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I would appreciate your or your panel of expert' s assistance with a patient. Patient is a 46 yo male with a multinodular goiter. He has no compressive symptoms and no symptoms of hyperthyroidism. At his lastvisit his pulse was 60. His TSH 0.09, FT4: 1.15, T3:120 T3RU: 33%. Recentultrasound multiple bilat nodules largest rt 2.8, left: 2.6, isthmus 3.9 cm. Extension below the suprasternal notch(new), nodules not sharply defined.A year ago he had a scan and RAIU: 6 hr 12%, 24 hr 21% . Scan inhomogeneity , cold area on left corresponding to 2.7 cmcyst on u/s, and cold area in isthmus 3.9 cm solid area , cold area on rt (1.5 cm cyst). Radiology suggested a biopsy of rt and isthmus nodules. Path: isthmus follicular lesion, favor hyperplastic nodule within nodular goiter, right nodular goiter. I am planning to recommend surgery based on substernal extension ( do you agree?) and was wondering whether you would recommend any treatment pre-op. (i.e.:antithyroid drugs until TSH normal, or beta- blocker.) Howeverhis pulse rate is low at 60.
Thank you very much,
Lisa Wisniewski, MD
Response
Firstly, I would get a CAT of the chest if I was considering resection for his MNG, to be sure we know what the anatomy really is. I assume the TSH has been checked more than once, and that there has not been any recent exposure to iodine that might cause a transient episode of hyperthyroidism. So his problem is a (possibly significant) substernal extension, an FNA report that is meant to be disquieting to you although it probably is a benign lesion, and very mild hyperthyroidism which may be due to his nodules. With all of that, in a 46 year old man in presumed good health, my approach would be to recommend resection by a skilled surgeon, expecting a very easy and safe course. Probably he could be operated with a short preparation under methimazole and later added KI for a week, since the degree of hyperthyroidism is clearly minimal. If it was not for the FNA result, one could treat with RAI, and RAI is used to shrink sub-sternal goiters, a point that Dr Hennemann may comment on.
Leslie J De Groot,MD
Response 2
Thanks for the opportunity to comment as well. The probability that a multinodular goiter (mng) is at an increased risk for carcinoma is controversial. My personal opinion and that of many Europeans, who have a lot of experience with this entity since it occurs frequently in Europe, is that this is most probably not the case. On the basis of this notion it is “dangerous” to do FNA for every cold nodule in such a goiter as many of these presumed benign nodules have a follicular structure. The first treatment choice in mng in Europe is administration of RAI. It is of no influence if these goiters are partially or even completely intrathoracically located. Even goiters of more than one kilogram are easily (really!) treated with RAJ. I have not treated any mng anymore with surgery since the last 20 years. My definition of a mng is that it should be longstanding, the thyroid is mostly asymmetrical, no X irradiation to the neck in the past, no hoarse voice, no rapid growth, no suspect lymph nodes in the neck and preferably a familiar tendency for mng. Some also include the presence of a “prominent” nodule what ever that may be. If most of these points are met, I do not perform a scan neither a FNA. The treatment of choice is then RAJ.In this particular patient there are 2 aspects that deserve further consideration
- The patient is a male and mng is more frequently occurring in females. This point argues only weakly against the goiter being benign.
- The fact that a FNA has been done that shows some follicular structures, carries the consequence of surgery. The possibility however is great that there is no malignancy at all.
SUMMARIZING: Considering the approach that has been adopted in this patient and the results as a consequence of this approach, I see no other way then to operate. The reason that we in Europe are so reluctant to have mng operated is that even in experienced hands, the risk for permanent hypoparathyroidism and vocal cord paralysis is about a few percent in this continent, but may be lower in the US.
Georg Hennemann, MD, PhD, FRCP, FRCP(E)