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Management of
Thyroid Nodules
and Differentiated
Thyroid Cancer

A Practical Guide

Sanziana A. Roman
Julie Ann Sosa
Carmen C. Solórzano
Editors

123
Management of Thyroid Nodules
and Differentiated Thyroid Cancer
Sanziana A. Roman • Julie Ann Sosa
Carmen C. Solórzano
Editors

Management of Thyroid
Nodules and Differentiated
Thyroid Cancer
A Practical Guide
Editors
Sanziana A. Roman Carmen C. Solórzano
Endocrine Surgery, Department of Surgery Division of Surgical Oncology and
Duke University Medical Center Endocrine Surgery, Vanderbilt Endocrine
Duke Cancer Institute Surgery Center
Durham Vanderbilt University Medical Center
North Carolina Nashville
USA Tennessee
USA
Julie Ann Sosa
Department of Surgery
Duke University Medical Center
Duke Cancer Institute
Durham
North Carolina
USA

ISBN 978-3-319-43616-6    ISBN 978-3-319-43618-0 (eBook)

DOI 10.1007/978-3-319-43618-0

Library of Congress Control Number: 2017931638

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

Thyroid nodules are a common problem in the USA and the world. They are present
in nearly 5 % of women and 1 % of men in the iodine-sufficient areas and have a
much higher incidence in iodine-deficient parts of the world. With the growing use
of imaging studies, such as ultrasound and computed tomography, it is estimated
that more than 70 % of the adult population in the USA harbors thyroid abnormali-
ties and nodules. While most nodules are benign, patient and physician anxiety
about their presence and possible lack of familiarity with thyroid disorders can lead
to either unnecessary interventions or to misdirected and inadequate treatments.
Understanding the meaning of detecting such abnormalities is important for allevi-
ating patient anxiety and undertaking the most efficient and effective diagnostic
work-up and treatment.
While much has been written about thyroid nodules, we realized that a compre-
hensive, easy-to-follow, organized approach to understanding thyroid nodules and
thyroid cancer was needed. Whether you are a primary care clinician, family practi-
tioner, pediatrician, obstetrician/gynecologist, general endocrinologist, general sur-
geon, otorhinolaryngologist, nurse practitioner, physician assistant, student, trainee,
or fellow, this book is designed to address numerous questions about patients with
thyroid nodules and cancer. We have organized the book in specific patient presenta-
tion scenarios, ranging from small and occult thyroid nodules detected incidentally
to palpable, clinical multinodular goiters, patients with benign nodules, patients
with indeterminate nodules, and those with clear malignant diagnoses. It encom-
passes easy-to-understand diagnostic approaches, including imaging, serologic test-
ing, and fine needle biopsies; it seeks to clarify molecular testing and to describe
appropriate surgical treatment, postoperative radioactive iodine administration for
differentiated thyroid cancer, and adequate thyroid hormone replacement. It
describes special and often anxiety-producing patient situations such as concomi-
tant pregnancy and thyroid nodules and cancer in children. It includes aspects of the
disease which are often not discussed, such as patient quality of life after thyroid
surgery and common long-term problems, and dedicates a chapter to integrative
medical approaches for patients who desire such interventions.

v
vi Preface

We have brought together experts and thought leaders from the USA in the fields
of thyroidology, thyroid surgery, nuclear medicine, pathology, radiology, pediatrics,
and integrative medicine and have edited an up-to-date book, which we feel speaks
directly to the concerns of our colleagues and our patients.

Durham, NC, USA Sanziana A. Roman, MD

 Julie Ann Sosa, MD, MA
Nashville, TN, USA Carmen C. Solórzano, MD
Contents

1 I ncidence and Epidemiology ���������������������������������������������������������������������� 1

Megan R. Haymart and Nazanene H. Esfandiari

Part I The Thyroid Nodule 

2  he Clinically Detected and Palpable Thyroid Nodule�������������������������� 13
T
Whitney Goldner and Anery Patel
3 Ultrasound of the Thyroid and Soft Tissues of the Neck������������������������ 23
Jennifer A Sipos
4  hyroid Nodule Biopsy������������������������������������������������������������������������������ 47
T
Denise Carneiro-Pla
5  he Bethesda System for Reporting Thyroid
T
Cytopathology (BSRTC)���������������������������������������������������������������������������� 59
Idris Tolgay Ocal and Mohiedean Ghofrani
6  ross-Sectional Imaging for the Evaluation of Thyroid
C
Nodules and Cancer���������������������������������������������������������������������������������� 93
James X. Wu, Masha Livhits, Ali Sepahdari, and
Michael W. Yeh
7  urveillance of Benign Thyroid Nodules������������������������������������������������ 103
S
Elizabeth H. Holt

Part II Management of Nodular Hyperthyroidism 

8  he Role of Medical Management for Nodular
T
Hyperthyroidism�������������������������������������������������������������������������������������� 115
Ana E. Espinosa De Ycaza and Marius N. Stan
9 The Role of Surgery for Nodular Hyperthyroidism ���������������������������� 133
Dawn M. Elfenbein and David F. Schneider

vii
viii Contents

Part III The Indeterminate Thyroid Nodule 

10  urgical Intervention for Indeterminate Thyroid Nodules������������������ 147
S
Snehal G. Patel and Linwah Yip

Part IV Papillary Thyroid Cancer 

11 Staging for Papillary Thyroid Cancer���������������������������������������������������� 165
Heather Stuart, Steven Rodgers, and Janice L. Pasieka
12 I mportance of Surgeon Experience in the Surgical
Management of Thyroid Cancer������������������������������������������������������������ 187
Kathryn E. Coan and Tracy S. Wang
13  he Pediatric Thyroid Nodule and Papillary Thyroid
T
Cancer Management�������������������������������������������������������������������������������� 199
Scott A. Rivkees and Catherine A. Dinauer

Part V Controversies in Papillary Thyroid Cancer 

14 Papillary Thyroid Microcarcinomas������������������������������������������������������ 219
Jennifer R. Cracchiolo and Ashok R. Shaha
15 Surgical Management of Low-Risk Papillary Thyroid Cancer ���������� 231
Jonathan Mark and David L. Steward
16  anagement of Central Compartment Lymph Nodes
M
in Patients with Papillary Thyroid Carcinoma ������������������������������������ 241
Joy C. Chen and Christopher R. McHenry
17  he Management of the Persistent and Recurrent Cervical
T
Lymph Node Metastases�������������������������������������������������������������������������� 255
J. D. Pasternak and W. T. Shen
18  hyroid Nodular Disease and Thyroid Cancer
T
During Pregnancy������������������������������������������������������������������������������������ 263
Trevor E. Angell and Erik K. Alexander
19  he Perioperative Management of the Voice and Serum
T
Calcium Levels ���������������������������������������������������������������������������������������� 273
David T. Hughes and Paul G. Gauger

Part VI Post-thyroidectomy Radioiodine Therapy, Hormonal

Therapy and Surveillance 
20 Initial Radioiodine Ablation�������������������������������������������������������������������� 297
Rebecca L. Weiss and Angela M. Leung
21 Treatment of Recurrent/Metastatic Thyroid Cancer
with Radioactive Iodine �������������������������������������������������������������������������� 315
Naykky Singh Ospina and M. Regina Castro
Contents ix

22  urveillance of Treated Thyroid Cancer Patients

S
and Thyroid Hormone Replacement and Suppression������������������������ 331
Jennifer M. Perkins
23 I ntegrative Approaches to Patients
Undergoing Thyroid Surgery������������������������������������������������������������������ 351
Beatriz Olson

Part VII Other Differentiated and Advanced Thyroid Cancer 

24 Follicular and Hürthle Cell Carcinoma ������������������������������������������������ 379
Naris Nilubol, Xavier Keutgen, and Electron Kebebew
25  ocally Advanced Differentiated Thyroid Cancer�������������������������������� 395
L
Ming Yann Lim, Mark Zafereo, and Elizabeth Grubbs
26  xternal Beam Radiation for Locally Advanced
E
and Metastatic Differentiated Thyroid Cancer ������������������������������������ 419
James D. Brierley, Meredith E. Giuliani, and Richard W. Tsang
27  ystemic Therapy for Advanced Metastatic Thyroid Cancer�������������� 433
S
Dwight Owen and Manisha H. Shah

Index������������������������������������������������������������������������������������������������������������������ 451
Contributors

