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When increased activity and hyperthyroidism are present then the condition is referred to as a toxic multinodular goiter or Plummer disease.
Multinodular goiter has been criticized as being a somewhat unhelpful term as some multinodular thyroids are not enlarged, resulting in the unwieldy term "multinodular non-enlarged thyroid" 7.
Multinodular goiter is seen more commonly in females (M:F=1:3) in the 35-50 years age range, who present with nodular enlargement in the midline of the neck. Patients are usually euthyroid, but the nodules may also be hypo- or hyperfunctioning, resulting in systemic symptoms from hypothyroidism or hyperthyroidism, respectively.
Multinodular goiters develop from simple goiters as a result of repeated instances of stimulation and involution 4.
Most of the nodules are hyperplastic or adenomatous with varying degree of cystic/liquefactive degeneration. Presence of serous/colloid fluid may be noted.
A nodule in multinodular goiter may harbor malignancy. A family history of malignancy and prior neck radiation exposure are known risk factors 2.
Sonography remains the first radiological investigation to screen the nodules and look for any suspicion of malignant change in the nodules which is not uncommon.
Usually, the benign nodules in a multinodular goiter show the following features:
- surrounding hypoechoic halo
- spongiform/honeycomb pattern
- peripheral (eggshell) or coarse calcifications
- Doppler: peripheral vessels are usually noted, may show intranodular vascularity (mostly in hyperfunctioning nodules)
It is important to screen for the presence of malignant features (if any) in any of the nodules and subsequent FNA can be done from the suspicious nodule.
Malignant sonographic features
- hypoechoic solid
- intranodular blood flow
- large size: the cut-off is often taken as 10 mm to warrant an FNA
- presence of microcalcifications: almost always warrants an FNA
Benign sonographic features
See main article assessment of thyroid lesions for further details.
- Tc-99m pertechnetate or radioiodine (I-123) demonstrate an enlarged gland, with heterogeneous uptake
- thyroid uptake scan determines the activity of the gland
- a toxic multinodular goiter will show high uptake within the nodules on a background of reduced uptake within the thyroid (cold thyroid)
- a non-toxic multinodular goiter will show mild nodular uptake on a background of normal thyroid uptake
- goiter is in the differential for an anterior/superior mediastinal mass and is associated with the cervicothoracic sign
- associated with deviation of the trachea
- not a primary modality for diagnosis, but may be seen incidentally
- CT may be useful for fully characterizing the extent of substernal (retrosternal) goiter
- an enlarged and heterogeneous thyroid gland suggests the diagnosis, which is confirmed by ultrasound or scintigraphy
Treatment and prognosis
Treatment of multinodular goiter may be pursued if the thyroid is hyperfunctioning, or if the goiter is causing local mass effect. There is no standard treatment and choice of treatment depends on local practice patterns, the activity of the goiter, and the results of FNA of any suspicious nodules.
- surgery: partial or complete resection
- radioiodine: occasionally used
- dose = (thyroid weight x planned radioiodine delivery to thyroid) / radioiodine uptake
- hypothyroidism may occur as an adverse event
Conservative management is also an option as some goiters decrease their rate of growth or may even decrease in size 6.
- patients with multinodular goiter are at increased risk of iodinated contrast-induced thyrotoxicosis (although this is rare in itself) 5
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