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Multinodular_goiter

Sub Title: 
Multinodular goiter with right thyroid lobe cysts
Short summary: 

Medical history: Slight mitral prolapse and common exanthematous conditions.

The patient has had thyroid nodules for 10 years, the largest of which is in her right lobe. Thyroid function is within normal limits and asymptomatic. She has had regular follow-up thyroid ultrasounds and a needle aspiration biopsy in ---(4 years prior to this report).

These tests resulted in a diagnosis of “multinodular colloid-cystic goiter”.

In ---(6 months prior), the patient had a thyroid ultrasound at the ---, the results of which were as follows: “Slightly dysmorphic thyroid due to the size of the right lobe which has a large colloid cyst formation of 3.8 cm with a solid part of 15 mm on the anterior side and for which a needle aspiration biopsy is advised in the solid part for evacuation and diagnostic purposes. In the right lobe and isthmus there are at least three other adenomatous hyperplastic nodules of 9, 10 and 12 mm respectively. The structure is homogeneous in the left thyroid lobe. No laterocervical lymphadenopathies.” Therefore, needle aspiration was carried out at the end of --- (1 month later), the results of which indicated “hemorrhagic colloid nodule with a solid part anterior to the right thyroid lobe”.

Immediately after the needle aspiration was performed, swelling appeared in the nodule on the right lobe. The patient reports that the swelling developed to such an extent that the size was comparable to that of a “tangerine” in her throat.

Therefore, the patient reported the onset of dyspnea and the inability to rest her head on a pillow. The physician who had performed the needle aspiration was contacted again and another ultrasound was carried out in early ---(approx 1 month before this report). Given the considerable increase in size of the nodule, the endocrinologist advised that therapy should be started immediately with Eutirox.

The patient was not convinced by the proposed therapy, so she had another ultrasound at the ----, where the endocrinologist, aspirated blood serum from the nodule and the swelling promptly subsided.

However, as expected by the endocrinologist, the swelling gradually increased again, which has recently led the patient to consult various specialists.

Unfortunately, these specialists have different views. Some advise a hemithyroidectomy, some a total thyroidectomy, others advise removing the single nodule and yet others propose therapy with Eutirox.

It should be emphasized that the patient is not in favor of taking the hormone for the rest of her life.

Patient's question: 
1) What therapies do you suggest? 2) Prognosis ? 3) What are the centres of excellence for this condition?
Experts Opinion: 

I had the pleasure of reviewing the case of this patient for a second opinion. Unfortunately, her ultrasound (US) images were not clear and my comments are only based on the historical information that is provided to me.

I will review the provided information first: The patient is 42 years old female with a history of a multinodular goiter for the last several years. She did not have any clinical or biochemical evidence of hypo or hyperthyroidism. In (approx 4 years prior), she underwent a fine needle aspiration of the dominant right sided nodule. It is unclear if only one nodule was aspirated or multiple nodules were tested for malignancy. The final conclusion was that it was a multi-nodular colloid-cystic goiter. In ---(approx 1 year prior), she had an US that confirmed the presence of multiple nodules on right side with the largest nodule 3.8 cm with 1.5 cm of solid portion. No other sonographic features were suggestive of malignancy (micro calcification, hypervascularity etc). There was no stated family history of thyroid cancer or any history of childhood radiation (other risk factors for carcinoma of thyroid). Also, it is unclear if patient was on any anti coagulation therapy or had any known bleeding disorders. She underwent a repeat fine needle aspiration of the right dominant thyroid nodule that was consistent with a “hemorrhagic colloid nodule”. Immediately post aspiration she had an increase in the size of the neck associated with dyspnea. She was seen at another center and hemorrhagic fluid was drained from the R side leading to reduction in the nodule size. Her symptoms also improved substantially. However, swelling recurred and now the question is how to proceed further. She has been asked to consider hemithyroidectomy or total thyroidectomy. Another opinion is to use Eutirox (levothyrxine) supplementation. Patient is not in favor of taking any thyroid supplementation for the rest of her life.

Questions:

1. What therapies do you suggest?

My clinical impression is that patient had bleeding during procedure (FNA) leading to a sudden increase in the size of the nodule and compressive symptoms with dyspnea. The symptoms relieved with cyst aspiration but there was re-accumulation of fluid within a short period of time.

There is no definite evidence that supplementation of levothyroxine will lead to significant reduction in the size of this mixed cystic-solid thyroid nodule. The levothyroxine supplementation in my mind is only required if patient has clinical and biochemical evidence of hypothyroidism. I will check that by testing her thyroid function tests.

As far as the treatment for thyroid cystic nodule is concerned, there are few possibilities. If patient has persistent compressive symptoms like dyspnea, swallowing difficulty etc then she should consider re-aspiration of fluid vs. hemi-thyroidectomy.

My feeling is that right hemithyroidectomy is more appropriate for the following reasons: It will preserve the left lobe of the gland which will be enough to keep her euthyroid (though that will need to be monitored post operatively), it will remove the abnormal lobe with multiple nodules and hence will not require close monitoring and finally it will give a definite diagnosis of these nodules. The disadvantage is that it is a more aggressive therapy, will require hospitalization, and may make her permanently hypothyroid (unlikely, unless left side is also involved). The advantage of cyst aspiration is that it is fairly straightforward; however, the disadvantage is that there is a risk of bleeding and there is likelihood that there will be re-accumulation of fluid within a short period of time. Total thyroidectomy should only be considered if the whole gland is affected. In that case she will require life-long levo-thyroxine supplementation. Cystic nodules that have a definite capsule can sometimes be treated with alcohol injections. In the United States we do not have much experience with this procedure but this is relatively common here. I would defer that decision to the local endocrinologists as we do not have much experience with the procedure.

If patient does not have any symptoms but the size of the nodule is increasing then she should consider the right hemithyroidectomy. On the other hand if the size of the nodule is decreasing then patient can be monitored with serial ultrasounds and monitoring her TSH to ensure biochemical euthyroid status. However, in that case these nodules need to be monitored for malignancy, compressive symptoms.

2. Finally, it should be ensured that patient is not on any anti-coagulation therapy and does not have any bleeding disorder.

3. Prognosis.

Excellent, with appropriate treatment.

4. What are the Centres of excellence for this condition?

In the United States, University of Pennsylvania (Philadelphia, Pennsylvania), Johns Hopkins University (Baltimore, Maryland), Mayo Clinic (Rochester, Minnesota).

Please let me know if you have any questions or concerns. I would be happy to see this patient in my practice if the patient wishes to travel to the United States. If we can be of any further help to you, please contact me through Medical Opinion.

Sincerely,

Dr---

Assistant Professor of Medicine

Chief of Endochronology