Erik K. Alexander, MD The Thyroid Section, Department of Medicine, Brigham

& Women’s Hospital and Harvard Medical School, Boston, MA, USA
Trevor E. Angell, MD The Thyroid Section, Department of Medicine, Brigham &
Women’s Hospital and Harvard Medical School, Boston, MA, USA
James D. Brierley, MBBS Department of Radiation Oncology, University of
Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
Denise Carneiro-Pla, MD Department of Surgery, Medical University of South
Carolina, Charleston, SC, USA
M. Regina Castro, MD Division of Endocrinology, Diabetes, Metabolism, and
Nutrition and Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
Joy C. Chen, MD, MS Department of Surgery, Stanford University Medical
Center, Stanford, CA, USA
Kathryn E. Coan, MD Department of Surgery, Division of Surgical Oncology,
Section of Endocrine Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
Jennifer R. Cracchiolo, MD Department of Surgery, Head and Neck Service,
Memorial Sloan Kettering Cancer Center, New York, NY, USA
Ana E. Espinosa De Ycaza, MD Endocrinology, Diabetes, Metabolism and
Nutrition, Mayo Clinic, Rochester, MN, USA
Catherine A. Dinauer, MD Department of Surgery, Yale University School of
Medicine, New Haven, CT, USA
Department of Pediatrics, Yale University School of Medicine, New Haven, CT,
USA
Dawn M. Elfenbein, MD, MPH Department of Surgery, University of California,
Irvine, Irvine, CA, USA

xi
xii Contributors

Nazanene H. Esfandiari, MD Internal Medicine: Metabolism, Endocrinology, &

Diabetes, & Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
Paul G. Gauger, MD Division of Endocrine Surgery, Department of Surgery,
University of Michigan, Ann Arbor, MI, USA
Mohiedean Ghofrani, MD Cytopathology, PeaceHealth Laboratories, Vancouver,
WA, USA
Meredith E. Giuliani, MBBS, MEd Department of Radiation Oncology,
University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
Whitney Goldner, MD Division of Diabetes, Endocrinology and Metabolism,
Department of Internal Medicine, University of Nebraska Medical Center, Omaha,
NE, USA
Elizabeth Grubbs, MD Departments of Surgical Oncology, University of Texas
MD Anderson Cancer Center, Houston, TX, USA
Megan R. Haymart, MD Division of Metabolism, Endocrinology, & Diabetes &
Hematology/Oncology, University of Michigan Health System, Ann Arbor, MI,
USA
Elizabeth H. Holt, MD, PhD Section of Endocrinology and Metabolism, Yale
School of Medicine, New Haven, CT, USA
David T. Hughes, MD Division of Endocrine Surgery, Department of Surgery,
University of Michigan, Ann Arbor, MI, USA
University of Michigan Hospitals and Health Centers, 2920 Taubman Center, SPC
5331, Ann Arbor, MI, USA
Electron Kebebew, MD Endocrine Oncology Branch, National Cancer Institute,
National Institute of Health, Bethesda, MD, USA
Xavier Keutgen, MD Department of Surgery, Rush University Medical Center,
Chicago, IL, USA
Angela M. Leung, MD, MSc Division of Endocrinology, VA Greater Los Angeles
Healthcare System, UCLA David Geffen School of Medicine, Los Angeles, CA,
USA
Ming Yann Lim Department of Otolaryngology, Tan Tock Seng Hospital,
Singapore, Singapore
Masha Livhits, MD Endocrine Surgery, UCLA David Geffen School of Medicine,
Los Angeles, CA, USA
Jonathan Mark, MD Department of Otolaryngology and Department of Internal
Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
Christopher R. McHenry, MD Case Western Reserve University School of
Medicine, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
Contributors xiii

Naris Nilubol, MD Center for Cancer Research National Cancer Institute,

Bethesda, MD, USA
Idris Tolgay Ocal, MD Pathology and Laboratory Medicine, Division of Anatomic
Pathology, Department of Laboratory Medicine/Pathology, Mayo Clinic Arizona,
Scottsdale, AZ, USA
Beatriz Olson, MD Endocrinology, Middlebury, CT, USA
Naykky Singh Ospina, MD Division of Endocrinology, Diabetes, Metabolism,
and Nutrition and Department of Internal Medicine, Mayo Clinic, Rochester, MN,
USA
Dwight H. Owen, MD Medical Oncology, Ohio State University, Columbus, OH,
USA
Janice L. Pasieka, MD Department of Surgery, Sections of General Surgery and
Surgical Oncology, University of Calgary, Cunning School of Medicine, Calgary,
AB, Canada
Department of Surgery and Oncology, Faculty of Medicine, University of Calgary,
Foothills Medical Centre, Calgary, AB, Canada
J.D. Pasternak, MD Division of General Surgery, University Health Network,
Toronto, Canada
Anery Patel, MD Division of Diabetes, Endocrinology and Metabolism,
Department of Internal Medicine, University of Nebraska Medical Center, Omaha,
NE, USA
Snehal G. Patel, MD Department of Surgery, Division of Endocrine Surgery and
Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
Jennifer M. Perkins, MD, MBA Division of Endocrinology, Duke University
Health System, Durham, NC, USA
Scott A. Rivkees, MD Department of Pediatrics, University of Florida College of
Medicine, Gainesville, FL, USA
Steven Rodgers, MD, PhD Department of Surgery, Division of Surgical Oncology,
University of Miami Miller School of Medicine, Miami, FL, USA
David F. Schneider, MD, MS Section of Endocrine Surgery, Department of
Surgery, University of Wisconsin, Madison, WI, USA
Ali Sepahdari, MD Radiological Sciences, Ronald Reagan UCLA Medical
Center, Los Angeles, CA, USA
Manisha H. Shah, MD The Ohio State University Comprehensive Cancer Center,
Arthur G. James Cancer Hospital and Richard J. Solove Research Institute,
Columbus, OH, USA
xiv Contributors

Ashok R. Shaha, MD Department of Surgery, Head and Neck Service, Memorial

Sloan Kettering Cancer Center, New York, NY, USA
W.T. Shen, MD Department of Surgery, Mt Zion Hospital, University of
California – San Francisco, San Francisco, CA, USA
Jennifer A Sipos, MD Endocrinology and Metabolism, The Ohio State University,
Columbus, OH, USA
Marius N. Stan, MD Endocrinology, Diabetes, Metabolism and Nutrition, Mayo
Clinic, Rochester, MN, USA
David L. Steward, MD Department of Otolaryngology and Department of Internal
Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
Heather Stuart, MD Department of Surgery, Division of Surgical Oncology,
University of Miami Miller School of Medicine, Miami, FL, USA
Department of Surgery, Sections of General Surgery and Surgical Oncology,
University of Calgary, Cunning School of Medicine, Calgary, AB, Canada
Richard W. Tsang, MD Department of Radiation Oncology, University of
Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
Tracy S. Wang, MD, MPH Department of Surgery, Division of Surgical Oncology,
Section of Endocrine Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
Section of Endocrine Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
Rebecca L. Weiss, MD Division of Endocrinology (111D), VA Greater Los
Angeles Healthcare System, UCLA David Geffen School of Medicine, Los Angeles,
CA, USA
James X. Wu, MD Surgery, Section of Endocrine Surgery, UCLA David Geffen
School of Medicine, Los Angeles, CA, USA
Michael W. Yeh, MD Surgery, UCLA David Geffen School of Medicine, Los
Angeles, CA, USA
Linwah Yip, MD Department of Surgery, Division of Endocrine Surgery and
Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Mark Zafereo, MD Departments of Head and Neck, University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Chapter 1
Incidence and Epidemiology

Megan R. Haymart and Nazanene H. Esfandiari

Rise in Thyroid Cancer Incidence

The incidence of thyroid cancer has tripled over the past 30 years (Fig. 1.1), with
thyroid cancer now the eighth most common cancer in the United States and the
fifth most common cancer in women [1–3]. Although thyroid cancers of all sizes
have increased in incidence, 87 % of the rise in thyroid cancer is attributed to small
papillary thyroid cancers (2 cm or smaller), which have an excellent prognosis [1].
It is estimated that in 2015, there will be 62,450 new cases of thyroid cancer but
only 1,950 deaths [4]. Because of this rising incidence, thyroid cancer is projected
to be the fourth most common cancer by 2030 [2, 5–9]. Not only has the incidence
risen in the United States, the rise in thyroid cancer incidence has been seen across
the world [10]. This rise in thyroid cancer incidence is most marked in Korea, where
thyroid cancer is now the most common cancer and the incidence is close to
70/100,000 [11]. This worldwide unexplained rise in thyroid cancer incidence
remains a major concern for physicians treating thyroid cancer.
The greatest rise in thyroid cancer incidence has been seen in women [12].
Women represent close to 75 % of all thyroid cancer cases and the incidence has

M.R. Haymart, MD (*)

