What is the management for multinodular non-toxic goiter?

Management of Multinodular Non-Toxic Goiter

For asymptomatic multinodular non-toxic goiter with benign cytology, observation with annual clinical monitoring and TSH measurement is the recommended approach, while surgery is indicated for compressive symptoms, cosmetic concerns, or malignancy risk. 1, 2, 3

Initial Diagnostic Workup

The diagnostic evaluation must establish both the benign nature and functional status of the goiter:

• Measure serum TSH first to confirm euthyroid status and ensure the goiter is truly non-toxic, as suppressed TSH indicates thyrotoxicosis requiring different management 1, 2
• Perform thyroid ultrasound as the preferred first-line imaging to confirm thyroid origin, characterize goiter size and morphology, and evaluate nodule features 1, 3
• Obtain fine-needle aspiration biopsy on nodules >1 cm with suspicious ultrasound features (hypoechogenicity, microcalcifications, irregular borders, taller-than-wide shape, intranodular blood flow) to exclude the approximately 5% malignancy risk 1, 3
• Consider CT neck without contrast when obstructive symptoms are present to evaluate substernal extension and degree of tracheal compression, as it is superior to ultrasound for these purposes 1, 4

Common Diagnostic Pitfalls to Avoid

• Do not use radionuclide scanning in euthyroid patients to determine malignancy risk, as most nodules are "cold" and most cold nodules are benign with low positive predictive value 1
• Do not skip ultrasound evaluation, as it is essential for identifying which specific nodules require FNA in a multinodular goiter 1

Management Algorithm Based on Clinical Presentation

For Small, Asymptomatic Goiters with Benign Cytology

Observation is the preferred strategy:

• Annual monitoring with serum TSH measurement and thyroid palpation is sufficient for patients with small, clinically asymptomatic goiters who are biochemically euthyroid with benign FNA results 2, 3
• Levothyroxine suppression therapy is controversial and generally not recommended, as it is often unsuccessful in reducing multinodular goiter size and carries risk of iatrogenic hyperthyroidism 2, 5
• Levothyroxine should absolutely not be used in patients with suppressed TSH levels to avoid toxic symptoms 2
• Periodic follow-up with neck palpation and ultrasound examination is recommended for all observed patients 3

For Large Goiters with Compressive Symptoms

Surgery is the preferred treatment:

• Surgical excision is indicated for patients with dysphagia, choking sensation, respiratory obstruction, dyspnea (especially when supine), or obstructive sleep apnea due to tracheal compression 4, 2, 5, 3
• Surgery provides rapid symptom relief and is the standard therapy, particularly for younger patients 2, 6
• Patients with large goiters become euthyroid more quickly following surgery compared to other modalities 2

For Patients with Surgical Contraindications

Radioactive iodine (¹³¹I) is an effective alternative:

• RAI therapy (20-100 mCi) is particularly appropriate for elderly patients, those with cardiopulmonary disease, recurrent goiter after surgery, or surgical contraindications 7, 6, 3
• RAI achieves mean thyroid volume reduction of 40% at 1 year and 50-60% at 3-5 years, with improvement in compressive symptoms and tracheal compression 6
• Important complications to counsel patients about: autoimmune hyperthyroidism develops in approximately 5% of patients several months post-treatment, and hypothyroidism occurs in 20-30% at 5 years 6
• The estimated lifetime risk of fatal and nonfatal cancer from RAI therapy is approximately 0.5% in elderly patients, making the benefits outweigh risks in this population 6
• For younger patients, surgery remains preferred, especially when high RAI doses would be required 6

For Malignant or Suspicious Cytology

Surgical referral is mandatory:

• Patients with malignant cytology on FNA should be referred for surgery 3
• Patients with suspicious (indeterminate) cytology are generally advised to have surgery, unless autonomous function can be confirmed by scintigraphy, though most will ultimately prove to have benign follicular tumors 3

Key Clinical Considerations

Weighing treatment risks: In all patients, carefully weigh the estimated risks of both surgery and radioiodine therapy based on age, comorbidities, and goiter characteristics 6. Surgery carries operative risks particularly in elderly patients with cardiopulmonary disease, while RAI has delayed complications and small cancer risk 7, 6.

Cosmetic indications: Surgery may be indicated when cosmetic deformity causes significant patient distress, even in the absence of compressive symptoms or malignancy 2, 5.