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Otolaryngologic Clinics of North America Feb 2003MNG is a common clinical problem. Though most goiters are benign and asymptomatic, they may cause concern when they create compressive symptoms, develop autonomous... (Review)
Review
MNG is a common clinical problem. Though most goiters are benign and asymptomatic, they may cause concern when they create compressive symptoms, develop autonomous functioning nodules, or form suspicious nodules. Diagnostic evaluation should include clinical evaluation, laboratory tests including TSH, and consideration of additional evaluation and imaging when there exists suspicion of complicating factors or risk of malignancy. In nontoxic MNG, suppression therapy or serial clinical exams and TSH values are appropriate in an asymptomatic, nonsuspicious goiter. In toxic MNG, treatment of the resulting thyrotoxicosis followed by RAI or surgery is indicated. When compressive symptoms, risk of malignancy, or cosmetic deformity develops, surgery also may be indicated.
Topics: Goiter, Nodular; Humans; Thyrotoxicosis
PubMed: 12803008
DOI: 10.1016/s0030-6665(02)00157-3 -
Annales D'endocrinologie Sep 2019Subclinical hyperthyroidism is a common clinical entity, defined by serum TSH below the reference range, with normal FT4 and FT3 levels in an asymptomatic patient.... (Review)
Review
Subclinical hyperthyroidism is a common clinical entity, defined by serum TSH below the reference range, with normal FT4 and FT3 levels in an asymptomatic patient. Whether or not subclinical hyperthyroidism should be treated remains a matter of debate. Cross-sectional and longitudinal population-based studies demonstrate association of subclinical hyperthyroidism with risk of atrial fibrillation and osteoporosis, and with cardiovascular and all-cause mortality. However, there are no randomized clinical trials addressing whether long-term health outcomes are improved by treating subclinical hyperthyroidism; in the absence of evidence one way or the other, it seems appropriate to use decision trees taking account of TSH concentration and presence of risk factors (age>65 years or post-menopause, osteoporosis and cardiac disease).
Topics: Aged; Aged, 80 and over; Asymptomatic Diseases; Atrial Fibrillation; Goiter, Nodular; Graves Disease; Humans; Hyperthyroidism; Risk Factors
PubMed: 31427038
DOI: 10.1016/j.ando.2018.09.004 -
Minerva Endocrinologica Sep 2010In many parts of the world, especially those of current or former iodine deficiency, multinodular goiter is still an endemic disease. In this brief review several... (Review)
Review
In many parts of the world, especially those of current or former iodine deficiency, multinodular goiter is still an endemic disease. In this brief review several clinically relevant issues in the complex association between nodular goiter and differentiated thyroid cancer will be highlighted. There are some intriguing links between the etiologies of multinodular goiter and that of thyroid cancer. This could also influence the incidence of thyroid cancer in multinodular goiter. However, multinodular goiter causes extra difficulties in the diagnosis of differentiated thyroid cancer; these same difficulties also cause additional issues in thyroid cancer treatment in multinodular goiter patients. Last but not least it will be discussed whether there is a possibility to impede the development of thyroid cancer in multinodular goiter.
