What is the management approach for a patient with nodular nontoxic goiter?

Management of Nodular Nontoxic Goiter

For nodular nontoxic goiter, begin with TSH measurement and thyroid ultrasound as first-line evaluation, perform fine-needle aspiration on nodules >1 cm with suspicious features to exclude malignancy, and reserve surgery for patients with compressive symptoms, substernal extension, malignant/suspicious cytology, or significant cosmetic concerns. 1, 2, 3

Initial Diagnostic Workup

Measure serum TSH first to confirm euthyroid status before proceeding with imaging, as this determines the entire diagnostic pathway. 2, 4

• Perform thyroid ultrasound as the mandatory first-line imaging modality to characterize nodule morphology, document goiter size and extent, and identify which nodules require biopsy. 1, 2, 3
• Ultrasound confirms the neck mass arises from thyroid tissue and evaluates for suspicious features in nodules including hypoechogenicity, microcalcifications, absence of peripheral halo, irregular borders, solid aspect, intranodular blood flow, and taller-than-wide shape. 1

Avoid radionuclide scanning in euthyroid patients with nodular goiter, as most nodules are "cold" and most cold nodules are benign, resulting in low positive predictive value for malignancy and no help in determining which nodules to biopsy. 1, 2, 3

Fine-Needle Aspiration Strategy

Perform FNA on any nodule >1 cm and on nodules <1 cm if there is clinical suspicion (history of head/neck irradiation, family history of thyroid cancer, suspicious palpation features, cervical adenopathy) or suspicious ultrasonographic features. 1, 3

• In multinodular goiter, target nodules with suspicious ultrasound features for FNA rather than attempting to biopsy all nodules. 1
• Do not skip FNA on suspicious nodules based solely on the multinodular nature of the goiter, as malignancy risk persists at 5-7% even in multinodular goiters. 1, 3
• If FNA yields inadequate samples, repeat the procedure; if results show follicular neoplasia with normal TSH and "cold" appearance on scan, consider surgery. 1

Indications for Surgical Treatment

Surgery is indicated for:

• Compressive symptoms including dyspnea, orthopnea, obstructive sleep apnea, dysphagia, dysphonia, or stridor that indicate significant tracheal or esophageal compression. 1, 3, 5
• Malignant or suspicious cytology on FNA, as surgery is the only way to definitively exclude cancer and provide appropriate staging. 1, 3, 4
• Substernal extension requiring evaluation of deep extension and degree of tracheal compression. 1, 3
• Significant cosmetic concerns that impact quality of life. 3, 5

Obtain CT neck without contrast when obstructive symptoms are present to quantify tracheal compression and evaluate substernal extension, as CT is superior to ultrasound for surgical planning. 1, 3

Non-Surgical Management Options

For asymptomatic patients with benign cytology:

• Observation with yearly follow-up including TSH measurement and thyroid palpation is appropriate for small, stable goiters with benign FNA results. 5, 4
• Levothyroxine suppression therapy is controversial and often unsuccessful for multinodular goiter, with potential for adverse effects from exogenous hyperthyroidism; avoid in patients with suppressed TSH. 5, 6

Radioiodine therapy may be considered for elderly patients or those with significant surgical contraindications (cardiopulmonary disease), achieving mean thyroid volume reduction of 40% at 1 year and 50-60% at 3-5 years, though it carries 5% risk of autoimmune hyperthyroidism and 20-30% risk of hypothyroidism at 5 years. 7, 4

Critical Pitfalls to Avoid

• Never proceed directly to radionuclide uptake scan in euthyroid patients, as this wastes resources and provides no useful information about malignancy risk. 1, 2
• Do not use CT or MRI as initial imaging unless there is concern for substernal extension with compressive symptoms or suspicion of invasive thyroid cancer. 1
• Avoid skipping ultrasound before proceeding to other imaging, as this can miss coexisting nodules requiring biopsy for malignancy evaluation. 2
• Do not assume all nodules in multinodular goiter are benign without proper FNA evaluation of suspicious nodules, as approximately 5-7% harbor malignancy. 1, 3, 4