Approach to the Patient with Nontoxic Multinodular Goiter

Abstract

Thyroid nodules are very common, and although the majority are benign, approximately 5% may harbor malignancy. The evaluation of the patient with solitary thyroid nodule is generally straightforward and will typically include measurement of serum TSH to assess thyroid function and fine-needle aspiration biopsy of the nodule, with or without ultrasound (US) guidance. The approach to the patient with nontoxic multinodular goiter represents a more difficult problem for the clinician. All patients should have serum TSH measured to assess functional thyroid status and US examination to evaluate the number, size, and sonographic features of the nodules and assist in the selection of nodules that may need fine-needle aspiration biopsy. Patients with nodules yielding malignant cytology should be referred for surgery. Given the lack of reliable markers to predict biological behavior of nodules with suspicious (indeterminate) cytology, patients with such nodules are generally advised to have surgery, unless autonomous function of these nodules can be confirmed by scintigraphy. Most of these patients, however, will ultimately prove to have benign follicular tumors. Many patients with benign but large goiters may experience clinical symptoms of pressure, such as dysphagia, choking sensation, or airway obstruction. Such patients will often require surgery for alleviation of symptoms. In the absence of malignancy, asymptomatic patients may be observed. Radioactive iodine, commonly used in many parts of Europe, is safe and effective and may be a reasonable option for many patients. Periodic follow-up with neck palpation and US exam is recommended for all patients.

Single, very low dose (0.03 mg) of recombinant human thyrotropin (rhTSH) effectively increases radioiodine uptake in the I-131 treatment of large nontoxic multinodular goiter

“…Despite the fact that RIT has been used in the treatment of thyroid diseases for over 70 years, some authors still consider it to be an unreliable method producing no satisfying results in the case of non-toxic nodular goiter [5,6,19,20]. First reports on Original non-invasive attempts at reducing goiter volume with I-131 were published at the beginning of the 1990s [21,22].…”

“…The degree of reduction in the volume of the goiter varies from 30% to 60% in different centers and depends on the characteristics of the study group, particularly on the size of the goiter. The smaller the goiter, the easier it is to achieve a larger Original reduction in its volume even at low doses of I-131 [5,19,22,23]. This results in considerably better effectiveness of the therapy as compared with conservative treatment with LT4 (and a lower risk of adverse effects as compared with conservative treatment).…”

“…the circulatory and respiratory systems, in whom surgical treatment of non-toxic goiter is not performed, is constantly growing. Nevertheless, the occurrence of local symptoms caused by an enlarged thyroid requires the treatment, not just conducting observations [5]. The use of LT4 is impossible due to comorbidities and the administration of I-131 becomes a method of choice.…”

“…Since I-131 was first used in order to reduce thyroid volume approx. 20 years ago, RIT has been growing in popularity and becoming an attractive alternative to surgical treatment [1,[5][6][7][8]. Advanced age and concomitant diseases, such as arrhythmia or circulatory failure, may hinder general anesthesia or constitute a contraindication for thyroidectomy.…”

“…In such cases, the duration of RIT is extended and the dose of radiation absorbed by the body increases [5,9,11,12].…”