A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the literature

Sasan Mirfakhraee,Dana Mathews,Stacey Woodruff,Lan Peng,Jeffrey M Zigman

doi:10.1186/1756-6614-6-7

Sasan Mirfakhraee, Dana Mathews + Show 3 more

Open Access

https://doi.org/10.1186/1756-6614-6-7

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Abstract

Hyperfunctioning nodules of the thyroid are thought to only rarely harbor thyroid cancer, and thus are infrequently biopsied. Here, we present the case of a patient with a hyperfunctioning thyroid nodule harboring thyroid carcinoma and, using MEDLINE literature searches, set out to determine the prevalence of and characteristics of malignant “hot” nodules as a group. Historical, biochemical and radiologic characteristics of the case subjects and their nodules were compared to those in cases of benign hyperfunctioning nodules. A literature review of surgical patients with solitary hyperfunctioning thyroid nodules managed by thyroid resection revealed an estimated 3.1% prevalence of malignancy. A separate literature search uncovered 76 cases of reported malignant hot thyroid nodules, besides the present case. Of these, 78% were female and mean age at time of diagnosis was 47 years. Mean nodule size was 4.13 ± 1.68 cm. Laboratory assessment revealed T3 elevation in 76.5%, T4 elevation in 51.9%, and subclinical hyperthyroidism in 13% of patients. Histological diagnosis was papillary thyroid carcinoma (PTC) in 57.1%, follicular thyroid carcinoma (FTC) in 36.4%, and Hurthle cell carcinoma in 7.8% of patients. Thus, hot thyroid nodules harbor a low but non-trivial rate of malignancy. Compared to individuals with benign hyperfunctioning thyroid nodules, those with malignant hyperfunctioning nodules are younger and more predominantly female. Also, FTC and Hurthle cell carcinoma are found more frequently in hot nodules than in general. We were unable to find any specific characteristics that could be used to distinguish between malignant and benign hot nodules.

Highlights

Thyroid nodules are frequently-encountered entities in clinical practice, occurring with a prevalence of 4% by palpation [1], 33% to 68% by ultrasound examination [2,3], and 50% on autopsy series [4]
This study complements the informative and excellent 2012 review by PazaitouPanayiotou and colleagues examining the association of thyroid carcinoma with a broader spectrum of hyperthyroid states, including Graves’ disease and toxic multinodular goiter in addition to hyperfunctioning thyroid nodule [81]
It was not the focus of the Pazaitou-Panayiotou et al review to perform a detailed analysis of the historical and clinical features of malignant hot nodule cases, as we did here, PazaitouPanayiotou and colleagues did include an evaluation of thyroid carcinoma prevalence

Summary

Introduction

Thyroid nodules are frequently-encountered entities in clinical practice, occurring with a prevalence of 4% by palpation [1], 33% to 68% by ultrasound examination [2,3], and 50% on autopsy series [4]. As the initial step for evaluation of a thyroid nodule is measurement of serum thyroid stimulating hormone (TSH) [6,7], it is not uncommon for patients with a solitary thyroid nodule to be diagnosed with hyperthyroidism. In this setting, the thyroid nodule may represent a solitary hyperfunctioning found that corresponds to the nodule in question, no cytologic evaluation is necessary” [6]. The results of a separate literature review aimed at estimating the prevalence of thyroid cancer within hot thyroid nodules are presented. Our goal is to call attention to the fact that hyperfunctioning thyroid carcinomas are welldescribed in the literature (and likely underreported), challenging the commonly-held notion that the hot thyroid nodule is very unlikely to be cancerous

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