Topics: Goiter, Nodular; Humans; Thyroid Neoplasms
PubMed: 20938421
DOI: No ID Found -
Journal of Endocrinological... 2002Toxic nodular goiter (TNG) is the most frequent cause of thyrotoxicosis in the elderly, specially in iodine deficient areas. Epidemiological studies have shown that in... (Review)
Review
Toxic nodular goiter (TNG) is the most frequent cause of thyrotoxicosis in the elderly, specially in iodine deficient areas. Epidemiological studies have shown that in iodine deficient areas (Jutland) the incidence of hyperthyroidism is significantly higher with respect to areas with normal iodine intake (Iceland) and it is due to TNG. A careful epidemiological study recently carried out in Pescopagano, in southern Italy, an area characterized by a mild to moderate iodine deficiency, indicates that, in its natural history, nodular goiter contributes to the development of functional autonomy and eventually hyperthyroidism. Somatic activating mutations of the TSH receptor are involved in the pathogenesis of TNG. It is supposed that the prolonged iodine deficiency associated with chronic TSH stimulation increases the replication of follicular thyroid cells, and favor the appearance and expression of mutations of the TSH receptor gene. The clinical signs are usually more subtle than those observed in Graves' disease: a long phase of subclinical hyperthyroidism (normal circulating thyroid hormones and undetectable TSH levels) can precede the appearance of the symptoms. Cardiac symptoms are most frequent, (arrhythmia and atrial fibrillation). Thyroid scintigraphy in toxic multinodular goiter shows an uneven distribution of the radionuclide with multiple hyperfunctioning nodules and cold nodules. Thyroid US shows goiter with inhomogeneous solid nodules often with ill-defined borders. The treatment with antithyroid drug does not allow a permanent remission of hyperthyroidism, but its use is indicated to achieve euthyroidism before the definitive treatment. The definitive treatment is radioiodine or thyroidectomy.
Topics: Aged; Goiter, Nodular; Humans; Incidence; Italy
PubMed: 12508907
DOI: No ID Found -
Nihon Rinsho. Japanese Journal of... Dec 2006The prevalence of toxic multinodular goiter (TMNG) is very rare in Japan which iodine intake is sufficient or excessive. It accounts for about < 1.0% of hyperthyroidism.... (Review)
Review
The prevalence of toxic multinodular goiter (TMNG) is very rare in Japan which iodine intake is sufficient or excessive. It accounts for about < 1.0% of hyperthyroidism. The pathogenesis of TMNG is unknown, especially iodine rich area like in Japan although in iodine-deficient arears iodine insufficiency and TSH stimulating is the major promoting factors in its pathogenesis. Unlike Graves' disease, TMNG is more prevalent among aged patients and its symptoms of hyperthyroidism develops insidiously. Radionuclide imaging and ultrasonography provide very important information about the diagnosis of TMNG in addition to thyroid function tests. The treatments for TMNG are surgery after amelioration of thyroid function with antithyroid drugs, radioiodine treatment and PEIT (percutaneous ethanol injection therapy). We always have to pay attention to the existence of thyroid cancer complicated with TMNG.
Topics: Adult; Antithyroid Agents; Diagnostic Imaging; Ethanol; Female; Goiter, Nodular; Humans; Injections, Intralesional; Iodine Radioisotopes; Thyroid Function Tests; Thyroid Neoplasms; Thyroidectomy
PubMed: 17154083
DOI: No ID Found -
Annales de Chirurgie 1999Despite its high prevalence, at least in areas with even mild iodine deficiency, the aetiopathogenesis of multinodular goitre is poorly understood. The combination of... (Review)
Review
Despite its high prevalence, at least in areas with even mild iodine deficiency, the aetiopathogenesis of multinodular goitre is poorly understood. The combination of genetic and environmental factors, the likely involvement of endocrine para and autocrine goitrogenic agents and the remarkable heterogenicity of thyroid tissue complicate elucidation of the mechanisms involved. Multinodular goitre follows an initial phase of hyperplastic goitre or results from the generation of several individual nodules. Alterations of the stromal and vascular tissues as well as the occurrence of somatic mutations are contributing factors. In many instances, multinodular goitres become autonomous in the long term.
