A large multinodular goiter with vascular compressive symptoms.                                EXIT

JMAO, 60-y-old, born and living in Sao Paulo .

            This patient was first seen in our out-patient Unit in October 2006. He recalled an enlargement of the cervical area (diagnosed by his family doctor as goiter) since he was 11 years old. He was never treated for this condition. The goiter  progressively grew in size mostly at the right cervical area.  Three years ago he noticed hoarseness and visible “veins” in the right scapular area. About 10 days before the consultation he complained of dysphagia. He is a heavy smoker, denied consuming alcoholic beverages and, to his knowledge, had no family history of goiter or thyroid diseases. A weight loss of approximately 6 kg was noticed in the past 8 months.

            At physical examination, weight was 48.4 kg, height 163 cm, BP normal and normal pulse. There was no finger tremor. The thyroid gland was enlarged mostly at the right side where a large nodule was palpable, with a firm texture. The thyroid was movable, not tender (Figure 1). There was a visible abnormal cutaneous venous circulation extending from the right neck to the upper part of the thorax. There was a visible Pemberton sign (Thyroid 13(4):407-409,2003) when the patient extended both arms upward. (Figure 1) The sign, first described in 1946, is elicited when the patient´s arms are extended above the head, producing facial erythema and suffusion.

Figure 1

Results of Lab tests (Table 1).

            Serum TSH was suppressed, Free T4 was elevated and thyroid auto- antibodies were negative. SerumTG was 58.8 ng/mL. Other routine biochemical tests were normal.

Thyroid echography in Oct 2006 demonstrated a solid hypoechoic nodule with several liquid cystic lesions on the right side, with size of 60X100X100 mm (total volume 312 mL). There were scattered micro calcifications and absence of a nodular halo. The left lobe was normal (about  12 grams). A Doppler study indicated intense vascular signs in the upper part of the nodule.
Figure 2

            Fine needle aspiration biopsy was performed five times with scarce and insufficient  material for cytological analysis at each procedure.

            Two months later the nodule increased in size, attaining a total volume of 480 mL (hemorrhage?). The patient was referred for further imaging procedures.       

  Results of Laboratory tests    

    Free T4:  0.9 - 1.7 ng/dl        Total T4: 4.5 – 11.0 µg/dL                TRAb <12%
Thyroid RAI uptake 12% (2h) and 42% (24h). Thyroid scintigraphy (using both 99m Technetium and MIBI as tracers) indicated scattered uptake in the nodule and normal uptake in the left lobe.

Figure 3

What would you like to do next?

1.      A cardiologic examination 

2.      A cervical and chest X-ray. 

3. Computerized Tomography scan of the cervical area and lungs fields.