Treatment of toxic adenoma and toxic multinodular goiter
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Toxic adenoma and toxic multinodular goiter (MNG) are common causes of hyperthyroidism, second in prevalence only to Graves' disease. The prevalence of toxic nodular goiter increases with age and in the presence of iodine deficiency, and may therefore be more common than Graves’ disease in older populations in regions of iodine deficiency. Toxic adenoma and MNG are the result of focal and/or diffuse hyperplasia of thyroid follicular cells whose functional capacity is independent of regulation by thyroid-stimulating hormone (TSH). Twenty to 80 percent of toxic adenomas and some nodules of multinodular goiters have somatic mutations of the TSH receptor gene that confers autonomous hyperactivity [1,2].
The treatment of toxic adenoma and MNG will be presented here. The clinical presentation, evaluation, and diagnosis of hyperthyroidism and of goiter, as well as the treatment of other causes of hyperthyroidism, are reviewed separately.
●(See "Diagnosis of hyperthyroidism".)
- Russo D, Arturi F, Suarez HG, et al. Thyrotropin receptor gene alterations in thyroid hyperfunctioning adenomas. J Clin Endocrinol Metab 1996; 81:1548.
- Tonacchera M, Chiovato L, Pinchera A, et al. Hyperfunctioning thyroid nodules in toxic multinodular goiter share activating thyrotropin receptor mutations with solitary toxic adenoma. J Clin Endocrinol Metab 1998; 83:492.
- Nygaard B, Hegedüs L, Ulriksen P, et al. Radioiodine therapy for multinodular toxic goiter. Arch Intern Med 1999; 159:1364.
- Cerci C, Cerci SS, Eroglu E, et al. Thyroid cancer in toxic and non-toxic multinodular goiter. J Postgrad Med 2007; 53:157.
- Singer PA, Cooper DS, Levy EG, et al. Treatment guidelines for patients with hyperthyroidism and hypothyroidism. Standards of Care Committee, American Thyroid Association. JAMA 1995; 273:808.
- Geffner DL, Hershman JM. Beta-adrenergic blockade for the treatment of hyperthyroidism. Am J Med 1992; 93:61.
- Bahn Chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011; 21:593.
- Porterfield JR Jr, Thompson GB, Farley DR, et al. Evidence-based management of toxic multinodular goiter (Plummer's Disease). World J Surg 2008; 32:1278.
- Kang AS, Grant CS, Thompson GB, van Heerden JA. Current treatment of nodular goiter with hyperthyroidism (Plummer's disease): surgery versus radioiodine. Surgery 2002; 132:916.
- Nygaard B, Hegedüs L, Nielsen KG, et al. Long-term effect of radioactive iodine on thyroid function and size in patients with solitary autonomously functioning toxic thyroid nodules. Clin Endocrinol (Oxf) 1999; 50:197.
- Ross DS. Radioiodine therapy for hyperthyroidism. N Engl J Med 2011; 364:542.
- Franklyn JA. The management of hyperthyroidism. N Engl J Med 1994; 330:1731.
- Kahraman D, Keller C, Schneider C, et al. Development of hypothyroidism during long-term follow-up of patients with toxic nodular goitre after radioiodine therapy. Clin Endocrinol (Oxf) 2012; 76:297.
- Ross DS, Ridgway EC, Daniels GH. Successful treatment of solitary toxic thyroid nodules with relatively low-dose iodine-131, with low prevalence of hypothyroidism. Ann Intern Med 1984; 101:488.
- Ceccarelli C, Bencivelli W, Vitti P, et al. Outcome of radioiodine-131 therapy in hyperfunctioning thyroid nodules: a 20 years' retrospective study. Clin Endocrinol (Oxf) 2005; 62:331.
- Nygaard B. Changes in the thyroid technetium-99m scintigram after antithyroid and subsequent radioiodine treatment for solitary autonomous nodules. Thyroid 1998; 8:223.
- Meller J, Siefker U, Hamann A, Hüfner M. Incidence of radioiodine induced Graves' disease in patients with multinodular toxic goiter. Exp Clin Endocrinol Diabetes 2006; 114:235.
- Walter MA, Christ-Crain M, Schindler C, et al. Outcome of radioiodine therapy without, on or 3 days off carbimazole: a prospective interventional three-group comparison. Eur J Nucl Med Mol Imaging 2006; 33:730.
- Papini E, Panunzi C, Pacella CM, et al. Percutaneous ultrasound-guided ethanol injection: a new treatment of toxic autonomously functioning thyroid nodules? J Clin Endocrinol Metab 1993; 76:411.
- Del Prete S, Russo D, Caraglia M, et al. Percutaneous ethanol injection of autonomous thyroid nodules with a volume larger than 40 ml: three years of follow-up. Clin Radiol 2001; 56:895.
- Guglielmi R, Pacella CM, Bianchini A, et al. Percutaneous ethanol injection treatment in benign thyroid lesions: role and efficacy. Thyroid 2004; 14:125.
- Janowitz P, Ackmann S. [Long-term results of ultrasound-guided ethanol injections in patients with autonomous thyroid nodules and hyperthyroidism]. Med Klin (Munich) 2001; 96:451.
- Monzani F, Caraccio N, Goletti O, et al. Five-year follow-up of percutaneous ethanol injection for the treatment of hyperfunctioning thyroid nodules: a study of 117 patients. Clin Endocrinol (Oxf) 1997; 46:9.
- Zingrillo M, Torlontano M, Ghiggi MR, et al. Radioiodine and percutaneous ethanol injection in the treatment of large toxic thyroid nodule: a long-term study. Thyroid 2000; 10:985.
- Døssing H, Bennedbaek FN, Bonnema SJ, et al. Randomized prospective study comparing a single radioiodine dose and a single laser therapy session in autonomously functioning thyroid nodules. Eur J Endocrinol 2007; 157:95.
- Ha EJ, Baek JH, Kim KW, et al. Comparative efficacy of radiofrequency and laser ablation for the treatment of benign thyroid nodules: systematic review including traditional pooling and bayesian network meta-analysis. J Clin Endocrinol Metab 2015; 100:1903.
- Sung JY, Baek JH, Jung SL, et al. Radiofrequency ablation for autonomously functioning thyroid nodules: a multicenter study. Thyroid 2015; 25:112.
- Verloop H, Louwerens M, Schoones JW, et al. Risk of hypothyroidism following hemithyroidectomy: systematic review and meta-analysis of prognostic studies. J Clin Endocrinol Metab 2012; 97:2243.
- CONFIRM THE ETIOLOGY OF HYPERTHYROIDISM
- INDICATIONS FOR TREATMENT
- THERAPEUTIC APPROACH
- Symptom control
- Decrease thyroid hormone synthesis
- - Choice of therapy
- - Indications
- - Extent of resection
- - Preoperative preparation
- - Complications
- Radioiodine therapy
- Thionamide administration
- - Pretreament before radioiodine or surgery
- - Long-term administration
- Other therapies
- Monitoring after therapy
- - Radioiodine
- - Surgery
- Persistent or recurrent disease
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS