Natural History

The natural history of nontoxic goiter varies. Children in endemic areas generally have diffuse goiters, whereas sporadic goiters tend to develop at an older age and tend to be nodular. Patients with multinodular goiter are usually older and have larger goiters than do patients with diffuse or uninodular goiters. The growth rate of thyroid nodules is usually slow, but some goiters increase up to 20% yearly.28 Rapid growth of a nodule is usually caused by hemorrhage or cyst formation. One must also be concerned about malignant tumors such as a thyroid lymphoma or a poorly differentiated or anaplastic cancer. Patients with goiters appear to have a slightly higher risk of thyroid malignancy (discussed later). Patients with multinodular goiters and suppressed TSH levels are generally older and have a higher plasma-free T4 level and larger goiters than those with multinodular goiters and a normal TSH. Up to 10% of patients with euthyroid nodular goiter eventually develop hyperthyroidism.29'30

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