From the Research
The next step in managing a patient with multinodular goiter, low TSH, and normal free T4 levels without suspicious ultrasound features is to initiate monitoring with repeat thyroid function tests in 2-3 months. No immediate medication is typically required for mild subclinical hyperthyroidism. The patient should be evaluated for symptoms of hyperthyroidism such as palpitations, heat intolerance, weight loss, or anxiety. If the patient is elderly or has cardiac risk factors, a lower threshold for treatment may be appropriate. In cases where treatment becomes necessary, options include methimazole (starting at 5-10 mg daily) or propylthiouracil (50-100 mg twice daily) 1. Beta-blockers like propranolol (10-40 mg three times daily) or atenolol (25-50 mg daily) can be used for symptom control if the patient develops palpitations or tremor. This monitoring approach is appropriate because many patients with multinodular goiter and subclinical hyperthyroidism remain stable without progression to overt hyperthyroidism, and the risks of treatment may outweigh benefits in asymptomatic individuals, as suggested by a study on the diagnosis and management of thyroid nodules 1. Additionally, a study on the ultrasound of benign thyroid nodules found that most benign nodules exhibit no significant size increase during 5 years of follow-up, supporting a conservative approach 2. The underlying pathophysiology involves autonomous functioning of multiple thyroid nodules producing excess thyroid hormone, sufficient to suppress TSH but not enough to elevate free T4 levels. Some key points to consider in the management of this patient include:
- The patient's thyroid nodules are benign and not suspicious for malignancy, as indicated by the ACR-TI-RADS score of 2 1.
- The patient's low TSH and normal free T4 levels suggest subclinical hyperthyroidism, which may not require immediate treatment 1.
- The patient should be monitored for symptoms of hyperthyroidism and treated if necessary, with options including methimazole, propylthiouracil, or beta-blockers 1.
- The use of ultrasound and fine-needle aspiration biopsy can help diagnose and manage thyroid nodules, but may not be necessary in this case given the benign appearance of the nodules 3, 4.
- The diagnostic accuracy of ultrasonographic features for subcentimeter thyroid nodules can be improved by excluding increased vascularity and adding solid composition to the suspicious ultrasonographic features, as suggested by a study on the diagnostic accuracy of the ultrasonographic features for subcentimeter thyroid nodules 5.