Topics: Adolescent; Adult; Goiter, Nodular; Humans; Hyperplasia; Thyroid Gland; Thyroidectomy
PubMed: 10339866
DOI: No ID Found -
Thyroid : Official Journal of the... Apr 1997Surgery is considered standard therapy for nontoxic goiter. However, surgical treatment of large goiters is not without risk, especially in elderly patients and in those... (Review)
Review
Surgery is considered standard therapy for nontoxic goiter. However, surgical treatment of large goiters is not without risk, especially in elderly patients and in those with cardiopulmonary diseases. Therefore, in recent years interest in 131I treatment of nontoxic goiter has increased. Studies, using ultrasonography and magnetic resonance imaging (MRI) for accurate measurements of thyroid volume, have shown that 131I treatment of nontoxic nodular goiter results in a mean thyroid volume reduction of 40% after 1 year of 50-60% after 3-5 years. Moreover, an improvement of compressive symptoms can be achieved. This has been objectified by a significant decrease in tracheal compression as measured by MRI. Early side effects due to radiation thyroiditis usually are mild. The development of autoimmune hyperthyroidism occurring several months after 131I therapy in approximately 5% of patients is the most important complication of 131I therapy for nontoxic goiter. The incidence of post-treatment hypothyroidism appears to be approximately 20-30% at 5 years. For elderly people, the lifetime risk of fatal and nonfatal cancer induced by this therapy (administered activity 1.9 +/- 0.9 GBq of 131I) was estimated to be approximately 0.5%. In all patients with nontoxic multinodular goiter the estimated risks of both surgery and radioiodine therapy should be weighed carefully. In younger patients surgery still is to be preferred, especially when the amount of 131I to be administered is high. However, for elderly patients, especially those with cardiopulmonary disease, the profits of radioiodine treatment will outweigh the lifetime risk of this mode of therapy.
Topics: Goiter, Nodular; Humans; Iodine Radioisotopes; Magnetic Resonance Imaging; Neoplasms, Radiation-Induced; Thyroid Neoplasms; Ultrasonography
PubMed: 9133693
DOI: 10.1089/thy.1997.7.235 -
World Journal of Surgery Jul 2008Reportedly, 10-15% of patients with goiters ultimately require operative intervention, and recurrences of multinodular goiter (MNG) account for up to 12% of all thyroid... (Review)
Review
BACKGROUND
Reportedly, 10-15% of patients with goiters ultimately require operative intervention, and recurrences of multinodular goiter (MNG) account for up to 12% of all thyroid operations.
METHODS
We performed an evidence-based review of articles published in the English language between January 1987 and October 2007 relevant to the subject.
RESULTS
Medical treatment with T4 appears to be associated with a greater proportion of patients whose nodules decreased in size by more than 50% (22% vs. 10%; range = 14-39% vs. 0-20%). Recurrence rates of benign nodular goiter after total thyroidectomy were essentially nonexistent (range = 0-0.3%) compared with those after subtotal thyroidectomy (range = 2.5-42%) and more limited resections (range = 8-34%). There was no difference between total and less-than-total thyroidectomy with respect to temporary recurrent laryngeal nerve (RLN) injury (1-10% vs. 0.9-6%, respectively) or permanent RLN palsy (0-1.4%). There was, however, a significantly higher rate of transient hypocalcemia after total thyroidectomy than less extensive operations (9-35% vs. 0-18%, respectively). In relation to redo surgery, permanent hypoparathyroidism appeared to be far more common in the redo group (0-22% vs. 0-4%) Moreover; the redo group had more frequent RLN injury, both temporary (0-22% vs. 0.5-18%) and permanent (0-13% vs. 0-4%). About half the studies examined conclude that postoperative TSH suppression is effective in reducing recurrences, while the other half state that it is not.
CONCLUSION
The definitive management and prevention of recurrence of benign nodular goiter is primarily surgical. Total thyroidectomy essentially eliminates the risk of recurrence without an accompanying increased risk of permanent hypoparathyroidism or RLN injury. Therefore, total thyroidectomy should be considered the procedure of choice for benign multinodular goiter whenever possible, especially considering that reoperations for goiter are significantly more morbid than any initial operation.
