How to manage the growth of multi-nodular goiter at 62?

Question

Hello doctor,

I am a 62-year-old male and have had multiple thyroid nodules for the past eight years and have not undergone treatment to date. Annual ultrasounds were done with the latest scan two years ago. The thyroid nodules were initially identified as a solitary nodule in the right lobe and later as multiple nodules in both lobes. Eight years ago, the nodule measured 0.35 inches × 0.24 inches. Two years ago, the largest nodule in the right mid pole was measured at 0.43 inches × 0.26 inches.

Three years ago, scan reports described the nodules as “small cystic nodules,” but two years ago, the nodules were described as “several small hypoechoic nodules.” There was no specific mention that two years ago, the nodules were cystic, solid, or mixed. In both reports, the nodules were described as having well-defined margins, a thin halo around the nodules, no evidence of calcification, no increased vascularity, and no lymph node enlargements in the neck.

The thyroid scan conclusion reports that three years ago and two years ago, there was a multinodular goiter suggestive of benign or adenomatous nodules. Two years ago, the nodules were given a rating of TIRAD 3. None of the previous reports until three years ago had a TIRAD rating.

My recent blood and urine test results from two years ago are as follows:

TSH - 1.10 μIU/ml, free T4 - 1.46 ng/dl, and free T3 - 3.31 ng/dl.
Serum creatinine—1.22 mg/dl.
HBA1C – 5.3 %

Please answer a few of my questions:

The growth of the largest nodule in six years from 0.35 inches × 0.24 inches to 0.43 inches × 0.26 inches. Is it a cause for concern?
Two years ago, the scan reports described the nodules as “small cystic nodules,” but two years ago, they were described as “several small hypoechoic nodules.” Does this mean that the nodules are no longer cystic? Or could it mean that the cystic nodule has also become hypoechoic?
The conclusion in the thyroid scan reports two and three years ago was "multinodular goiter suggestive of benign or adenomatous nodules.” Can I understand from this that the nodules are most likely benign?
If the nodules identified eight years ago were malignant, would symptoms of cancer have already started showing? It has been over six years, and I do not have any thyroid or thyroid cancer symptoms, hence the question.
An endocrinologist I consulted suggested an FNAC even though the nodules are rated TIRAD 3. At TIRAD 3, an FNAC is offered only if the nodule size is ≥ 0.98 inches. Do the endocrinologists follow the TIRAD ratings?

Please guide me.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

I have replied below for all the above five queries in order:

The increase in growth during the six years is not a cause for concern.
All cystic nodules are hypoechoic, but not all hypoechoic nodules are cystic. I understand the word hypoechoic has been used for cystic nodules. We need to confirm from the images.
Benign adenomatous nodules indicate a benign cause.
Malignant nodules proliferate, and if the nodules six years ago were malignant, this would have been evident in follow-up scans.
TIRADS-3 (thyroid imaging reporting and data system) is mildly suspicious, and only four percent of such nodules are likely malignant. TIRADS is a recent criterion, and many endocrinologists follow the ratings.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I understand your concern.

Thanks for sharing the images (attachments removed to protect the patient’s identity). The nodules in the thyroid are looking benign. However, follow-up is suggested.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.

Answer 3

Hello,

Welcome back to icliniq.com.

I understand your concern.

I have replied below for all the above four questions in order:

Most of the nodules are cystic and show fluid contents. There are a few settings on the machine that need to be used when doing scans to confirm the pure cystic nature. The word "hypoechoic" is synonymous with cystic nature for many of the nodules.
An annual ultrasound is sufficient, but if you find any nodules or the thyroid gland showing recent enlargement in a few weeks, it needs to be scanned.
No one can guarantee that a nodule will not get cancerous, but in view of your previous history and age, it is likely that cancer transformation changes are rare.
Thyroid disease is common and has a wide spectrum. If a person has significant abnormal thyroid hormones, then they need treatment with medicines. Most nodules do not require specific treatment unless they cause discomfort or show suspicious features of neoplasm.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.