Division of Metabolism, Department of Internal Medicine, Endocrinology, and
Diabetes and Hematology/Oncology, University of Michigan Health System,
North Campus Research Complex, 2800 Plymouth Rd. Bldg. 16, Rm 408E,
Ann Arbor, MI 48109, USA
e-mail: meganhay@med.umich.edu
N.H. Esfandiari, MD
Department of Internal Medicine, Metabolism, Endocrinology, and Diabetes,
University of Michigan, 24, Frank Lloyd Wright Drive, Domino’s Farm,
Lobby C, Suite 1300, Ann Arbor, MI 48109, USA
e-mail: nazanene@med.umich.edu
© Springer International Publishing Switzerland 2017 1
S.A. Roman et al. (eds.), Management of Thyroid Nodules and Differentiated
Thyroid Cancer, DOI 10.1007/978-3-319-43618-0_1
2 M.R. Haymart and N.H. Esfandiari

15

100,000 PERSONS

10
NUMBER PER

New Cases

Deaths
0
1992 1995 2000 2005 2012
YEAR

Fig. 1.1 Based on SEER data, the number of new cases of thyroid cancer was 13.5 per 100,000
men and women per year. The number of deaths was 0.5 per 100,000 men and women per year.
These rates are age adjusted and based on 2008–2012 cases and deaths [5]

risen in both men and women but at a greater rate in women. From 1980 to 1983
versus 2003 to 2005, papillary thyroid cancer rates tripled among white and black
females and doubled among white and black males [12]. Although two-thirds of
thyroid cancers occur in patients < age 55, the fastest rise in incidence has been seen
in adults over age 65 [13, 14]. Older adults have the highest incidence of thyroid
cancer per 100,000, with 25.84 new cases diagnosed in patients ages 65–74 years
versus 15.16 diagnosed in patients ages 20–49 [5]. Adults aged ≥ 65 also have the
greatest growth in incidence with an annual percentage change of 8.8 % versus
6.4 % for those aged < 65 years [5, 15]. The rise in incidence has been seen across
race groups, but incidence rates tend to be higher among whites than blacks and
among white non-Hispanics than white Hispanics and Asian Pacific Islanders [12].
Historically, thyroid cancer diagnosis has been more common in cohorts with higher
socioeconomic status (SES). Based on Surveillance, Epidemiology and End Results
(SEER) data from 497 counties in the United States, county papillary thyroid cancer
incidence positively correlates with rates of college education, white-collar employ-
ment, and family income [15].

The Origin of Thyroid Cancer

Diagnosing thyroid cancer usually starts with identifying a thyroid nodule and/or
occasionally lateral neck mass. Between 20 and 70 % of adults have thyroid nodules
with older adults having a higher prevalence than younger [16, 17]. In patients with
thyroid nodules, male gender, younger age, and high-risk ultrasound characteristics,
such as irregular borders, solid, hypoechoic, larger size, and microcalcifications, are
associated with greater likelihood of thyroid cancer [18–21].
1 Incidence and Epidemiology 3

The majority of thyroid cancers are identified with fine-needle aspiration of a

thyroid nodule. Of the nodules that undergo fine needle aspiration (FNA), only
5–8 % are thyroid cancer [22–24]. Although most cancers are diagnosed by FNA,
6–21% of the thyroid operations planned for treatment of benign disease have inci-
dental discovery of thyroid cancer postoperatively [25–27].
The most common thyroid cancer diagnosed is papillary thyroid cancer, which rep-
resents 85 % of all thyroid cancers [28]. Additional thyroid cancers include other well-
differentiated cancers, such as follicular and Hürthle cell which represent approximately
10 and 3 % of thyroid cancers, respectively [28]. Medullary thyroid cancer arises from
c-cells and accounts for less than 5 % of all thyroid cancers [28–30]. Anaplastic is rare
and deadly and represents only 1 % of all thyroid cancers [31, 32].

Risk Factors for Thyroid Cancer

As shown in Table 1.1, there are two accepted risk factors for well-differentiated
thyroid cancer: ionizing radiation and family history. Ionizing radiation is thought
to cause cancer through somatic mutations and DNA strand breaks [14, 33]. When
catastrophic events such as Chernobyl happen, the risk of thyroid cancer is dose and
age related [34]. Children and young adults under age 20 years are most susceptible
to radiation-induced thyroid cancers [14, 35, 36]. Similarly, children who under-
went radiation therapy for childhood cancers, acne, treatment of enlarged thymus,
etc. also have an increased risk for thyroid cancer [37]. In addition, to radiation
exposure, familial nonmedullary thyroid cancer does exist. If two or more first-­
degree relatives have well-differentiated thyroid cancer, then it is presumed to be
hereditary. However, this hereditary form of well-differentiated thyroid cancer can-
not be tracked with genetic testing and is thought to represent just over 5 % of all
well-differentiated thyroid cancers [38–41]. Recently, a germline variant in HABP2
was identified in familial nonmedullary thyroid cancer [41]. Therefore, for the

Table 1.1 Accepted risk factors for thyroid cancer

Radiation
 Nuclear events such as Chernobyla or Fukushimab
 Treatment of childhood cancers with ionizing (external beam) radiation
 Treatment of acne, thymus, etc., with ionizing (external beam) radiation
 Environmental exposures are currently under investigation by several researchers
Family history
 RET mutations with MEN2A and MEN2B
 Familial nonmedullary thyroid cancers and syndromes
a
Chernobyl happened on April 25, 1986
b
Meltdown of the reactor in Fukushima happened on March 11, 2011
RET RET proto-oncogene gain of function mutation is associated with the development of medul-
lary thyroid cancer, MEN multiple endocrine neoplasias
4 M.R. Haymart and N.H. Esfandiari

majority of patients with well-differentiated thyroid cancer, there is no clear etiol-

ogy of their thyroid cancer and the cancer thought to be sporadic.
In comparison, for medullary thyroid cancer, up to 1–7% of patients with appar-
ently sporadic medullary thyroid cancer end up having germline mutations and
associated syndromes MEN2A and MEN2B [42, 43]. Genetic testing can identify
the RET mutation involved in development of the medullary thyroid cancer, and
then subsequent testing can identify family members at risk. In addition to germline
mutations, up to half of patients with sporadic medullary thyroid cancer patients
have an unidentified somatic RET mutation [44].
There are no clear risk factors for anaplastic thyroid cancer. However, anaplastic
thyroid cancer is thought to arise from a well-differentiated thyroid cancer, and it is
more common in older adults [32]. There is an accepted “second hit” hypothesis
that well-differentiated thyroid cancers typically need a second mutation, often p53,
to develop anaplastic thyroid cancer [31].

 roposed Explanations for the Rise in Thyroid Cancer

P
Incidence

Table 1.2 illustrates the two broad theories to explain the rise in thyroid cancer inci-
dence [14]. One theory is that new or previously unidentified risk factors for thyroid
cancer explain the rise in incidence. These proposed risk factors would include
radiation exposure outside of known catastrophic events or treatment of childhood
cancers, obesity/diabetes, autoimmune thyroid disease, and iodine deficiency or
excess. Another conflicting theory is that we have detection bias or in essence over-
diagnosis leading to the rise in thyroid cancer incidence. In principle, there is a large
reservoir of indolent thyroid cancer, and the more we “look,” the more we find.
Based on this overdiagnosis theory, increased use of imaging, FNA, surgery, and

Table 1.2 Proposed explanations for the rise in thyroid cancer incidence
Novel risk factor
 Background environmental radiation
 Obesity/diabetes mellitus
 Autoimmune thyroid disease
 Iodine deficiency or excess
 Other environmental agents
Overdiagnosis
 Greater use of neck imaging leading to more nodule detection and cancer diagnosis
 More fine-needle aspirations of nodules leading to more cancer diagnosis
 More surgery leading to more post op incidental cancer discovery
 Greater pathologic inspection leading to more cancer diagnosis
a
Adapted from Table 1.1. Potential Contributors to the Increasing Incidence of Thyroid Cancer in
the United States, by Category [14]
1 Incidence and Epidemiology 5

pathologic inspection leads to detection of cancers that otherwise may have been
unidentified. In the following section, we will explain both conflicting theories.

