	· An asymptomatic diffuse soft goitre or stable known multinodular goitre can simply be monitored clinically (and the patient themself is often the best person to do this) · Annual thyroid function appropriate in nodular or autoimmune thyroid disease
Patient Information	· British Thyroid Foundation information on Thyroid nodules and Swellings

Goitre and Thyroid Nodules: What will we do in the specialty Endocrinology clinics?
Outline of Management	· We will assess symptoms and assess the goitre or nodule by clinical examination. · Typically we will arrange thyroid ultrasound (as a single visit in the Joint Surgical-Endocrine Clinic). · Fine needle aspiration cytology (FNA) will be advised for isolated thyroid nodules or for any dominant nodules in a multinodular goitre. This is usually performed under ultrasound control. · Cystic thyroid nodules may be treated by aspiration. · If FNA excludes malignancy then treatment is guided by pressure symptoms and patient choice (particularly on cosmetic appearance). · Thyroid function and TPO antibodies will be checked if not previously performed. · Other types of imaging (CT or Isotope scans) are occasionally required.
Treatment options	· Thyroid surgery is the main treatment option – excision of nodule, lobectomy or near-total thyroidectomy. · Radioactive iodine has been advocated for euthyroid benign thyroid goitre. For technical reasons this is not currently available in Leicester – but it may become an option in future.
Follow up plan	· We will review patient in clinic with results of FNA and any additional investigations (typically 1-2 months after initial attendance). · Depending on the nature of findings, and the patient’s current view on the desirability of surgery, we may arrange follow up review 4-6 months after that. · With positive FNA we will arrange urgent review and management in line with national guidance, including review by the Thyroid Cancer Multidisciplinary Team.
Long term monitoring	· Thyroid cancer will be followed up long-term by appropriate members of the Thyroid Cancer Multidisciplinary Team. · We will not normally follow up stable goitre long-term in the endocrinology clinic – but will discharge to primary care for long term monitoring (primarily self-monitoring in most cases). · We will be happy to review if subsequent enlargement occurs

Referrals to all clinics can be arranged via Choose and Book.

We are also happy to receive written referrals and will allocate patients to the most appropriate clinic slot.

If you consider that your patient needs urgent assessment, then all consultants are happy to discuss directly (by phone or email) and arrange prompt review if appropriate.

In the case of a real or potential endocrine emergency we will almost certainly be happy to see the patient the same or the next working day whether or not a clinic is available.

Contact the endocrinologist:

By email: endocrinology@uhl-tr.nhs.uk or individual consultant emails

By phone: 0116 258 6140 and ask to talk to one of the consultants

Fax: is less reliable and usually no faster than written mail