Thyroid Research Thyroid Research Archive Nodular Goiter

Physicians evaluate and treat patients with nontoxic multinodular goiter in widely different ways

(March 2002)

The background of the study. Nontoxic multinodular goiter is among the most common thyroid disorders, but physicians disagree about the optimal evaluation and treatment of patients with these goiters.

How the study was done. A questionnaire describing patients with a multinodular goiter was sent to 270 members of the American Thyroid Association. Responses were received from 140 (52 percent). The index case was a woman with a multinodular goiter that was estimated to weigh 50 to 80 g and had a normal serum thyrotropin (TSH) concentration. Variations of this patient were described, each different by a single characteristic, for example, age, sex, or size of goiter. The clinicians were asked to choose the diagnostic tests and treatments they would recommend for the index patient and the other patients.

The results of the study. For the index case, 100 percent of respondents would order measurement of serum TSH, 54 percent serum free thyroxine (T4), and 4 percent serum calcitonin. The in vivo diagnostic tests and the percentages of respondents ordering them were: ultrasonography, 59 percent; scintigraphy, 24 percent; both ultrasonography and scintigraphy, 11 percent; no imaging, 29 percent; fine-needle aspiration biopsy, 74 percent; and ultrasound-guided fine-needle aspiration biopsy, 36 percent. With respect to treatment of the index case, 56 percent of clinicians would recommend T4 therapy, 36 percent periodic reevaluation, 1 percent radioiodine therapy, and 6 percent surgery.

Among the variations in the index case, a low serum TSH concentration had the largest effect on diagnosis and treatment; more physicians would order scintigraphy (61 percent) and radioiodine therapy (56 percent), and none would treat with T4. For a 75-year-old woman, 34 percent would still recommend T4 therapy.

The conclusion of the study. Thyroidologists in North America vary widely in their use of diagnostic tests and their recommendations for treatment in patients with a nontoxic nodular goiter.

The original article. Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus L. Management of the nontoxic nodular goiter: a North American survey. J Clin Endocrinol Metab 2002;87:112-7.