Management of the nontoxic multinodular goitre: A European questionnaire study

Abstract

BACKGROUND AND OBJECTIVE. The optimum management strategy for the patient with a multinodular nontoxic goitre is still a matter of debate. Our aim was to assess the attitudes towards management of such patients throughout Europe by means of a questionnaire. DESIGN. The questionnaire was circulated to all clinician members of the European Thyroid Association (ETA). A case report was followed by diagnostic investigations and choice of therapy in the index case (a 42-year-old woman with an irregular non-tender bilaterally enlarged thyroid of 50-80 g and no clinical suspicion of malignancy). Eleven variations of the basic case report were proposed in order to evaluate the impact on management of each alteration. SUBJECTS AND METHODS. One hundred and sixty-seven members replied to the letter, and 120 individuals from 22 countries completed the questionnaire (corresponding to approximately two-thirds of the clinical members of the ETA). RESULTS. Based on the index case, serum TSH was the routine choice of 100%, and serum free T4/T4-index was included by 74%. Serum TPO autoantibodies, Tg autoantibodies and calcitonin were measured by 65%, 49% and 32%, respectively. The median number of blood tests used was four (range 1-11). Considerable intercountry variations were seen in the preferred imaging methods. Ninety-one percent of the clinicians would use at least one imaging modality. Ultrasound (US) was used by 84%, thyroid scintigraphy by 76%, and both methods by 69%. US had first priority (53% vs. 19% for scintigraphy). If scintigraphy was performed, fine-needle aspiration cytology was routinely used by 17% (inhomogeneous uptake) and 95% (dominant 'cold' area), and 63% used US-guidance. L-T4 treatment was supported by 52% of the clinicians, iodine supplementation by 4%, radioiodine by 6% and surgery by 10%. In the case of a suppressed serum TSH, radioiodine treatment was preferred by 44%, while surgery was the favoured recommendation in four clinical variations with a large goitre or suspicion of malignancy. Marked differences between the countries were suggested by L-T4 therapy being the dominant treatment in Italy, France and Germany in contrast to the prevailing use of radioiodine in Denmark and a wait and see policy in the UK. CONCLUSIONS. Fundamental differences between European countries exist as regards diagnosis and treatment of the multinodular nontoxic goitre suggesting difficulties in reaching a consensus.