Percutaneous ethanol injection under Power Doppler ultrasound assistance in the treatment of autonomously functioning thyroid nodules

Radiofrequency Ablation and Autonomous Functioning Thyroid Nodules: Review of the Current Literature

OBJECTIVE

Autonomously functioning thyroid nodules (AFTNs) have long been treated with either surgery or radioactive iodine (RAI). Being an invasive procedure, even thyroid lobectomy for this condition is associated with complications such as anesthesia side effects, scarring, iatrogenic hypothyroidism, and injury to other structures. Similarly, RAI is associated with hypothyroidism and may require multiple courses. Therefore, minimally invasive techniques such as radiofrequency ablation (RFA) are being advocated as an alternative treatment for AFTNs. To date, only few studies have been published on this topic and are largely on European and Asian populations. The aim of this review is to assess the efficacy and safety of RFA as a potential alternative for treatment of AFTNs compared to conventional surgery and radioiodine.

METHODS/STUDY DESIGN

Comprehensive PubMed and Embase searches were performed using the following terms such as (autonomously functioning thyroid nodules and radiofrequency ablation), (radiofrequency ablation and hyperthyroidism), and (radiofrequency ablation and toxic thyroid nodule). Both prospective and retrospective studies were included based on the inclusion and exclusion criteria specified in the text.

RESULTS

Initially, 57 studies were identified and after excluding 47 studies, finally 10 studies were included in the review.

CONCLUSION

Although surgery remains the first line treatment for AFTN. However, RFA is a safe option compared to RAI or surgery, especially in patients who are high-risk surgical candidates or have absolute contraindications to RAI. Currently, trials with follow-up greater than or equal to 5 years are warranted. It will aid in formulating a standardized surveillance protocol and also generalize RFA's use for AFTN. Laryngoscope, 2021.

[Sclerotherapy as an alternative to surgery for recurrent nodular goiter]

OBJECTIVE

To evaluate the results of treatment of recurrent nodular goiter using sclerotherapy with polidocanol.

MATERIAL AND METHODS

A comparative analysis of sclerotherapy (30 patients) and conventional surgical treatment (17 patients) of recurrent goiter was performed.

RESULTS

Sclerotherapy ensures reduction of nodes (linear dimensions of nodes decreased by 14.2±1.1 mm after 3 courses), correction of endocrine imbalance in patients with functional autonomy and relief of initial signs of cervical organ compression in all patients with recurrent goiter. Sclerotherapy is associated with less pain syndrome and no need for inpatient treatment. However, the most significant advantage is reduced risk of complications. Hypoparathyroidism and laryngeal paresis developed in 53 and 24% of patients after conventional surgery while these events were not observed after sclerotherapy.

CONCLUSION

Sclerotherapy with polidocanol is a perspective alternative to conventional surgery for recurrent nodular goiter.

Comparison between radioiodine therapy and single-session radiofrequency ablation of autonomously functioning thyroid nodules: A retrospective study

OBJECTIVE

To compare the efficacy of Radioiodine (RI) and Radiofrequency ablation (RFA) in the treatment of autonomously functioning thyroid nodules (AFTNs). End-points: nodule volume reduction (NVR) and thyroid function normalization.

DESIGN, PATIENTS AND MEASUREMENTS

Twenty-two patients (2:20 M:F; 51.9 ± 13.9 years) affected by 25 AFTNs, treated by RFA were retrospectively compared with 25 patients (8:17 M:F; 57.2 ± 12.8 years) affected by a single AFTN treated by RI. Both group showed analogous characteristics as to age, gender, toxic/pretoxic phase and pretreatment nodule volume (calculated by the ellipsoid formula). Thyroid hormone levels and autoimmune thyroid profile were assessed before treatment. A fixed RI activity of 555 MBq (15 mCi) was administered. RFA was performed with an 18G, single-tipped electrode, by the "modified moving shot technique." Thyroid hormones were assessed and the nodule post-treatment volume calculated 12 months after treatment.

RESULTS

No statistical difference was found between the post-treatment NVR by comparing RI and RFA (P = 0.69). The volume reduction rates were 68.4 ± 28.9% and 76.4 ± 16.9% after RI and RFA, respectively. As to the thyroid function, 5/25 patients developed clinical hypothyroidism after RI. After RFA, all the 22 patients silenced their AFTN and normalized the thyroid hormones. Subclinical hypothyroidism was recorded in two patients after both RI and RFA. Thus, the functional therapeutic success, defined as the restoration of euthyroidism, was achieved in 18/25 (72%) patients treated by RI and in 20/22 (90.9%) treated by RFA.

