E-case # 21-B

Audrey Young, M.D.

November 5-9, 2001

A 29-year-old woman, recently immigrated from Southern China, presents with the complaint of neck swelling. The swelling has increased over the last year and the patient is concerned that something is very wrong with her.  She denies dysphagia or shortness of breath.  She has had normal regular menstrual periods and denies heat or cold intolerance, weight loss or weight gain, constipation or diarrhea, or history of neck irradiation.  She has not had any skin, hair, or nail changes.  Of note, her mother had a thyroid goiter removed at age 45.

She is anxious-appearing on exam.  The thyroid is visually enlarged and about 30 grams to palpation.  A firm, mobile 2cm nodule is palpable on the superior aspect of the right lobe of the thyroid.  The left lobe feels diffusely nodular.  There is no lymphadenopathy.  The remainder of her exam is normal.

Thyroid ultrasound shows a diffusely enlarged gland of heterogeneous density, with a hypoechoic 2 cm solid nodule in the right lobe, plus several small nodules measuring less than 1 cm..

What is the diagnosis and how should her case be managed?

She has multinodular goiter (MNG). General management principles:

• Likelihood of cancer is < 1% in MNG.  Features of nodules worrisome for malignancy are size > 4 cm and fixed/hard lesions with lymphadenopathy.

• Establish benignity by fine-needle aspiration of nodules > 1 cm.

• Check for overt or subclinical hyperthyroidism and treat with antithyroid medications, surgery, or I-131.

• Compression symptoms such as dysphagia, hoarseness, and venous-outflow obstruction are indications for thyroidectomy.

• In euthyroid patients, nodule and goiter growth can be suppressed with T4 as first-line and I-131 as second-line therapy.

• Alcohol can sclerose autonomously-functioning thyroid nodules.

Reference

Hermus AR and Huysmans DA. Treatment of benign nodular thyroid disease. NEJM 1998; 338:1438-1447.