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In some instances, adjuvant use of low dose recombinant TSH may increase iodine uptake in the thyroid and allow for more efficient treatment with radioactive iodine, as described in Low-dose recombinant human thyrotropin-aided radioiodine treatment of large, multinodular goiters in elderly patients.

L-Thyroxine is contraindicated in older patients with nontoxic nodular goiter, because these goiters rarely shrink and may harbor areas of autonomy so that l-thyroxine therapy can result in hyperthyroidism. One type of goiter is a multinodular goiter, in which an enlarged thyroid will have separate bumps ( nodules ) on it. Most multinodular goiters don't cause symptoms. Thyroid hormone replacement therapy is a common treatment for goiters that are caused by an underactive thyroid (hypothyroidism) or overactive thyroid (hyperthyroidism).

There are a few types of goiters with various causes, but in general, a goiter is a swelling in the neck due to an enlarged thyroid gland. ( See Hyperthyroidism ) The exact causes of thyroid nodules or multinodular goiters are unknown. If the goiter is related to a condition causing hyperthyroidism, as in Graves disease or toxic nodular goiter, treatment with radioactive iodine may be effective in both controlling gland overactivity and decreasing its size.

Patients can present with a single large nodule or with multiple smaller nodules in the gland when first detected (see Thyroid Nodule brochure ). Thus, in early stages of a multinodular goiter with many small nodules, the overall size of the thyroid may not be enlarged yet. Most of the increased mortality among patients with nodular thyroid diseases was due to thyroid cancer deaths, and this mortality diminished during prolonged follow-up ( 277 ). Hence, the disclosure of a thyroid cancer in a nodular goiter after 131I therapy raises the question whether malignancy in a nodule was overlooked at the time of therapy. It has recently been shown that patients with a substernal goiter may also benefit from 131I therapy ( 258 ). Because thyroid malignancy may be more prevalent in goiters with a substernal component ( 86 , 236 , 238 ), some risk of overlooking a cancer must be taken with this approach.

A visibly diffusely enlarged goiter has often reached a volume of 30-40 ml. In general, the size of smaller goiters is overestimated, and the size of larger goiters is underestimated ( 2 ). Detection of nodules depends on their size, morphology, location within the thyroid parenchyma, anatomy of the patient's neck, and most of all the training of the physician. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, we support the increasing use of fine-needle aspiration biopsy (cytology). The exact causes of thyroid nodules or multinodular goiters are unknown.

Goiters are classified as either nontoxic (euthyroid) or toxic (hyper or hypothyroid functional state), as well as simple (one enlarged nodule) or multinodular (many enlarged nodules). The 1885 edition of Hirsch's classic pathology text states: Chatin's idea of goiter being caused by the absence of iodine in the drinking water and in the air was a short-lived opinion.” Hirsch concludes goiter and cretinism have to be reckoned among the infective diseases” but still recommends iodine for treatment of the condition ( 7 ). Medical authorities recognized cretinism only occurred in areas of endemic goiter but were puzzled by the fact that many cretins had an atrophic or absent thyroid gland, the opposite of goiter. Less commonly, the iodine load causes activation of subclinical Graves disease or toxic multinodular goiter; %RAIU is elevated.

131I is increasingly used as first-line therapy for Graves' hyperthyroidism and is the treatment of choice for patients with relapsed hyperthyroidism after antithyroid drug treatment and toxic nodular goiter. Iodine therapy suppresses thyroid hormone release only in Graves' disease and should not be given to patients with toxic nodular goiter. Coverage progresses from the normal thyroid and assessment of thyroid structure and function, through thyrotoxicosis, hypothyroidism, nontoxic diffuse and multinodular goiter, and thyroid cancers.