Treatment of Thyroid Adenoma With a Solitary Hyperfunctioning Nodule and Subnormal TSH

This protocol covers thyroid adenoma presenting as a solitary or dominant thyroid nodule that is functioning — or hyperfunctioning — on thyroid scintigraphy, with visible suppression of the surrounding peri-nodular thyroid tissue and a subnormal serum TSH.

Clinical Scenario

Approximately 5–10% of solitary or dominant thyroid nodules are found to be functioning on thyroid scintigraphy, with suppression of the peri-nodular thyroid tissue. The subnormal serum TSH is the defining biochemical feature that characterises this presentation.

Treatment Approach

Management involves targeted ablative or interventional strategies. One well-established approach delivers a form of targeted internal radiation to the nodule; in patients who are severely hyperthyroid or have cardiac comorbidity, a preparatory medical step may be used beforehand. Surgical and thermal interventional options also form part of the evidence-based approach, with nodule size being a key factor in selection.

Clinical Goals

The primary aims are restoration of euthyroidism and a clinically meaningful reduction in nodule size assessed at twelve months. The complete structured protocol contains full patient-selection criteria, sequencing, and follow-up guidance.

References

DOI: 10.1530/ETJ-23-0067

Approximately 5–10% of solitary/dominant thyroid nodules are functioning on thyroid scintigraphy, with suppression of the peri-nodular thyroid tissue.
RAI is recommended as an alternative to surgery and MIT in hyper-functioning solitary thyroid nodules.
Unless severely hyperthyroid or with cardiac comorbidity, individuals rarely need pre-treatment with anti-thyroid drugs.
TA is an alternative to RAI and surgery in small hyperfunctioning nodules (<10 mL), while it performs poorer in larger nodules.
Surgery is one of the available therapeutic options, besides RAI and MIT, for hyperfunctioning nodules and toxic multinodular goiter.
RAI is most often given as a fixed activity (e.g. 185–370 MBq), most often achieves euthyroidism, may cause hypothyroidism, and reduces nodule size by 30–50% in 12 months.

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