Endocrinology Question 72

A 65-year-old man is evaluated because of painless neck swelling and difficulty swallowing that has progressively worsened over the last year. He does not have hoarseness, but he feels as though his voice is not as strong as it was in the past. Medical history is significant for multiple thyroid nodules. Fine-needle aspiration of three of the largest nodules 5 years ago showed that all nodules were benign on cytologic examination. Medical history is otherwise unremarkable, and he takes no medications.

On physical examination, vital signs are normal. The thyroid is diffusely enlarged and mobile with swallowing. He has facial flushing when raising his hands above his head as shown.

No cervical lymphadenopathy is noted. Cardiovascular and pulmonary examinations are normal. Reflexes are normal, and there is no visible tremor.

Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of 4.0 µU/mL (4.0 mU/L).

Thyroid ultrasound shows innumerable coalescent nodules with no suspicious sonographic features. There is diffuse enlargement of the thyroid, and the inferior edge of the gland cannot be visualized. CT scan shows substernal extension of the goiter in the left lobe with mild tracheal narrowing and tracheal deviation to the right.

Which of the following is the most appropriate treatment?

A  External-beam radiotherapy

B  Levothyroxine

C  Radioactive iodine

Thyroidectomy

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