Explanation 1: New Risk Factor

Exposure to ionizing radiation is an accepted risk factor for well-differentiated thy-

roid cancer. However, typically patients aged 20 years and younger are most at risk,
and in the absence of a recent catastrophic world event, such as Chernobyl or the
2011 reactor meltdown in Fukushima, Japan, this seems like an unlikely explana-
tion for the worldwide rise in thyroid cancer incidence [14, 36]. Although some do
worry that the background level of radiation exposure, especially due to increased
use of CT scans, has increased and may contribute to the rise in thyroid cancer inci-
dence, it has been estimated that pediatric CT scans account for <1% of the increased
incidence of thyroid cancer [14]. Obesity and diabetes mellitus are increasingly
common problems in well-developed countries. In parallel to the thyroid cancer
epidemic is the obesity and diabetes epidemic [12, 45, 46]. Thus, it has been hypoth-
esized that the thyroid cancer epidemic may be related to the rise in obesity and
diabetes mellitus. A pooled analysis of five prospective studies found that obesity is
an independent risk factor for thyroid cancer [47]. However, there is more conflict-
ing data when evaluating diabetes and its relationship to thyroid cancer [48, 49].
To-date although correlations between both obesity and diabetes mellitus with thy-
roid cancer have been noted, causality has not been shown [47, 48].
Autoimmune thyroid disease, specifically Hashimoto’s thyroiditis and Graves’
disease, are common benign thyroid conditions that are similar to the thyroid cancer
in the fact that they are far more common in women. There has been longstanding
controversy about whether or not autoimmune thyroid disease is associated with
thyroid cancer. Surgical studies have suggested a clear association, whereas studies
based on FNA samples or antibodies have been less supportive [50–53]. Although
thyroid cancer incidence has been rising, there is no clear data that autoimmune
thyroid disease is more prevalent now than 30 years ago. Thus, this is an unlikely
explanation for the recent rise in thyroid cancer incidence.
Iodine deficiency or excess is known to affect the proportions of thyroid cancer
types in the world, as iodine deficiency is associated with a higher proportion of fol-
licular thyroid cancer [54, 55]. However, the relationship between iodine levels and
the recent pattern of diagnosing smaller papillary thyroid cancers is unclear [55].

Theory 2: Overdiagnosis

Suggesting that we may be tapping into a reservoir of indolent disease, the great-
est rise in incidence has been in low-risk disease. Eighty-seven percent of the
increase in thyroid cancer incidence is attributed to papillary thyroid cancers
6 M.R. Haymart and N.H. Esfandiari

measuring 2 cm or smaller [1]. Since most disease detected is small, the prognosis
for most patients is excellent [56]. Mortality for thyroid cancer has consistently
been around 0.5 per 100,000 population [5]. Five-year disease-specific survival
for localized disease is 99.8%, and for regional disease, it is 97% [2, 9]. Finally,
thorough autopsy studies have revealed incidental small thyroid cancers in up to
36% of adults who die from another cause [57]. If pathologic slicing of thyroid
specimens were finer, some have suggested that the actual prevalence may be as
high as 100% [57]. This implies that there may be a bottomless reservoir of indo-
lent disease. The fact that the rise in thyroid cancer incidence is primarily due to
increased detection of low-risk disease and the fact that thyroid cancer is a com-
mon incidental finding on autopsy studies support the hypothesis that overdiagno-
sis may play an important role in the rise of thyroid cancer incidence in developed
countries.
Excess thyroid imaging may be one of the reasons for the overdiagnosis of small
thyroid cancers. Since at least half of all adults have thyroid nodules, increased
imaging can lead to incidental nodule discovery [16, 17, 58, 59]. The rates of detec-
tion of thyroid nodules are 67% with thyroid ultrasound (US), 16% with CT and
MRI, 9% with carotid duplex, and 3% with positron emission tomography (PET) or
PET/CT [59–63]. Over the past 15 years, there has been a rise in the use of imaging
studies that are associated with incidental thyroid nodule discovery. Based on data
from a large health plan, between 1997 and 2006 use of US increased 40%, use of
computed tomography (CT) doubled, and use of magnetic resonance imaging
(MRI) tripled [64]. In addition to the rise in use of imaging associated with inciden-
tal cancer discovery, thyroid US is increasingly becoming an extension of the physi-
cal exam. When there is a palpable nodule, thyroid US is the preferred method of
imaging [19]. Neck imaging to evaluate thyroid nodules and symptoms and neck
imaging performed for other reasons have contributed to the rise in thyroid cancer
incidence [65, 66].
Related to more imaging, greater use of thyroid FNA also leads to more cancer
diagnosis. Use of thyroid FNAs more than doubled between 2006 and 2011 [67].
Since approximately 5–8% of thyroid nodules undergoing FNA are cancer and 20%
are indeterminate, more FNAs will result in more cancer diagnoses [22–24].
More surgery may also play a role in the thyroid cancer epidemic. The number
of thyroid surgeries being performed in the United States increased by 39%
between 1996 and 2006 with one-third of the surgeries performed for thyroid
cancer [68, 69]. Between 6 and 21% of thyroid surgeries that are planned for treat-
ment of benign disease have an incidental discovery of thyroid cancer postopera-
tively [25–27]. Therefore, more thyroid surgery will result in more detection of
more low-risk thyroid cancer, thus contributing to the rise in thyroid cancer
incidence.
In addition to surgery, in recent years pathologic evaluation has become more
detailed. Currently pathologists examine the entire thyroid and 14 versus five
descriptive areas are reported [14, 70, 71]. This too could potentially contribute
to the rise in thyroid cancer incidence as more small incidental cancers are
detected.
1 Incidence and Epidemiology 7

Conclusion

There has been a rise in thyroid cancer incidence. Although there is an ongoing
debate as to whether a new risk factor versus overdiagnosis explains the rise in
incidence, most data support overdiagnosis playing a significant role in the devel-
oped countries for this finding. Regardless of etiology, this rise in thyroid cancer
incidence has implications for patients, physicians, and society. As we diagnose
more thyroid cancer, it becomes increasingly important to understand which
patients need intensive treatment to prevent poor outcome, including death and
recurrence, and which patients have low-risk disease and need minimal interven-
tion or surveillance only.

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 Part I
The Thyroid Nodule
Chapter 2
The Clinically Detected and Palpable
Thyroid Nodule

Whitney Goldner and Anery Patel

Abbreviations

ATC Anaplastic thyroid cancer

FAP Familial adenomatous polyposis
FTC Follicular thyroid cancer
FMTC Familial medullary thyroid cancer
MEN Multiple endocrine neoplasia
MTC Medullary thyroid cancer
PTC Papillary thyroid cancer

Introduction

Thyroid nodules are common, but they are not always easy to detect clinically or by
physical exam. Historically, nodules were discovered only if they had a visible or
palpable neck mass. Additionally, nodules were suspected if a patient had compres-
sive symptoms in the anterior neck or symptoms of hormone deficiency or excess.
Before the advent and routine use of imaging, thyroid nodules were estimated to
occur in approximately 5–10 % of people, when discovered by palpation alone
­[1–3]. Even in the most experienced hands, physicians may fail to detect smaller
nodules (less than 1 cm) [4]. Large anterior thyroid nodules can be palpable and
easy to visualize, but smaller or posterior nodules frequently are not palpable, but
may be associated with compressive symptoms [5, 6]. Variations in individual

W. Goldner, MD (*) • A. Patel, MD

Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine,
University of Nebraska Medical Center,
984120 Nebraska Medical Center, Omaha, NE 68198-4120, USA
e-mail: wgoldner@unmc.edu; anery.patel@unmc.edu

© Springer International Publishing Switzerland 2017 13

S.A. Roman et al. (eds.), Management of Thyroid Nodules and Differentiated
Thyroid Cancer, DOI 10.1007/978-3-319-43618-0_2
14 W. Goldner and A. Patel

anatomy of the neck can also make the thyroid exam difficult and thyroid nodules
even less likely to be palpable. In kyphotic persons, or those with shorter necks, the
thyroid may be situated more inferiorly either near the sternal notch or substernal,
making it difficult to palpate [7].
As ultrasound and cross-sectional imaging of the neck with computed tomogra-
phy (CT) or magnetic resonance imaging (MRI) became available, many non-­
palpable thyroid nodules have been incidentally detected. The prevalence of thyroid
nodules is now estimated to be 20–60 %, depending on age, gender, and geographic
location [1, 3, 6, 8]. This is consistent with previous observations in autopsy studies
reporting the prevalence of thyroid nodules as high as 50 % [4, 9].
Even though many nodules are asymptomatic and incidentally noted, there is a
subset of nodules that are identified because of presenting symptoms or based on
physical examination. Physical assessment is a valuable first step in evaluating neck
masses for patients with symptoms suggestive of a thyroid nodule and thyroid hor-
mone deficiency or excess or for those who are at high risk for nodules or thyroid
cancer based on personal or family history.
Thyroid cancer is now the eighth most common cancer in the United States and
the fifth most common cancer in women, with its incidence rising approximately
5 % per year over the last 10 years [10] (see Chap. 1). When looking at the total
number of thyroid nodules, it is estimated that approximately 5–10 % of all thyroid
nodules are malignant [11, 12], and similar rates of thyroid cancer have been
reported in patients who have solitary or multiple thyroid nodules [13]. However,
it is now recognized that the overall risk of malignancy in an individual nodule is
dependent on age, gender, radiation exposure, family history, and imaging charac-
teristics of the nodule, as well as history and physical examination characteristics
[14]. Nodules occurring at extremes of age, particularly in men, are more likely to
be malignant [1]. Symptoms, such as rapid growth, hoarseness, fixation to sur-
rounding tissues, and the development of cervical lymphadenopathy make the risk
of malignancy in thyroid nodules higher [14]. Thyroid nodules and some thyroid
cancers are also more commonly associated with specific hereditary genetic syn-
dromes (Table 2.1). A good physical examination may not only identify a thyroid
abnormality or lymphadenopathy but also can identify other physical findings that
may be associated with genetic syndromes or medical conditions that have
increased risk for thyroid nodules or cancer.