Topics: Goiter, Nodular; Humans; Secondary Prevention; Thyroidectomy
PubMed: 18305998
DOI: 10.1007/s00268-008-9477-0 -
Otolaryngologic Clinics of North America Aug 1996Nodular goiters are encountered commonly in clinical practice by primary care physicians, endocrinologists, surgeons, and otolaryngologists. Epidemiologic data suggest... (Review)
Review
Nodular goiters are encountered commonly in clinical practice by primary care physicians, endocrinologists, surgeons, and otolaryngologists. Epidemiologic data suggest that in the United States, the incidence of such goiters is approximately 0.1% to 1.5% per year, translating into 250,000 new nodules annually. Nodular goiters are more common in women than in men, with advancing age, and after exposure to external irradiation. These goiters may be asymptomatic, with normal TSH levels (nontoxic), or may be associated with systemic thyrotoxic symptoms (toxic MNG or Plummer's disease). Diagnostic evaluation of patients with nodular goiters consists of clinical evaluation, biochemical testing, FNA, and imaging studies. The serum TSH level is a sensitive and reliable index of thyroid function. FNA results are pivotal to assess cancer risk in patient management for prominent palpable and suspicious nodules. Chest radiography, high-resolution ultrasonography, and computed tomography help to delineate the size and extent of a goiter in evaluating compression symptoms. Indications for treatment in patients with MNG include hyperthyroidism, local compression symptoms attributed to the goiter, cosmesis, and concern about malignancy based on FNA results. The use of levothyroxine suppression therapy to effectively decrease and control MNG size is controversial. Thyroid hormone should not be used, however, in patients with suppressed serum TSH levels, to avoid the development of toxic symptoms. Management of toxic MNG by surgery is well established. Radioiodine is also effective therapy for many of these patients. When treatment is necessary for nontoxic MNG, surgical excision is preferred. Our recommendations are as follows. For patients who have small, nontoxic multinodular goiters that are clinically asymptomatic, who are biochemically euthyroid according to serum TSH levels, and who have prominent palpable or suspicious nodules benign by FNA, yearly evaluation with serum TSH determinations and thyroid palpation is sufficient. Patients with modest but stable MNG size and normal serum TSH levels may also be managed by yearly clinical observation. In this second group, levothyroxine suppression therapy is often unsuccessful and has the potential for untoward effects from exogenous hyperthyroidism. For large nontoxic multinodular goiters with local compression symptoms, the preferred treatment is surgery. In patients with toxic MNG, treatment with either surgery or radioiodine is recommended, although patients with large goiters and large, autonomously functioning nodules become euthyroid more quickly following surgery.
Topics: Age Factors; Biopsy, Needle; Diagnostic Imaging; Female; Goiter, Nodular; Humans; Incidence; Male; Radiation Injuries; Sex Factors; Thyroid Gland; Thyroidectomy; Thyrotoxicosis; Thyrotropin
PubMed: 8844728
DOI: No ID Found -
Annali Italiani Di Chirurgia 1996Nodular goiter is the natural evolution of nontoxic goiter, that may be endemic, sporadic or familiar. Iodine deficiency is the cause of endemic goiter, while genetical... (Review)
Review
Nodular goiter is the natural evolution of nontoxic goiter, that may be endemic, sporadic or familiar. Iodine deficiency is the cause of endemic goiter, while genetical defects, impairing the thyroid hormone biosynthetic efficiency or altering the number and/or activity of growth factor receptors, play the major role in the pathogenesis of sporadic and familiar nontoxic goiter. The prevalence of nodular goiter is directly related to the degree of iodine deficiency that is still present in several areas of the world. In iodine deficient areas such as some Italian regions, nodular goiter is present in 25-33% of the population, its frequency increasing with age. In iodine sufficient areas the prevalence of nodular goiter is comprised between 0.4 and 7.2% high in iodine deficient areas and about 4% in iodine sufficient countries, its frequency increasing with the age. Dysphagia, dyspnea and coarsening of the voice may occur for esophagous, tracheal or laryngeal nerve compression, respectively. Iodine deficiency has little if any effect on the frequency of thyroid carcinoma, while, with regard to the histological pattern, it leads to an increased ratio papillary/follicular. Thyroid function is normal in uncomplicated nontoxic goiter. However, the evolution of nodular goiter is toward the functional autonomy of nodules that may result in thyrotoxicosis. Hypothyroidism is rare and is usually the result of thyroid autoimmunity. All the cases due to iodine deficiency can be prevented by an adequate iodine prophylaxis that can be accomplished in industrialized countries by the use of sale enriched in iodine.
Topics: Goiter, Nodular; Humans; Italy
PubMed: 9019982
DOI: No ID Found