May I pick your brain? I read Cooper’s article on subclinical hyperthyroid. However I have a 44yo woman with nodule TSH 0.17 sent to me for Bx.I deferred the Bx and recommended a scan.The nodule was hypervascular on Doppler, however it was 2.8cm vs 1.5cm 3 years earlier.How do you approach hot nodules in subclinical hyperthyroidism?
I will presume that the has no symptoms, the isotope scan shows a hot nodule with the rest of the gland suppressed, and that the FT4 and T3 are in the “normal” range. If so, her gland is indeed producing a bit too much hormone, and perhaps she has a mutated constitutively active TSH-receptor. According to Joel Hamburger she most likely will become overtly toxic in time, but has a significant chance of staying the same for years, or even undergoing regression (maybe bleeding and necrosis?). If she has no symptoms, waiting seems OK, to see what develops. But she does have an increased risk of developing AF, and maybe some bone trouble over many years If she has symptoms of hyperthyroidism now, I believe most thyroidologists would treat with RAI, and assume the risk of malignancy was low.. There is a 10-20 % risk of hypothyroidism. Surgery is also a nice alternative if the diagnosis is clear and you have a good surgeon, since the residual gland is presumably normal.
L De Groot, MD