Symptoms

Most patients with thyroid nodules have no hyper- or hypothyroid symptoms. They
are often asymptomatic; a minority of nodules can be detected by physical examina-
tion, and more are detected incidentally with imaging. If the nodules are palpable,
patients can present with a slowly enlarging mass in the neck. The most common
symptoms associated with thyroid nodules are those due to pressure on or invasion
of adjacent structures and can include dysphagia, globus sensation, compressive/
constrictive feeling in the neck, hoarseness or change in speech quality, difficulty
2 The Clinically Detected and Palpable Thyroid Nodule 15

Table 2.1 Hereditary thyroid cancer syndromes

Pattern of
inheritance and
Syndrome Rate of thyroid cancer Associated conditions mutations
Gardner’s 2–12 % with PTC [15] with Gastrointestinal polyps Autosomal
syndrome mean age at diagnosis of 28 Osteomas dominant tumor
(FAP) years Epidermoid cysts suppressor APC
Desmoid tumors [16] gene
Cowden’s Two-thirds with thyroid Multiple hamartomas Autosomal
syndrome pathology including Breast cancer dominant tumor
(PTEN multinodular goiter, Endometrial cancer suppressor PTEN
hamartoma follicular adenomas, FTC, gene
syndrome) and PTC [17]
Carney 15 % of patients with PTC Adrenal and pituitary Autosomal
complex and FTC [18] gland pathology dominant
Myxomas of the soft PRKA1α gene
tissue, heart, skin, and
brain
Schwannomas
Testicular tumors
Lentigines
Werner 18 % of patients with thyroid Soft tissue sarcomas Autosomal
syndrome malignancy including PTC, Melanomas recessive
FTC, ATC [19] Osteosarcomas WRN gene
Familial 3.2–9.4 % of all thyroid Differentiated thyroid Not identified
Non- cancer cases [20] cancer of follicular origin
medullary in two or more first-degree
Thyroid relatives [21]
cancer
MEN 2, 25 % cases of MTC [22, 23] MEN 2A – Autosomal
FMTC pheochromocytoma, dominant
hyperparathyroidism RET
MEN 2B – proto-oncogene
pheochromocytoma,
mucosal neuromas,
ganglioneuromatosis of GI
tract, megacolon

breathing, and cosmetic concerns. Occasionally, they can also cause anterior neck
pain with radiation to the ears [7]. There can be pain in the thyroid itself when there
has been acute hemorrhage into the nodule and there is associated inflammation or
rapid growth [24]. In extremely large goiters, patients can have a Pemberton’s sign,
which is facial flushing upon elevation of the arms above the head, due to partial
obstruction of the superior vena cava [7]. If a nodule is visible and palpable, it is
possible to deduce how quickly the nodule has grown and if symptoms have been
stable or changing. Patients who present with symptoms of tracheal or esophageal
compression, vocal cord paralysis, or persistent hoarseness may be more likely to
harbor malignancy [14].
If nodules are functioning, they can be associated with symptoms of hyperthy-
roidism. Autonomously hyperfunctional thyroid nodules can be either solitary or
16 W. Goldner and A. Patel

multiple and can lead to thyrotoxicosis. If a thyroid nodule is noted in a patient

with symptoms of tachycardia, anxiety, tremor, heat intolerance, weight loss, and
frequent bowel movements, this is suggestive of a toxic thyroid nodule. However,
Graves’ disease can also present with hyperthyroid symptoms [25] along with a
diffusely enlarged thyroid, or asymmetric enlargement, which can simulate a nod-
ule. Additional clinical characteristics that can be associated with Graves’ disease,
that are not seen with a toxic nodule, include the presence of ophthalmopathy and
dermopathy. Patients with ophthalmopathy, or thyroid eye disease, can have peri-
orbital edema, proptosis, exophthalmos, lid lag, stare, and conjunctival injection
[26]. Dermopathy can present as non-pitting edema, usually of the lower extremi-
ties in the pretibial area. If a patient presents with thyroid dysfunction associated
with ophthalmopathy, the pretibial area should be carefully examined for subtle
signs of dermopathy, such as localized thickening of the skin with reddish discol-
oration [27].
A slowly growing, diffusely enlarged thyroid or thyroid nodule associated with
typical symptoms [28] such as dry skin, cold sensitivity, fatigue, muscle cramps,
voice changes, and constipation could suggest hypothyroidism.

Family History and Cancer Syndromes

Several familial syndromes are associated with increased risk of thyroid cancer.
These include Gardner’s syndrome, PTEN hamartoma syndrome (Cowden’s syn-
drome), Carney complex, Werner syndrome, familial non-medullary thyroid carci-
noma, multiple endocrine neoplasia type 2 (MEN 2), and familial medullary thyroid
carcinoma (FMTC) [15–23, 29] (Table 2.1).
Hirschsprung disease and McCune-Albright, Peutz-Jeghers, Pendred, and ataxia-­
telangiectasia syndromes also have been reported to be associated with thyroid can-
cer, but the links are less established [29]. If family history is significant for any of
these syndromes, it is important to not only evaluate for thyroid nodules but also for
the non-thyroid manifestations of these syndromes (Table 2.1).

Radiation Exposure

Studies have shown that children exposed to ≥1 Gy of ionizing radiation are at

higher risk of development of thyroid nodules at a rate of 2 % annually [30], and
these nodules have a higher risk of malignancy, estimated at 20–50 % [31]. This risk
can persist for over 50 years [31]. Additionally, a history of external radiation expo-
sure in low or medium doses (40–50 Gy) given to patients with lymphoma or head
and neck cancer, particularly in childhood, is a highly concerning risk factor for
both benign and malignant nodules [32].
2 The Clinically Detected and Palpable Thyroid Nodule 17

Iodine Exposure

The risk of thyroid disease from iodine exposure is U-shaped which shows potential
harm for the patients from both iodine deficiency and iodine excess [33]. Iodine
deficiency and excess can both cause thyroid dysfunction; iodine deficiency has
also been associated with a diffusely enlarged thyroid and goiter [34] and can trig-
ger formation of nodules. The possible mechanism is due to chronic stimulation by
TSH and the effects of increased reactive oxygen species in the iodine-deficient
thyroid [35].

Physical Examination

Knowing how to perform a good physical examination of the thyroid and neck is
essential. First, it is important to know the anatomy of the neck, which will help
the examiner identify essential landmarks (Fig. 2.1). The thyroid is made up of a
right and left thyroid lobe and the connection in the middle is the isthmus. Some
people may have a pyramidal lobe, which extends superiorly from the isthmus

Fig. 2.1 Neck anatomy including cervical lymph node levels

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Title: Sous les eaux tumultueuses

Author: Dora Melegari

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*** START OF THE PROJECT GUTENBERG EBOOK SOUS LES

EAUX TUMULTUEUSES ***
SOUS LES EAUX TUMULTUEUSES

TABLE DES
MATIERES
 DORA MELEGARI

SOUS LES EAUX

TUMULTUEUSES

PARIS
LIBRAIRIE FISCHBACHER
33, RUE DE SEINE, 33

1923

Droits de traduction et de reproduction réservés pour tous les pays

Copyright by Librairie Fischbacher 1923
 Je dédie ce livre à ceux qui, comme moi, ont fermement espéré et
espèrent encore qu’après la guerre et avec l’établissement de la paix,
s’ouvrira pour l’homme une destinée meilleure que celle qu’il a connue
jusqu’ici.

PRÉFACE

Je ne fais pas un livre, il se fait.

Il mûrit et croît dans ma tête, comme un fruit.
Alfred de Vigny.

