Nontoxic Goiter

Nontoxic goiter is a common condition related to deficiency in the iodine intake. Other etiological factors include genetic susceptibility, female gender, age, and tobacco smoking. Since the thyroid tissue has preponderance for nodular degeneration, most goiters harbor nodules of different size and texture. In some patients with long-standing goiter, hyperthyroidism will emerge gradually due to functional autonomy of one or more nodules. Although the risk of malignancy in nodular goiter is low in unselected patients, evaluation by thyroid ultrasonography, and by fine-needle aspiration biopsy of nodules with suspicious features, is crucial for determining the nature of the goiter. In reaching a treatment decision, a range of factors should be taken into account. Asymptomatic patients with a benign goiter most often need no treatment. Thyroid surgery, typically in the form of a hemi- or a total thyroidectomy, can rapidly remove the target tissue and is the treatment of choice if the goiter is very large, if it compromises the upper airways, or if there is suspicion of thyroid malignancy. Specific risks, correlating with goiter size, include vocal cord paralysis and hypoparathyroidism, and these risks increase in cases of reoperation for recurrent goiter. The noninvasive nature is the major advantage of radioiodine ( ¹³¹I) therapy, resulting in a goiter volume reduction of 35–50% within 2 years. However, a low thyroid ¹³¹I uptake (RAIU) is a hindrance for ¹³¹I therapy efficacy in some patients. In such cases, recombinant human TSH (rhTSH) stimulation can augment the goiter shrinkage, which reduces the need for additional treatment due to goiter recurrence. Alternatively, rhTSH stimulation allows a reduction of the administered ¹³¹I, while achieving a goiter reduction comparable to that obtained by ¹³¹I therapy given without rhTSH stimulation. In selected patients, noninvasive interventional treatment may be an option in solitary thyroid lesions.