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.
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