Ces eaux qui, jadis, couvraient le monde sont aujourd’hui étrangement

bourbeuses et agitées. La surface des choses apparaît partout inquiétante.
Qu’y a-t-il sous cette surface? L’angoissante question se pose à tous les
cœurs qui sentent et à tous les cerveaux qui réfléchissent!
Du temps où le respect de soi-même, l’intérêt bien entendu et la savante
hypocrisie imposaient aux hommes intelligents, ou du moins cultivés, une
attitude correcte, les mots sous la surface des choses avaient une
signification bien différente de celle que je leur attribue aujourd’hui.
Auparavant, ils auraient indiqué ce que les individus cachaient de
médiocre, de brutal, et même de cruel sous des dehors corrects et
conventionnels. Aujourd’hui que la plupart des êtres n’essayent même plus
de masquer leurs légèretés, leurs petitesses et leurs convoitises, il n’y a
guère, sous leurs actes et leurs allures, de motifs secrets à découvrir.
Toutes les laideurs sont devenues apparentes et visibles. Nous vivons à
une époque de terrible sincérité; on ne le relève pas suffisamment.
Stendhal a dit quelque part que, pour les femmes, dire la vérité équivalait
à enlever leur fichu; mais, aujourd’hui, elles ne portent plus de fichu, et les
disgraciées elles-mêmes exposent avec courage les défectuosités physiques
que jadis les filles d’Ève essayaient soigneusement de dissimuler aux
regards. Quant aux hommes, combien d’entre eux ne tentent même plus de
se défendre si l’on attaque leur caractère ou leur probité!
Ceux qui en manquent n’en éprouvent plus de honte; ceux qui les
possèdent, s’ils y mettent encore du prix dans le fond de leur âme, sont
devenus indifférents à l’opinion publique. Ce mépris de l’opinion publique
est un signe caractéristique de notre temps.

*
**

Ce qu’il faut discerner sous la surface des eaux tumultueuses, ce ne sont

donc pas les laideurs secrètes, puisqu’avec tant de complaisances on les
étale, mais bien plutôt les aspirations d’ardente générosité et de pure beauté
qui se cachent parfois sous les apparences déconcertantes de la psyché
moderne, tels des symptômes annonciateurs d’une aube nouvelle!
Cependant, malgré ces fugitives lueurs, le désarroi des pauvres âmes est
resté lamentable. Après l’ébranlement cérébral de la guerre et les déceptions
de la paix, on a pu croire qu’elles étaient devenues muettes pour toujours!
Ce phénomène d’anéantissement paraît d’autant plus redoutable qu’il est
universel et se manifeste aussi bien chez les vainqueurs que chez les
vaincus! Le monde est devenu semblable à une mer en tempête, sillonnée
de barques sans pilotes, et la marée ne cesse de monter...
Le spectacle, vraiment effarant, abat les plus fermes courages. Une
mystérieuse intuition avertit cependant ceux qui ont l’habitude de regarder
et d’observer que des feux s’allument encore sur les montagnes, et que de
ce chaos effrayant, de ce déchaînement de convoitises violentes, naîtra un
monde meilleur, précurseur du règne de l’esprit. Ces ouragans qui soufflent
de toutes parts, c’est l’âme d’une humanité renouvelée qui s’élabore dans
un douloureux enfantement.

*
**

Ce livre était destiné à paraître au commencement de l’an dernier: les

espoirs qu’il contient et proclame auraient alors, peut-être, semblé
chimériques aux esprits positifs. La plupart de ceux qui se complaisent dans
la triste grisaille des instincts et des forces matérielles, ne voyaient en ce
moment aucune lumière à l’horizon, et ne discernaient pas la bordure
d’argent des nuages noirs.
Les événements extraordinaires qui se sont vérifiés récemment dans l’un
des pays de l’Europe, ont prouvé à ces intelligences trop unilatérales que le
réveil de l’esprit n’était point un simple mirage, mais bien une réalité
puissante. L’importance de la révolution politique qui vient de sauver un
peuple, s’étend moralement bien au delà de la limite de ses frontières, car
elle a proclamé une vérité universelle: L’homme doit avoir pour mot d’ordre
la défense de la patrie et de Dieu! C’est un règne nouveau qui apparaît à
l’horizon du monde, celui de l’esprit! On entend l’air trembler au son des
cloches invisibles qui en annoncent l’avènement.
Dora Melegari.
Paris, 1923.

SOUS LES EAUX

TUMULTUEUSES
 PREMIÈRE PARTIE

Pendant que la nuit dure encore.

CHAPITRE PREMIER

ESPÉRANCES PRÉMATURÉES

Hence the most vital movement mortal feel,

Is hope; the balm and life blood of the soul.
(Ralph-Waldo Trine.)

Je dédie ce livre à ceux qui ont besoin d’espérance, et ne peuvent se

contenter du simple pain quotidien, qu’ils l’aient gagné par leur travail, ou
leur péché, ou que, parasites, ils le doivent au travail ou au péché d’autrui.
C’est dans ces âmes assoiffées que l’espérance doit refleurir. Quant aux
autres, à celles qui se satisfont d’apparences et de fumée, elles
appartiennent à la catégorie des âmes qui, selon certains pères de l’Église,
seraient autorisées à refuser l’immortalité.

*
**

Rien n’est plus démoralisant que de cesser d’espérer et une partie du

désarroi actuel provient des grandes espérances conçues durant la guerre[A]
et qui ont été déçues ensuite. Ces espérances sont destinées cependant, j’en
ai la conviction, à se réaliser plus tard, mais bien plus tard, à travers
d’autres expériences, d’autres surprises, d’autres souffrances... L’erreur des
esprits de bonne foi a été de croire que, dès le lendemain du formidable
conflit, tout se remettrait en équilibre et que les grands principes, qui
avaient armé les bras et enthousiasmé les cœurs, s’imposeraient à tous,
vainqueurs et vaincus.
On s’était imaginé que la sagesse de Salomon pénétrerait les cerveaux, et
que la cité des mensonges s’écroulerait, ensevelissant dans sa chute les
convoitises que l’orgueil des combats avait exacerbées.
Peut-être bien y avait-il un manque de réflexion et un peu d’ingénuité
dans les espérances qui avaient ainsi gonflé les cœurs. On se figurait que le
palais de la vérité allait s’élever dans la cité de la justice. Le réveil fut amer,
et alors, criant à l’utopie, chacun renia ses dieux. Pourtant, logiquement, ces
espérances avaient été fondées. Jamais on n’avait assisté à une pareille
trépidation d’âmes, à un semblable élan moral chez les peuples.

*
**

Comment advint-il que dans le cœur des hommes, au lieu de cette

floraison magnifique, les plus basses passions se soient dressées, et que le
mal se soit incarné? Je ne veux pas faire de politique ou de sociologie dans
ces pages qui n’envisagent que la reconstitution de la mentalité générale;
mais il est certain que l’Esprit n’a pas soufflé sur les arbitres des destinées
du monde—comme en certains conclaves qu’enregistre l’histoire—et que,
par son silence, il a permis à l’ignorance humaine de jeter entre les peuples
des germes de discorde qui ont aiguisé les armes des haines futures.
L’obscurcissement de la pensée a été la première inoculation fatale, et, à
sa suite, la défiance a empoisonné le cœur des frères d’armes, et provoqué
ces malentendus qui, aigrissant les amour-propres nationaux, ont empêché
jusqu’ici les bienfaisantes conséquences de la paix de se faire sentir.

*
**

L’une des plaies de l’époque d’avant-guerre était le mensonge et le culte

du faux sous toutes ses formes: fausses valeurs, fausses consciences,
fausses pitiés... On se figurait que le triomphe du bon droit les ferait
s’écrouler instantanément, comme les trompettes de Josué firent tomber les
murs de Jéricho. Mais rien ne s’est effondré. La victoire a été, comme
toutes les autres victoires de ce monde, un alambic où se sont élaborés les
grands courages et les merveilleux héroïsmes, mais elle n’a pas transformé
l’homme dans son essence. Il s’est, comme toujours, montré, après la paix,
l’esclave de ses passions et de ses tendances particulières.
 La grande guerre des nations,—c’est un fait prouvé aujourd’hui,—n’a
donc pas eu le résultat miraculeux qu’on en attendait. Un vent de violence a
promptement dispersé les sentiments de solidarité et de reconnaissance qui
avaient paru relier les peuples entre eux durant la période des dangers
communs. Ces sentiments ont été remplacés d’un côté par le prestige de la
force et de l’arrogance; de l’autre, par des nécessités économiques. Trop
cyniquement étalées, elles furent cause de déboires amers, de désillusions
cruelles qui desséchèrent et réduisirent en cendres les germes de la féconde
récolte sur laquelle on comptait.
Tout cela est si connu, qu’il n’est point utile de s’attarder sur le fait en
lui-même, ni d’en rechercher les causes secrètes, ou d’en indiquer les
résultats desséchants. Les conséquences en sont d’une trop pénétrante
mélancolie pour ceux qui avaient espéré. Or, comme la constatation
perpétuelle du mal est éminemment décourageante, on doit essayer au plus
vite de dépasser cette période.

