THYROID SEMINAR II Goiter

and Thyroid Nodules

Case #1

A 22 -year-old woman is found to have a goiter on routine examination. Her older

sister and mother have “thyroid conditions” and take medication. The patient feels
well. On examination she has a firm thyroid gland enlarged to about three times
normal size, ca. 30 g, with a slightly irregular surface, but no nodules. Laboratory
studies show low- normal free T4 0.8 (normal 0.8-1.8 ng/dL), and TSH 7.8 (normal
0.4-4.0 mcIU/ml).

What is the cause of her goiter?

What laboratory test could confirm the diagnosis?

How would you treat the patient and why?

Case #2

A 56 y.o. woman asks to be evaluated for thyroid enlargement. She was first told of
a goiter twenty years earlier on a routine examination. In the last ten years she has
noted a gradual enlargement of a visible swelling in her neck. She denies difficulty
swallowing, hoarseness, and x-ray treatments in childhood. Her mother and sister
have goiters, too. On exam she has a 60-gram visible and palpable thyroid gland,
consisting of 2-3 soft mobile nodules on each side, measuring up to 3 cm in
diameter. There is no palpable cervical lymphadenopathy.

What is the most likely diagnosis?

What is the cause of this disease?

Is she likely to be hypothyroid, euthyroid, or hyperthyroid?

What symptoms might be caused by a large goiter?

Case #3

A 35 y.o. woman is found to have a right thyroid nodule. She is not aware of the
nodule, denies x-ray treatments in childhood, and feels well. TSH is normal at
0.8. On exam she has a slightly firm, mobile 2.5 cm right thyroid nodule
without associated adenopathy.

What are the chances that this nodule is malignant?

What factors in the history or physical examination might increase the likelihood
that the nodule is a thyroid cancer?

What would be the best test to evaluate the nodule for malignancy? What would be
the best test to accurately measure the size of the nodule during follow-up?

Case #4

Assume the same patient (Case 3) is found to have a TSH of 0.08 (normal 0.4 - 4.0).

What does this suggest about the nodule? What test would confirm this suspicion? If

the suspicion is confirmed, what is the likelihood of malignancy? When is radioiodine

scanning helpful in the evaluation of thyroid nodules?