From the Guidelines
The workup for multinodular goiter should begin with a thorough history and physical examination, followed by thyroid function tests (TSH, free T4, and free T3) and ultrasound of the thyroid to characterize the nodules and assess their size, composition, and features that might suggest malignancy. According to the most recent evidence 1, the initial evaluation should focus on determining the presence of thyrotoxicosis and characterizing the nodules using ultrasound. The ultrasound features associated with malignancy, such as hypoechogenicity, microcalcifications, and irregular borders, should be assessed 1. For nodules larger than 1 cm or those with suspicious ultrasound features, fine-needle aspiration biopsy (FNAB) should be performed to rule out malignancy. Additional tests, such as thyroid antibodies (anti-TPO, anti-thyroglobulin) and calcitonin levels, may be necessary in certain cases 1. A thyroid scan using radioactive iodine or technetium may also be helpful in determining if nodules are functioning (hot) or non-functioning (cold) 1. Ultimately, the goal of the workup is to determine the underlying cause of the multinodular goiter, assess the risk of malignancy, and guide treatment decisions. Key considerations in the workup include:
- Thyroid function tests (TSH, free T4, and free T3) to determine if the goiter is causing hyperthyroidism, hypothyroidism, or if the patient is euthyroid
- Ultrasound of the thyroid to characterize the nodules and assess their size, composition, and features that might suggest malignancy
- Fine-needle aspiration biopsy (FNAB) for nodules larger than 1 cm or those with suspicious ultrasound features
- Additional tests, such as thyroid antibodies (anti-TPO, anti-thyroglobulin) and calcitonin levels, as necessary
- Thyroid scan using radioactive iodine or technetium to determine if nodules are functioning (hot) or non-functioning (cold) 1.
From the Research
Initial Evaluation
- The initial evaluation of a multinodular goiter should include ultrasonography of the thyroid and fine-needle aspiration biopsy (FNAB) of dominant nodules or suspicious nodules 2, 3.
- Serum TSH measurement is also recommended to assess thyroid function 3, 4.
- Thyroid radionuclide scans are less frequently used in the initial evaluation of a nodular goiter, but may be used to evaluate autonomous function of nodules 3.
Diagnostic Evaluation
- Diagnostic evaluation of patients with nodular goiters consists of clinical evaluation, biochemical testing, FNA, and imaging studies 4.
- FNA results are pivotal to assess cancer risk in patient management for prominent palpable and suspicious nodules 4.
- Chest radiography, high-resolution ultrasonography, and computed tomography help to delineate the size and extent of a goiter in evaluating compression symptoms 4.
Treatment Options
- Surgery is the primary therapy for patients with nodular thyroid disease, including multinodular goiter 2, 4.
- Radioiodine is also an effective therapy for many patients with toxic multinodular goiter 4, 5.
- Levothyroxine suppression therapy may be used in some cases, but its use is controversial and should be avoided in patients with suppressed serum TSH levels 4, 6.
- Periodic follow-up with neck palpation and US exam is recommended for all patients 3.
Indications for Treatment
- Indications for treatment in patients with multinodular goiter include hyperthyroidism, local compression symptoms, cosmesis, and concern about malignancy based on FNA results 4, 6.
- Patients with large, nontoxic multinodular goiters and local compression symptoms may require surgery 4, 6.
- Patients with toxic multinodular goiter may be treated with surgery or radioiodine 4, 5.