*
**

Il faudrait de l’aveuglement ou de la niaiserie pour nier la crise que

l’humanité traverse, et ne pas la combattre équivaudrait à un maladroit aveu
d’impuissance; mais la plus grande faute serait encore d’en avoir peur et de
la croire durable.
L’unique moyen efficace pour en arrêter le développement est de lever
les yeux et de regarder au-dessus et au delà. Tout ce qui est précieux reste
caché aujourd’hui au tréfond des cœurs, et l’apparence des choses est
déconcertante. La vanité pousse partout des racines formidables: chaque
soldat prétend être Maréchal et, s’il y a encore des maîtres, il n’y a plus de
disciples, ni de serviteurs! Or, comme autour des grands palmiers solitaires
il n’y a que des plaines sablonneuses, c’est vers un immense désert que la
société semble marcher... Puisque toutes les forces vives des nations sont
dressées, l’arme au poing, les unes contre les autres, elles ne peuvent se
coaliser efficacement contre l’épouvantable danger qui les menace. Il en est
ainsi dans toute l’Europe, il en est ainsi dans chaque pays séparément.

*
**
 Chacun sait, chacun a constaté ce que je viens de dire. Parmi les gens qui
ont une vision claire de la réalité, il y en a de faibles qui désespèrent
stérilement, et de forts qui, pour précipiter l’évolution, ne croient qu’à
l’existence des faits. Mais les faits semblent partout s’accumuler,
irréconciliables les uns avec les autres. Pour créer des faits supérieurs
comme valeur et comme puissance, pour ouvrir la route à de nouveaux
courants, pour allumer des flammes capables de détruire les scories qui
encombrent la route, il faut, avant tout, avoir confiance dans le pouvoir
créateur de la pensée humaine.
A tous les hommes d’intelligence et de bonne volonté une croisade
s’impose pour laquelle la première arme de combat est l’attente sage,
patiente, perspicace...

CHAPITRE II

L’ATTENTE

C’est la nuit qu’il est beau de croire à la lumière.

(Ed. Rostand.)

Dans toutes les religions, l’attitude de l’attente est vivement

recommandée; c’est, du reste, l’attitude perpétuelle de la vie humaine pour
ceux surtout qui en admettent le renouvellement infini et qui croient à
l’existence d’une force supérieure à laquelle l’homme peut avoir recours.
Toute espérance formulée n’a-t-elle pas, d’ailleurs, pour conséquence
logique l’attente de la réponse?
Donc il faut attendre, qu’on le veuille ou non. L’important c’est de
savoir attendre! Chez quelques-uns c’est une disposition naturelle: chez
d’autres une vertu acquise ou qu’il faut acquérir.

*
**

Les mots de Dieu à Adam: «Désormais tu gagneras ton pain à la sueur

de ton front», s’appliquent à tous les services, à tous les genres de labeur et
vont bien au delà de l’effort matériel des bras et des muscles. Ils
comprennent chaque effort dont est capable l’âme humaine. Même quand
l’homme produit des fruits remplis non de pulpe, mais de cendres, ces fruits
sont dus au travail de sa personne ou de sa pensée. Les imaginations
perverses se fatiguent à élaborer sans cesse des forces destructrices, et c’est
aussi à la sueur de leur front qu’elles poussent le monde aux actes
démoralisants.
Dieu a appelé l’homme à collaborer avec lui en tout ce qui s’accomplit
sur notre planète, même lorsqu’il s’agit de miracles comme la résurrection
de Lazare. C’est là un fait fondamental que l’homme ne devrait jamais
perdre de vue.

*
**

Dans la signification qu’il faut donner au mot attendre, toute idée de

paresse doit, bien entendu, être exclue. L’homme qui sait attendre n’est pas
un fainéant, car il est constamment en état de veille. Il ne s’agite pas, il ne
se précipite pas, il ne s’irrite pas, mais son esprit est sans cesse tendu vers
l’objet de son attente, et ce n’est pas là un mince labeur.
L’attente doit être patiente, mais non résignée. Ces deux mots s’excluent:
quand on se résigne, on n’attend plus! Il faut donc que l’attente soit
vigilante et optimiste. «Le monde appartient aux optimistes, disait M.
Guizot, les pessimistes n’ont jamais été que des spectateurs.»
En ce moment, l’ordre donné par Dieu à Adam a cessé d’être obéi et
compris dans sa signification précise, qui est l’obligation absolue du travail.
Une vague de paresse a passé sur le monde, et, aujourd’hui, l’homme,
symptôme effrayant, se refuse à travailler de ses mains: il refuse même de
semer le blé et le riz dont il doit vivre! Quant à ceux qui ne labourent pas,
qui ne produisent pas les matériaux nécessaires à la production, ils
demeurent assoupis dans une apathie criminelle, une sorte
d’engourdissement de la pensée. On dirait qu’ils attendent, dans une espèce
de léthargique sommeil, l’égorgement final de leur classe.
Pour la défendre, ils ne tentent même pas un effort. A les voir évoluer
dans la vie avec des allures nonchalantes, il semble qu’il assistent à un jeu
sur les résultats duquel ils n’ont pas engagé de pari!
Les individus de cette catégorie n’attendent rien évidemment. Leurs
yeux ne sont pas tournés comme ceux des Rois Mages vers l’étoile qui doit
se lever à l’Orient. Ils subissent les événements, ils n’y concourent pas. Or,
subir, c’est déjà un état inférieur.

*
**

L’attente féconde se manifeste extérieurement de deux façons: par le

silence gros de pensées qui équivaut à des forces infinies d’action; et par la
parole qui peut avoir sur les esprits et les cœurs une si puissante
répercussion. Voyons comment l’homme se comporte vis-à-vis du silence et
de la parole, comment il en use dans la vie publique et privée.

CHAPITRE III

LE SILENCE

Seul le silence est grand, tout le reste est faiblesse

(Alfred de Vigny.)

Le vers admirable d’Alfred de Vigny est la condamnation de

l’abondance inutile des mots. Il faut avoir une grande foi dans le silence,
non le silence qui naît d’un caractère morose, d’un orgueil démesuré, d’un
manque de sincérité, d’imagination, d’expansion, d’une sorte de pauvreté
d’esprit ou bien simplement d’une humeur sauvage, mais le silence intuitif
ou voulu de ceux qui voient, sentent et savent.
Cette force muette a toujours exercé un merveilleux pouvoir mais jamais
elle n’a été plus nécessaire que dans ce moment suprême de l’histoire du
monde, où l’on meurt de trop de paroles!
Avec notre organisation politique et sociale, qui admet la libre discussion
sur les points les plus graves et les plus délicats, il est difficile de mettre un
frein aux langues qui parlent. Aujourd’hui qu’aux voix masculines, les voix
féminines s’unissent, et que dans son for intérieur, chaque homme, même le
plus médiocre, se croit un stratège et un chef politique, le bruit est devenu
assourdissant, et le chaos croît chaque jour davantage.
Dans ce réseau serré de mensonges, d’intérêts inavoués, d’astuce et de
perfidie, il est naturel que l’esprit perde son équilibre, ne sache où se poser
et soit emporté par le flux et le reflux de la pensée en désarroi.
 *
**

La vérité qui devait, après la guerre, surgir victorieuse, tirée du sépulcre

où la fausseté et la veulerie des hommes l’avaient reléguée, dans quel puits
se cache-t-elle aujourd’hui? Nous la cherchons et ne la trouvons pas! Faut-il
l’inscrire, comme sur les champs de bataille, parmi les «disparus» puisqu’à
l’appel désespéré de ses fervents adorateurs, elle ne répond pas: «Présente!»
Pour ceux qui avaient confiance, pour les optimistes qui avaient espéré
sa résurrection prochaine, le désappointement est amer. Les autres, ceux
qui, à coup de grosse caisse, avaient inscrit son nom en vedette sur leurs
drapeaux, ne cachent plus aujourd’hui leur sourire dédaigneux pour les
ingénus qui avaient cru de bonne foi à la mensongère devise.
La Fontaine, dans une de ses Fables, nous montre le plus sincère et le
plus modeste des animaux de la création condamné à payer pour tous...
L’histoire, comme la Fable, se renouvelle continuellement.
Mais il est dangereux d’insister sur les points noirs des événements
contemporains: cela est contraire à cette vertu du silence que nous devons
apprendre à pratiquer. Il est évident que les paroles inutilement prononcées
pendant quatre années et demie de guerre et plus de trois ans de paix, ont
nui à la restauration de la vérité dans le monde.
Elle ressuscitera cependant. Plus on voudra l’étouffer, l’écraser, la railler,
plus puissante elle s’affirmera un jour; mais pour arriver à ce jour il faudra
souffrir encore. Essayons au moins d’en accélérer la venue et de ne pas
retarder, par d’imprudentes paroles pessimistes, son avènement dans le
monde. Évitons soigneusement ce qui est propre à semer la discorde, à
aigrir les cœurs, à décourager les bonnes volontés.

