Management of the Nontoxic Multinodular Goiter: A North American Survey
Steen J. Bonnema,
Finn N. Bennedbæk,
Paul W. Ladenson and
Laszlo Hegedüs
Department of Endocrinology, Odense University Hospital (S.J.B., F.N.B., L.H.), DK-5000 Odense C, Denmark; and Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine (P.W.L.), Baltimore, Maryland 21287-4904
Address all correspondence and requests for reprints to: Steen J. Bonnema, M.D., Department of Endocrinology M, Odense University Hospital, DK-5000 Odense C, Denmark. E-mail: steen.bonnema{at}dadlnet.dk
To assess approaches to the diagnosis and therapy of patientswith nontoxic multinodular goiter, a questionnaire was circulatedto all members of the American Thyroid Association (ATA). Anindex case report was presented (42-yr-old woman with an irregular,nontender, bilaterally enlarged thyroid of 50–80 g andno clinical suspicion of malignancy or thyroid dysfunction),and 11 variations were proposed to evaluate how each alterationwould affect management. One hundred and forty responses wereretained (50% of clinically active ATA members). For the indexcase, a TSH determination was the routine choice of 100%, andserum thyroid autoantibodies were measured by 74%. Simultaneoususe of serum TSH, a thyroid hormone assay, and antithyroid peroxidasewas employed by 49%. Only 4% included a calcitonin assay. Themedian number of blood tests ordered was 3 (range, 1–7).Ultrasound was used by 59%, thyroid scintigraphy by 24%, andboth imaging modalities by 11%. Fine needle aspiration biopsy(FNAB) was performed by 74%. If scintigraphy showed inhomogeneoustracer distribution or a dominant hypofunctioning region, FNABwas performed by 15% and 97%, respectively. L-T4 treatment waspreferred by 56%, radioiodine by 1%, surgery by 6%, and 36%would recommend no treatment. A large goiter, a history of externalradiation, or rapid growth increased the preference for surgery.In case of a suppressed serum TSH level, radioiodine was usedby 56%. In conclusion, in the work-up of patients with nontoxicmultinodular goiter, ATA clinicians employ determinations ofTSH often combined with a T4 and/or T3 assay and antithyroidperoxidase antibodies. Thyroid imaging, primarily ultrasound,is performed by more than two thirds, and FNAB by three fourths.This diagnostic evaluation is significantly less extensive thanthat of the European Thyroid Association members, but the distributionof treatment choices is quite similar. In accordance with theirEuropean colleagues, the majority of ATA members prefer theuse of L-T4 therapy. There is, however, still a wide variationin the perceived optimal management of this condition amongmembers of both organizations.
This work was supported by grants from the Agnes and Knut MørkFoundation. The results were presented in part at the 73rd AnnualMeeting of the ATA, Washington, D.C., November 7–10, 2001.
Abbreviations: ATA, American Thyroid Association; ETA, EuropeanThyroid Association; FNAB, fine needle aspiration biopsy; US,ultrasound.
This article has been cited by other articles:
S. Fast, V. E. Nielsen, P. Grupe, S. J. Bonnema, and L. Hegedus Optimizing 131I Uptake After rhTSH Stimulation in Patients with Nontoxic Multinodular Goiter: Evidence from a Prospective, Randomized, Double-Blind Study
J. Nucl. Med.,
May 1, 2009;
50(5):
732 - 737.
[Abstract][Full Text][PDF]
S. Fast, V. E. Nielsen, S. J. Bonnema, and L. Hegedus Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy
Eur. J. Endocrinol.,
April 1, 2009;
160(4):
517 - 528.
[Abstract][Full Text][PDF]
Y. Erbil, U. Barbaros, A. Salmaslioglu, O. Mete, H. Issever, S. Ozarmagan, D. Yilmazbayhan, and S. Tezelman Effect of Thyroid Gland Volume in Preoperative Detection of Suspected Malignant Thyroid Nodules in a Multinodular Goiter
Arch Surg,
June 1, 2008;
143(6):
558 - 563.
[Abstract][Full Text][PDF]
B. Biondi and D. S. Cooper The Clinical Significance of Subclinical Thyroid Dysfunction
Endocr. Rev.,
February 1, 2008;
29(1):
76 - 131.
[Abstract][Full Text][PDF]
Y. Erbil, A. Bozbora, N. Ozbey, H. Issever, F. Aral, S. Ozarmagan, and S. Tezelman Predictive Value of Age and Serum Parathormone and Vitamin D3 Levels for Postoperative Hypocalcemia After Total Thyroidectomy for Nontoxic Multinodular Goiter
Arch Surg,
December 1, 2007;
142(12):
1182 - 1187.
[Abstract][Full Text][PDF]
S. J. Bonnema, V. E. Nielsen, H. Boel-Jorgensen, P. Grupe, P. B. Andersen, L. Bastholt, and L. Hegedus Improvement of Goiter Volume Reduction after 0.3 mg Recombinant Human Thyrotropin-Stimulated Radioiodine Therapy in Patients with a Very Large Goiter: A Double-Blinded, Randomized Trial
J. Clin. Endocrinol. Metab.,
September 1, 2007;
92(9):
3424 - 3428.
[Abstract][Full Text][PDF]
H. Volzke, C. Schwahn, H. Wallaschofski, and M. Dorr The Association of Thyroid Dysfunction with All-Cause and Circulatory Mortality: Is There a Causal Relationship?
J. Clin. Endocrinol. Metab.,
July 1, 2007;
92(7):
2421 - 2429.
