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multinodular goiter

Etiology: - nearly all long-standing simple goiters become transformed into multinodular goiters Epidemiology: - common in the elderly, especially women Pathology: 1) heterogeneous 2) nodularity created by islands of colloid-filled or hyperplastic follicles 3) random irregular scarring 4) focal hemorrhages & hemosiderin deposition 5) focal calcifications in areas of scarring 6) microcyst formation Genetics: - associated with defects in DICER1 (type 1) - with or without Sertoli-Leydig cell tumors, usually of the ovary Clinical manifestations: - multinodular goiters produce the most extreme thyroid enlargements - compression on adjacent structures may occur - dyspnea, stridor, cough, dysphagia, hoarseness Laboratory: - serum TSH, serum T4, free T4 - hyperthyroidism may occur if one of the nodules becomes autonomous or hyperfunctioning Special laboratory: - spirometry with flow volume loops to assess mass effect [3] - laryngoscopy for direct vocal cord visualization to assess mass effect [3] - indications for fine needle aspiration of each nodule as described for solitary thyroid nodule Radiology: 1) CT or MRI to assess mass effect [3] 2) radioactive iodine uptake (RAIU) test to rule out adenomatous 'cold' nodules 3) ultrasound of cold nodules 4) barium swallow to assess mass effect [3] Complications: 1) compression of the trachea -> dyspnea 2) compression of the esophagus -> dysphagia 3) superior vena cava syndrome a) neck vein distension b) distension of veins of upper extremities c) edema of eyelids & conjunctiva d) syncope on coughing 4) thyrotoxicosis after exposure of hyperfunctioning nodule to iodide, i.e. contrast agents used during angiography [5] 5) risk of malignancy is the same as that for a solitary pulmomary nodule Differential diagnosis: - subacute thyroiditis - not associated with thyrotoxicosis after exposure iodide-containing contrast agents used during angiography [5] Management: 1) differentiation from tumor is often difficult 2) most patients are asymptomatic & require no therapy 3) no evidence that thyroxine shrinks size of thyroid 4) subtotal thyroidectomy a) compression on adjacent structures b) cosmetic in the absence of symptoms c) malignancy suspected [3] 5) radioactive I-131 ablation has been used for hyperthyroidism due to autonomous or hyperfunctioning nodule [3] - effect on goiter size is unpredictable [3]

Related

thyroid nodule

Specific

toxic multinodular goiter (Plummer's disease)

General

goiter

Database Correlations

OMIM 138800

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 473
  2. Cotran et al Robbins Pathologic Basis of Disease, 5th ed. W.B. Saunders Co, Philadelphia, PA 1994 pg 1132
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17. American College of Physicians, Philadelphia 1998, 2012, 2015. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Bahn RS, Castro MR. Approach to the patient with nontoxic multinodular goiter. J Clin Endocrinol Metab. 2011 May;96(5):1202-12. PMID: 21543434
  5. NEJM Knowledge+ Endocrinology