Treatment of euthyroid multinodular goitre
	It is not the aim to enter a detailed discussion on therapy of multinodular goitre in a euthyroid subject. It depends considerably on the informed opinion of the patient. If the risk of malignancy is negligible and thyroid function is normal observation may be the choice. In areas with relatively low iodine intake, a lifelong small iodine supplement may be recommended. We use vitamin/mineral tablets containing 150 µg iodine. Iodine, even in small doses, increases the risk for hyperthyroidism, especially in more advanced autono-mous multinodular goitre. Therefore thyroid function should be controlled. This type of iodine induced hyperthyroidism is reversible (fig. 5). Another option is radioiodine therapy 3. We use radioiodine therapy as a primary choice in euthyroid multinodular goitre if treatment is needed. Surgery effectively removes the goitre. A trend among thyroid surgeons is to perform total thyroidectomy to avoid regrowth of the goitre from remnant abnormal tissue. Obviously this implicates life long thyroid hormone substitution therapy in all patients. Surgery includes the well known risks of vocal cord paralysis and hypoparathyroidism and the general risks of surgery. In general we follow the principle that surgery should not be performed if cheaper non invasive alternatives are at hand. Numerous trials have evaluated the effect of T4 treatment to suppress TSH on the size and growth of goitre and thyroid nodules. In many studies it is impossible to judge the nature of the goitre and nodules (solitary neoplastic lesion in a normal gland? thyroid autoimmunity with an increase in TSH? multinodular goitre?). There is at present no evidence that a solitary neoplastic lesion in an otherwise normal thyroid gland of a person living in an area with sufficient iodine intake will behave differently on T4 or iodine therapy than on placebo. Studies in areas where patients presumeably had multinodular goitre have shown that neither T4 nor iodine have any major effect in patients with advanced disease (and many develop hyperthyroidism). In the early stages with only few nod-ules and moderate follicular cell proliferation, both iodine and T4 reduce goitre size and diminish progression of disease moderately. It is at present unclear to what extent the effect of T4 is due to the iodine content of the preparation (2/3 by weight) and/or to the decrease in serum TSH.