Multinodular Thyroid Goiter with normal functioning
Short Summary

60-year-old female with previous history of IgG monoclonal gamopathy. An ultrasound of the thyroid showed a 10 mm diameter nodule to the right and a 12 mm diameter nodule to the left with associated colloid accumulations. Another thyroid US was performed and there seems to be enlargement of the existing nodules and appearance of new nodules. The patient suffers from sense of oppression of the trachea. The endocrinology specialist recommends total Thyroidectomy or treatment to suppress TSH with follow-up.

Patient's Questions
Following this annoying problem with the trachea connected to the presence of the aforementioned thyroid nodules, the patient would like to know:
 
1)         Does the possibility exist of effective medical treatment without undergoing the surgery proposed by the doctor?
 
2)         If the surgery were necessary, what are the healthcare centers and professionals of excellence in Italy to refer to?
 
3)         Prognosis?
Medical Background

Age : 60. Sex: Female
Diagnosis: Multinodular Thyroid Goiter with normal functioning
Patient with IgG↑ and IgA↓ monoclonal gammopathy.
In 2003 normal thyroid hormone profile and negative for thyroid antibodies.
In 2005 an ultrasound of the thyroid showed regular volume, heterogeneous echotexture due to the presence of a 10 mm diameter nodule to the right and a 12 mm diameter nodule to the left with associated colloid accumulations. There were no locoregional adenopathies.
On February 2008, another thyroid ultrasound showed: “Thyroid of regular size (AP diam. of the right lobe is 16.5 mm and left lobe is 16.4 mm). At the lower middle third of the left lobe a nodule with prevalently hyperechoic echotexture was shown, with central anechoic component and demarcated by a thin hypoechoic halo of 20 x 11.5 mm, with peripheral vascularization shown on CD. 12.5 x 11 mm isoechoic nodule at the right lobe adjacent to the isthmus. Another hypoechoic nodule is revealed at the right middle third, with minute calcifications in the background, demarcated by hypoechoic halo and peripheral vascularization on CD. 4.5 mm colloid cystic nodule at right middle third. FNAB useful for complete information. There are no significant adenopathies in the laterocervical region.”
FNAB results of March 2008 favored:
A)        FNAB Thyroid: Right lobe:
Cytology results consistent with: colloid goiter with associated lymphocytosis.
B)        FNAB Thyroid: Right Lobe (adjacent to isthmus):
Aspects of follicular hyperplasia with some anisonucleosis, with associated lymphocytosis (chronic thyroiditis?).
C)        FNAB Thyroid Left Lobe:
Aspects of follicular hyperplasia, with some anisonucleosis, with associated lymphocytosis (chronic thyroiditis?).
A visit was therefore scheduled on March 2008 with endocrinology specialist who after studying the tests performed above and examining the patient (weight 65.600 kg - neck circumference 35 cm - BP 120/80 – pulse 74/m), reached the following conclusions:
“I examined the patient, patient with multinodular goiter, with needle biopsy suspicious for possible degeneration. My advice is to proceed with total Thyroidectomy; alternatively, follow-up in 6 months after treatment to suppress TSH. At this time I advise: TSH, FT3, FT4, TPOAb, TGAb, CEA, calcitonin.” These blood tests were performed and the relevant report is attached.
Following a sense of oppression of the trachea with a finding of a thyroid nodule > 2 cm, the patient was examined by an ENT who requested further diagnostic examination with investigation of the tracheal column axis with possible compression and/or dislocation by the new growth of the sublaryngeal neck.
X-ray of the trachea on April 2008 revealed tracheal air band, median, regular for size and lumen profiles. Signs of spondyloarthrosis, with reduction in d C5-C6 and C6-C7 interval.
To supplement the examinations, Color Doppler of the cerebral afferent vessels was performed on May 2008, which found intimal medial thickening of the carotid vessels.

Expert's Opinion

It seems that there is no tracheal narrowing secondary to the thyroid enlargement on the attached X-ray.
Discussion:
This 60 years old female has a commonly seen problem. From the previous sonograms it seems that the thyroid nodules are enlarging in size and in number. This is obviously an alarming sign that may suggest that the FNA is not accurate and that the nodules are in fact malignant. The chances of malignancy are low but it is still an option and the safest treatment plan for that reason would be thyroidectomy.
Other than the risk of malignancy, enlarging thyroid nodules in a young and healthy individual is a relative indication for surgery. Since life expectancy is long, chances are the nodules will enlarge in size and cause symptoms related to tracheal compression such as feeling of neck tightness and fullness as well as shortness of breath. The options in that case are either follow-up with serial sonograms twice a year (and surgery in case the nodules keep growing) or proceed with immediate surgery.
Altogether it seems to me that surgery is the safe modality, however, I usually do not perform a total thyroidectomy upfront but try to perform a subtotal thyroidectomy and remove all suspicious nodules for pathology (In this case a left total lobectomy and a right subtotal lobectomy would be performed) . A frozen section analysis is performed during surgery and if the nodules are benign than the procedure is terminated. If, on the other hand, a malignant tumor is found, a total thyroidectomy is performed.
To the patients' question, there is no other treatment that can both diagnose malignancy and also treat the tumor other than surgery.
The prognosis is dependent on the final pathology: if the nodules are benign- then the prognosis is not an issue and the patient is 100% healthy. If a thyroid cancer is diagnosed than obviously there is a risk of locoregional recurrence or distant spread, however, thyroid cancer, especially in women are a slow growing "friendly" cancers and the prognosis is excellent (in the case the tumor is papillary carcinoma- the most common thyroid malignancy).
To conclude- I do believe the nodules are benign but still suggest surgery as the preferred treatment option. A subtotal thyroidectomy may suffice.
 
 
This opinion is based on the clinical data without clinical examination of the patient. In such cases the clinical examination is helpful in determining the preferred treatment since tumor that is hard on palpation, or that causes vocal cord paralysis for example are an absolute indication for surgery, as are other clinical signs.
Surgery takes about 1 hour and is performed through a small cervical incision (usually 4-5cm). The patient is usually discharged from the hospital on the following day and sometimes on the same day.
Regarding facilities in Italy: the only thyroid surgery center that I know of in Italy is located in Pisa.

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