CLINICAL MANIFESTATIONS OF TOXIC ADENOMA AND TOXIC MULTINODULAR GOITER

Overview and Pathophysiology

1. Definition
   • Hyperthyroidism caused by hyperfunctioning thyroid adenoma(s) independent of TSH (thyrotropin) regulation.
   • Second most common cause of hyperthyroidism after Graves disease.
2. Somatic Mutations
   • Often related to activating mutations in the TSH receptor gene → constitutive thyroid hormone production.
   • Toxic Multinodular Goiter: Multiple nodules with similar mutations in some nodules, others differ in function.
   • Toxic Adenoma: Typically a single, autonomously functioning thyroid nodule.

Clinical Features Distinct from Graves Disease

1. Demographics
   • Patients usually >40 years old.
   • Often have a long-standing multinodular goiter or single thyroid nodule.
2. Cardiovascular Dominance
   • Marked shortness of breath, tachycardia, frequently atrial fibrillation.
   • Heart failure can occur, but no prolonged circulation time (unlike Graves).
3. Lack of Eye and Skin Findings
   • No ophthalmopathy, pretibial myxedema, or thyroid acropachy (common in Graves).
   • Possible mild eyelid retraction or eyelid lag, but minimal if any.
4. Less Severe Hypermetabolic Symptoms
   • Less muscle weakness, less weight loss, and lower nervous excitability compared to Graves.
   • Many female patients are postmenopausal → fewer menstrual cycle changes.
5. Hormone Levels
   • Moderate elevations in serum free T4 and total T3 (not as high as Graves).
   • Slight decrease in total and HDL cholesterol.

Radioactive Iodine Uptake and Imaging

1. Toxic Adenoma (Solitary Nodule)
   • High uptake localized in the hyperfunctioning nodule.
   • No uptake in the rest of the gland (“suppressed” normal thyroid).
2. Toxic Multinodular Goiter
   • One or more areas of focal increased uptake (hot nodules).
   • Remaining gland may show multiple “cold” (nonfunctioning) or normal areas.

Management

1. Symptomatic Control
   • β-Adrenergic blockers (e.g., propranolol) to manage palpitations, tremor, tachycardia.
2. Definitive Treatment
   • Thionamides (e.g., methimazole, propylthiouracil) → typically used short-term in elderly or cardiac-compromised patients to achieve euthyroidism before definitive therapy.
     • Unlike Graves disease, hyperthyroidism recurs if thionamides are withdrawn without further intervention.
   • Radioiodine Ablation → destroys hyperfunctioning nodule(s) over 2–4 months.
     • Most patients become euthyroid because normal thyroid tissue is suppressed and takes up little radioiodine.
     • Large toxic multinodular goiters may respond less to radioiodine → surgery is often preferred.
3. Surgery
   • Especially if goiter is very large, causing compressive symptoms, or if there is suspicion of malignancy.
   • Also for those who prefer surgical resolution or are not good candidates for radioiodine.

PATHOPHYSIOLOGY OF TOXIC ADENOMA AND TOXIC MULTINODULAR GOITER

Typical Patient Profile

• Often an older adult (commonly middle-aged woman).
• History of nontoxic (euthyroid) nodular goiter that later becomes hyperfunctional.

Cardiac Manifestations

• High-output heart failure: Short circulation time with high venous pressure.
• Palpitations, atrial fibrillation, dyspnea.
• Fewer extrathyroidal findings compared to Graves disease (no ophthalmopathy, dermopathy, or muscle weakness typical of Graves).

Pathologic Findings

1. Single Toxic Adenoma
   • One enlarged hyperfunctioning nodule (often red in color).
   • Remaining gland is suppressed, smaller or nonfunctional.
   • Very rare to hear a bruit or feel a thrill.
   • Histology: Uniform hyperplasia of follicular cells with minimal papillary infolding, no lymphocytic infiltration.
2. Multinodular Goiter
   • Multiple nodules: Some hyperfunctioning (hot), others hypofunctioning (cold).
   • Possibly malignant or premalignant foci in one nodule.
   • Histology of functioning areas resembles an adenoma (well-differentiated hyperplasia), distinct from surrounding normal tissue.
3. Molecular Basis
   • Constitutive activation of TSH receptor in the nodule(s) from somatic point mutations.