*
**

Entendons-nous! Limiter nos paroles, et réfléchir à leurs conséquences

ne signifie point s’isoler, cesser d’écouter, de veiller et d’être prêt à
intervenir pour protester utilement. «On devrait bâillonner la presse», dira-t-
on; mais la presse, qui ferait bien, certes, de se museler un peu elle-même, a
une autre tâche à remplir que les individus! Elle doit informer largement le
public des diverses tendances, des divers bruits, des diverses nouvelles qui
courent. Ce devoir d’informateur n’incombe pas au simple citoyen: il a
celui, au contraire, d’être prudent, vigilant, de ne pas exaspérer les âmes, de
ne pas donner un poids exagéré aux rancœurs, aux malentendus, aux
doutes...
Dans les moments angoissants que traversent certains pays, il faudrait, je
ne dis pas suspendre tout jugement, mais formuler ceux qu’on porte de
façon à faire comprendre leurs torts aux coupables sans les accabler de
reproches qui, par leur violence, ressemblent presque à des injures.
Il est opportun aussi de ne pas exciter les victimes, afin qu’elles ne
perdent pas leur sang-froid, cette suprême qualité des triomphateurs.
L’habileté vraie consiste à observer toujours, à tout écouter et à se recueillir
souvent. C’est là un programme auquel on peut joindre un conseil: «Élevez
dans vos cœurs un temple au silence!»

*
**

Ce n’est pas seulement dans les heures suprêmes de la vie publique, mais
encore dans toutes nos relations avec les faits et les individus, qu’il y a
avantage à user de peu de paroles. Dans la vie domestique et familiale, le
silence est certainement plus efficace que les reproches, il touche
davantage, émeut plus, il donne aux mots, quand finalement ils sont
prononcés, un prestige plus grand.
Les maîtresses de maison les mieux obéies, les mères de famille les plus
respectées, ont été presque toujours des silencieuses. En amour aussi, la
femme qui parle peu et semble se réfugier dans sa vie intérieure, est celle
qui sait retenir l’amour le plus longtemps. Il y a en elle une saveur de
mystère qui fascine les âmes. A l’armée, à l’école, le prestige exercé sur les
soldats et les enfants est, en général, réservé aux laconiques, des lèvres
desquels ne sortent que des ordres précis, des enseignements nets et clairs.

*
**

Que de fois également, dans des circonstances délicates, une situation a

été sauvée uniquement par le silence! Une seule parole aurait tout gâté et
tout perdu. Le silence, semblable à un baume merveilleux, a cicatrisé la
plaie et a empêché la tragédie d’éclater. Tous les êtres humains ne peuvent
pas être des silencieux efficaces; il faut pour cela du tact, de l’intelligence,
de la finesse! Ces privilégiés sont rares; mais tous peuvent mettre un frein à
leur langue pour qu’elle ne devienne pas une source d’antagonismes et
d’amers mécontentements. Cela n’est pas toujours facile, quand le cœur bat
d’une indignation justifiée, mais c’est pourtant obligatoire.
Nous ne devons pas oublier que toute parole acerbe est une joie pour
l’ennemi qui, secrètement et incessamment, essaye de semer la haine dans
les lignes des vainqueurs.

*
**

Comme le poète d’Eloa, rendons un culte au silence, mais n’oublions pas

cependant qu’il en peut être une mauvaise espèce: celui-là est le fruit de
l’orgueil et de l’obstination; il ferme ses oreilles à la vérité, s’entête dans les
fausses appréciations, refuse d’écouter les conseils de l’expérience. Dans la
politique, comme dans la vie familiale, ce mutisme est souvent cause de
malheurs infinis et de périlleuses rancœurs.
Nul homme, quelle que soit sa valeur intellectuelle, n’est autorisé à
mépriser complètement l’échange des idées avec ses semblables.
Il faut seulement être perspicace, savoir discerner les valeurs et ne pas
donner sa confiance aux médiocres qui ne la méritent pas.

*
**

Si la parole trop prolixe présente des inconvénients, l’échange des mots

est cependant nécessaire au bon mécanisme de la vie. Il n’y a rien de plus
triste qu’une famille de silencieux moroses. Le mari, le fils rentrent au
foyer, mais pas une phrase ne sort de leur bouche, ils ne racontent rien de ce
qu’ils savent, de ce qu’ils ont vu!... Si on leur pose une question ils en
semblent exaspérés et y répondent à peine. Combien de familles souffrent
de ce système d’inique silence.
Que demandent au fond ces mères, ces épouses, ces filles? Elles
n’exigent pas de longs discours, mais seulement un sourire, un mot qui les
mette un peu au courant des choses; un simple regard affectueux suffit
même souvent à les satisfaire, à dissiper l’oppression de ce mutisme
offensant, à compenser la rareté des mots prononcés.

*
**

La cause de ce mal est unique: c’est l’égoïsme orgueilleux, joint à

l’habitude de ne jamais réfléchir suffisamment aux conséquences des
attitudes que l’on prend ou à la signification que les autres leur attribuent.
L’heure est si grave aujourd’hui qu’une sévère discipline est devenue
indispensable à tous; nous devons apprendre à contrôler notre langue, et
ceux auxquels leur conscience impose un mea culpa doivent être les
premiers à réparer les ennuis, et parfois les malheurs que leur trop grande
impulsivité a pu causer.
Élevons donc un hymne à la noblesse du silence conscient, qui signifie
sagesse, philosophie, tact, dignité, altruisme, et dénonçons le silence de
l’orgueil, de l’égoïsme, de l’obstination, et ce désintéressement complet de
la pensée d’autrui qui, non seulement pèse sur la vie familiale, mais peut
aussi devenir dangereux dans la vie politique des peuples.

CHAPITRE IV

L’INSTRUMENT MAGIQUE

Et que tes lèvres gardent la connaissance.

(Prov. V-2.)

Après avoir affirmé la beauté, le prestige, la dignité du silence, il faut

parler un instant de l’instrument magique dont l’homme dispose et qui
s’appelle la parole!
Trois syllabes! Et dans ces trois syllabes, toutes les manifestations de
l’âme universelle peuvent se condenser. Ces trois syllabes dispensent la
guerre et la paix, la fortune la plus éclatante et la plus épouvantable misère,
la félicité la plus complète et la plus atroce douleur.
Elles édifient et détruisent, consolent et désespèrent, allument les
incendies, propagent les haines, exaltent l’orgueil de l’homme et le
réduisent en poussière; elles pénètrent son âme d’une infinie douceur et la
déchirent d’angoisse. Elles séparent les amants les plus tendres, arment l’un
contre l’autre les amis les plus sûrs, éloignent les fils des mères, et si,
parfois, elles rapprochent l’homme de Dieu, souvent elles le poussent dans
les bras toujours ouverts de Lucifer qui étend inlassablement sur le monde
son ombre gigantesque.
Et cet instrument magique et merveilleux, le plus extraordinaire des dons
qui ont été faits à l’homme, celui-ci est maître de s’en servir au gré de sa
fantaisie. On l’a laissé, au fond, très ignorant des forces terrifiantes qu’il
pouvait mettre en jeu par le seul mouvement de ses lèvres. Comment serait-
il conscient de ses responsabilités, puisqu’on les lui a à peine indiquées, et
que ni les religions ni les philosophies n’en ont fait, comme elles l’auraient
dû, l’objet d’un enseignement spécial et de capitale importance.
Elles se sont bornées à des conseils d’ordre général. Quelques proverbes,
appartenant pour la plupart à la littérature orientale, mettent bien l’homme
en garde contre le danger des paroles surabondantes et irréfléchies, mais
c’est comme en passant, sans y attacher d’importance, sans insister sur les
terribles responsabilités qu’il peut encourir de ce chef.

*
**

Apprendre à l’homme, dès sa première enfance, à se méfier des mots

devrait être, au contraire, le principal objet de toute intelligente préparation
à la vie. Il faudrait enseigner à l’enfant que la parole doit être maniée avec
mesure et prudence, comme s’il s’agissait d’une arme de précision. Elle tue,
en effet, mieux que le browning le plus perfectionné.
Il est vraiment inconcevable que les pédagogues, les philosophes, les
grands prêtres de toutes les religions et les arbitres de la destinée humaine
n’aient pas mieux compris l’incalculable portée de la parole, et tenté de la
maîtriser pour la faire servir aux fins qu’ils poursuivaient. Or, cela n’a
jamais été fait! Au XXᵉ siècle, la parole a pris des allures désordonnées
contre lesquelles aucune sanction ne s’exerce plus. Auparavant, les citoyens
des différentes nations ne pouvaient toucher à certains sujets politiques ou
religieux sans encourir de graves remontrances, et même des pénalités.
Mais il ne s’agissait que de quelques terrains prohibés, car, dans le domaine
privé, l’homme a toujours été libre de déshonorer son prochain et de le tuer
moralement autant de fois qu’il le pouvait dans une journée! Qui a jamais
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