[Abstract][Full Text][PDF]
M. C. Frates, C. B. Benson, P. M. Doubilet, E. Kunreuther, M. Contreras, E. S. Cibas, J. Orcutt, F. D. Moore Jr., P. R. Larsen, E. Marqusee, et al. Prevalence and Distribution of Carcinoma in Patients with Solitary and Multiple Thyroid Nodules on Sonography
J. Clin. Endocrinol. Metab.,
September 1, 2006;
91(9):
3411 - 3417.
[Abstract][Full Text][PDF]
V. E. Nielsen, S. J. Bonnema, H. Boel-Jorgensen, P. Grupe, and L. Hegedus Stimulation With 0.3-mg Recombinant Human Thyrotropin Prior to Iodine 131 Therapy to Improve the Size Reduction of Benign Nontoxic Nodular Goiter: A Prospective Randomized Double-blind Trial.
Arch Intern Med,
July 24, 2006;
166(14):
1476 - 1482.
[Abstract][Full Text][PDF]
M Niedziela Pathogenesis, diagnosis and management of thyroid nodules in children.
Endocr. Relat. Cancer,
June 1, 2006;
13(2):
427 - 453.
[Abstract][Full Text][PDF]
T. Watt, M. Groenvold, A. K. Rasmussen, S. J. Bonnema, L. Hegedus, J. B. Bjorner, and U. Feldt-Rasmussen Quality of life in patients with benign thyroid disorders. A review.
Eur. J. Endocrinol.,
April 1, 2006;
154(4):
501 - 510.
[Abstract][Full Text][PDF]
O. Cohen, J. Ilany, C. Hoffman, D. Olchovsky, S. Dabhi, A. Karasik, E. Goshen, G. Rotenberg, and S T. Zwas Low-dose recombinant human thyrotropin-aided radioiodine treatment of large, multinodular goiters in elderly patients
Eur. J. Endocrinol.,
February 1, 2006;
154(2):
243 - 252.
[Abstract][Full Text][PDF]
V. E. Nielsen, S. J. Bonnema, H. Boel-Jorgensen, A. Veje, and L. Hegedus Recombinant Human Thyrotropin Markedly Changes the 131I Kinetics during 131I Therapy of Patients with Nodular Goiter: An Evaluation by a Randomized Double-Blinded Trial
J. Clin. Endocrinol. Metab.,
January 1, 2005;
90(1):
79 - 83.
[Abstract][Full Text][PDF]
L. A. Diehl, V. Garcia, S. J. Bonnema, L. Hegedus, C. C. Albino, H. Graf, and for the Latin American Thyroid Society Management of the Nontoxic Multinodular Goiter in Latin America: Comparison with North America and Europe, an Electronic Survey
J. Clin. Endocrinol. Metab.,
January 1, 2005;
90(1):
117 - 123.
[Abstract][Full Text][PDF]
L. J. Deftos Should Serum Calcitonin Be Routinely Measured in Patients with Thyroid Nodules--Will the Law Answer before Endocrinologists Do?
J. Clin. Endocrinol. Metab.,
September 1, 2004;
89(9):
4768 - 4769.
[Full Text][PDF]
V. E. Nielsen, S. J. Bonnema, and L. Hegedus Effects of 0.9 mg Recombinant Human Thyrotropin on Thyroid Size and Function in Normal Subjects: A Randomized, Double-Blind, Cross-Over Trial
J. Clin. Endocrinol. Metab.,
May 1, 2004;
89(5):
2242 - 2247.
[Abstract][Full Text][PDF]
L. Hegedus, S. J. Bonnema, and F. N. Bennedbaek Management of Simple Nodular Goiter: Current Status and Future Perspectives
Endocr. Rev.,
February 1, 2003;
24(1):
102 - 132.
[Abstract][Full Text][PDF]
D. S. Ross Nonpalpable Thyroid Nodules--Managing an Epidemic
J. Clin. Endocrinol. Metab.,
May 1, 2002;
87(5):
1938 - 1940.
[Full Text][PDF]
50% of clinically active ATA members). For the index case, a TSH determination was the routine choice of 100%, and serum thyroid autoantibodies were measured by 74%. Simultaneous use of serum TSH, a thyroid hormone assay, and antithyroid peroxidase was employed by 49%. Only 4% included a calcitonin assay. The median number of blood tests ordered was 3 (range, 1–7). Ultrasound was used by 59%, thyroid scintigraphy by 24%, and both imaging modalities by 11%. Fine needle aspiration biopsy (FNAB) was performed by 74%. If scintigraphy showed inhomogeneous tracer distribution or a dominant hypofunctioning region, FNAB was performed by 15% and 97%, respectively. L-T4 treatment was preferred by 56%, radioiodine by 1%, surgery by 6%, and 36% would recommend no treatment. A large goiter, a history of external radiation, or rapid growth increased the preference for surgery. In case of a suppressed serum TSH level, radioiodine was used by 56%. In conclusion, in the work-up of patients with nontoxic multinodular goiter, ATA clinicians employ determinations of TSH often combined with a T4 and/or T3 assay and antithyroid peroxidase antibodies. Thyroid imaging, primarily ultrasound, is performed by more than two thirds, and FNAB by three fourths. This diagnostic evaluation is significantly less extensive than that of the European Thyroid Association members, but the distribution of treatment choices is quite similar. In accordance with their European colleagues, the majority of ATA members prefer the use of L-T4 therapy. There is, however, still a wide variation in the perceived optimal management of this condition among members of both organizations. 
