Case presentation:

• Female.
• 66 y.o.
• Recurrence of multinodular goiter (MNG) with intra-thoracic extension.
• History of mild, intermittent asthma and chronic hypertension treated with ACEI, with no cardiovascular symptoms.
• Her MNG was discovered 33 years before, treated with subtotal thyroidectomy, with benign changes on pathology examination.
• Seven years ago she had a thyroid scintigram performed using 99mTc pertechnetate which revealed significant residual thyroid tissue extending to mediastinum, with globally decreased uptake.
• She received no treatment at that time.
• Two years later she presented with large MNG recurrence, surgery being contraindicated because of anatomic considerations.
• Radiometabolic treatment was performed with 30 mCi of 131I in an attempt to reduce gland volume.

Teaching points:

• Recombinant human TSH (rhTSH)-stimulated iodine scintigraphy is an effective and safe alternative to thyroid hormone withdrawal,to be used during the post-surgical follow-up of papillary and follicular thyroid cancer.
• Its clinical efficiency for the detection of persistent and recurrent disease is similar to that of thyroid hormone withdrawal.
• As a novel clinical application, compressive goiters with benign changes and low uptake of 131I can be efficiently treated with the use of rhTSH.
• Recombinant human TSH-stimulated radioiodine therapy of nodular goiter allows major reduction of the radiation burden with retained efficacy.