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Toxic Adenoma and Multinodular Toxic Goiter

  • Massimo Tonacchera
  • Dagmar Führer
Reference work entry
Part of the Endocrinology book series (ENDOCR)

Abstract

Toxic thyroid adenoma (TA) is a well-encapsulated homogeneous neoplasia secreting thyroid hormones in the absence of a TSH stimulus, in an otherwise normal gland. The diagnosis involves the ability to take up iodide autonomously and the decreased or suppressed uptake in the rest ofthe thyroid, as demonstrated by scintigraphy. Toxic multinodular goiter (TMNG) encompasses a spectrum of pathologies ranging from a single hyperfunctioning nodule within an enlarged thyroid gland, which has additional normal or nonfunctioning nodules, to multiple hyperfunctiong nodules.Toxic adenoma is more common in women, and can occur at any age, being more frequent between the ages of 30 and 60 years, while TMNG tends to occur at older age. The prevalence of TA and TMNG as a cause of thyrotoxicosis varies throughout the world, and higher prevalences are observed in areas with mild to moderate iodine deficiency. Both TA and TMNG are characterized by the presence of autonomous tissues. TA are monoclonal benign encapsulated tumors that grow, metabolize iodide and secrete thyroid hormones independently of TSH control. The metabolism in autonomous adenomas is characterized mainly by a greatly increased iodine accumulation and consequently by a high iodination rate. Activating TSHR mutations and with lower frequencies Gs-alpha mutations are the main causes of TA or in hyperfunctioning nodules within TMNGs. Furthermore, a recent study has identified a second hit mutation in enhancer of zeste homolog 1 (EZH1) in TA. A significant proportion of patients with TA or TMNG develops thyrotoxicosis, and this is directly related to the duration the goiter has been present. Typically, the thyrotoxicosis comes about insidiously, hence the patient is often unaware of the symptoms. This is particularly seen in the elderly. The symptoms of thyrotoxicosis are those observed with other causes of thyroid hormone excess. The diagnosis of TA and TMNG is based on clinical examination, thyroid function tests, thyroid ultrasound and scintiscanning. Due to the underlying molecular defect, there is no spontaneous resolution of TA and TMNG. Hence ablative treatment is generally indicated, once thyroid autonomy is diagnosed with subclinical or overt hyperthyroidism. The two most widely used ablation modalities are thyroid surgery and radioiodine. Both options, their advantages and potential risks should be openly discussed with the patient and the final decision will be based on patient characteristics (age, the severity of hyperthyroidism, goitre size and extent of nodular thyroid disease, concomitant non-thyroid illness), patient’s preferences, possibly costs and and also logistics.

Keywords

Toxic adenoma Toxic multinodular goiter Goiter TSH receptor mutations Cell proliferation Hyperthyroidism 131-I therapy Surgical treatment Antithyroid drugs 

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Clinical and Experimental Medicine, Endocrinology UnitUniversity Hospital of Pisa, University of PisaPisaItaly
  2. 2.Department of Endocrinology, Diabetes and MetabolismUniversity Hospital Essen, University Duisburg-EssenEssenGermany

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