Nodules, Positive Antibodies, and Treatment?


Question

34 yr old female with multinodular goiter. She displays no symptoms and labs are

TSH 2.02 ìIU/ml

FT3 2.5 pg/ml

FT4 1.01 ng/ml

anti TPO 12.45 IU/ml

anti TG 17.49 IU/ml

TBG 194 ng/ml

Ultrasound: 3.2 x 2.1 cm nodule L, 2.1 cm nodule R as well as a 7mm nodule R

Thyroid scan w/ 274 uCi I-123 : displayed neither hot nor cold nodules. Thyroid uptake was within normal range

This patient was followed sonographically one year ago displaying a 2.8 cm nodule L and a 2.0 cm nodule R and a TSH of 1.61 IU/ml

She has been receiving levothyroxine 0.1mg for 2 weeks and her endocrinologist suggested thyroidectomy due to the nodule size. Another endocrinologist suggested FNA of both large nodules, continuation of meds and if biopsy is negative and TBG falls within normal range in three months to continue meds and ultrasound follow-up to ensure that nodule is not growing. If not thyroidectomy.

This patient also has a history of cheloid formation.

I would appreciate your opinion on the most appropriate therapeutic strategy for this atient.Thank you for your time and effort.With Regards Emily Katakis,MD,Chania General Hospital,Mournies,Chania, Crete, Greece

First Response

Dear Dr Atakis,If I may summarize this patient, then she has a multinodular goiter, is euthyroid and no cold nodules. No growth of 2 out of 3 nodules have been documented over the last year and follow up size of the smallest nodule lacks or this nodule was not seen at the second ultra sound. I assume that no suspect lymph nodes have been detected. There are no mechanical complaints.

If my summary is OK then there is no doubt in my mind that only follow up of this patient is the maximum that should be considered. If there is a family history of multinodular goiter one could be even more sure about the absence of malignancy in this goiter, but even without this suspicion for cancer is really low. I am not in favour of treatment with thyroid hormone,that caries more risks than benefits as growth is rarely reversed or inhibited but that thyrotixosis may ensue because of autonomous function of parts of the gland. Neither is there any indication for FNA or operation because suspicion for malignancy is low to absent.

If any treatment should be considered then this should be administration of radio-active iodine, but only then in the case that the thyroid becomes subclinically- (suppressed TSH but normal T4 and T3 paparameters) or full blown hyperthyroid or that serious trachea stenosis develops. In the case of tracheal deviation but no or only mild stenosis, RAI treatment is optional but not necessary. I do not understand the reasoning about TBG. I understand that this value is elevated? So what? This has nothing to do with thyroid function and FT3 and FT4 are corrected for this and I assume normal. Maybe this patient is using oestrogens or TBG maybe congenitally elevated?Georg Hennemann, MD, PhD, FRCP, FRCP

Second Response

The patient must have Hashimoto’s thyroiditis in view of the antibodies and the scan without nodules. Pseudo-nodules are common on US of Hashimoto’s glands, but usually are not distinct. Thus she may well have two thyroid diseases. In the USA, where multinodular goiter is less common (how about Crete?), I believe that in this young woman the usual approach would be to biopsy both nodules under US guidance. If benign on FNA, and they remain static and asymptomatic, and whether the final Dx is Hashimoto’s or MNG, no treatment is clearly required. However some of us still prescribe replacement ( not suppressive) doses of T4 in patients with benign nodules and MNG. The goals, especially at age 34, would be the occasional (25% of cases) reduction in size, possible help preventing further growth in lesions that are in part TSH dependent, and certain help in keeping in touch with the patient. Leslie J De Groot,MD