CONCLUSIONS

No statistical difference in NVR was found between RI and RFA. All patients responded to RI but 5/25 were "over-treated" developing hypothyroidism. RFA was effective in all patients with no case of post-treatment clinical hypothyroidism. No radiation exposure and lower risk of post-treatment hypothyroidism might make RFA the favourite option especially for young patients.

Image-guided chemical and thermal ablations for thyroid disease: Review of efficacy and complications

Image-guided ablation of thyroid disease is increasingly being commonly reported. Techniques including ethanol injection and thermal ablation using radio-frequency, laser, and microwave devices have been described. Minimally invasive approaches to the management of benign cystic, solid, and functional thyroid nodules as well as both primary and recurrent thyroid malignancy have been reported. The purpose of this article is to review the current evidence relating to image-guided ablation of thyroid disease with a focus on clinical outcomes and complication rates for patients treated with this minimally invasive approach.

Esclerose: uma opção de tratamento para os nódulos tireoidianos císticos

OBJETIVO: Verificar o efeito da injeção percutânea de etanol guiada por ultra-sonografia no tratamento dos nódulos tireoidianos císticos. MATERIAIS E MÉTODOS: Comparou-se o volume de 34 nódulos benignos císticos, em 30 pacientes (26 do sexo feminino e quatro do sexo masculino), antes e uma média de 3,9 meses depois da alcoolização. O volume inicial dos nódulos foi avaliado por dois observadores, que realizaram a ultra-sonografia em momentos diferentes, sem qualquer informação prévia a respeito do tamanho dos nódulos, cuja finalidade foi conhecer a variação interobservador das medidas ecográficas. RESULTADOS: A média de volume dos nódulos antes do tratamento foi de 12,3 ± 18,0 ml. A média de redução de volume foi de 74,0 ± 26,1% (p = 0,0001), e 20,6% (7/34) deles desapareceram. Não houve correlação entre o volume inicial e o percentual de redução dos nódulos. A média de variação das medidas interobservadores foi de 0,5 ml para um alfa de 5%. Dor moderada, no momento da aplicação, foi a complicação mais freqüente. CONCLUSÃO: A injeção percutânea de etanol é uma opção segura e eficaz no tratamento dos nódulos tireoidianos císticos.

Efeito da injeção percutânea de etanol na redução de nódulos tireoideanos

Para verificar a eficácia da injeção percutânea de etanol (IPE) no tratamento de nódulos tireoideanos (NT) comparou-se o volume de 86 nódulos (77 pacientes), antes e após uma ou duas sessões de alcoolização. As medianas do volume inicial e final foram respectivamente: 3,5 mL (0,3 a 82,7) e 1,8 mL (0 a 29,4). Sete por cento dos nódulos desapareceram e a média de redução volumétrica foi de 52,6% ± 31,1 (p< 0,0001). Os diferentes padrões ultra-sonográficos responderam distintamente ao tratamento, com as seguintes medianas de redução: 37,3% (variando de -39,0 a 82,6) nos NT sólidos; 53,5% (14,6 a 88,0) nos predominantemente sólidos; 58,0% (21,0 a 64,5) nos mistos; 71,0% (18,8 a 100,0) nos predominantemente císticos e 90,9% (45,9 a 100,0) nos císticos. Adicionalmente, buscou-se comparar a variação do maior diâmetro dos NT, inicialmente sem tratamento, e após a alcoolização, cuja diferença foi estatisticamente significante (p< 0,00001). A complicação mais freqüente foi dor moderada, em 27,6% dos casos. Concluímos que a IPE mostrou ser uma forma de tratamento segura e eficaz no tratamento de NT benignos.

Tissue Chemoablation

PURPOSE

To provide an overview of the state of the art of tissue chemoablation in animal and human organs and cancers. We also describe our experience with the feasibility, predictability, and reproducibility of necrosis produced by needle chemoablative therapies including ethanol, hypertonic saline, and acetic acid solutions as well as gels in a porcine renal model.

MATERIALS AND METHODS

A MEDLINE search was performed for articles on animal and human tissue chemoablation published since 1965. In addition, at Washington University, experimental chemoablation was performed in pigs with 95% ethanol (4 mL), 24% hypertonic saline (4 mL), or 50% acetic acid (4 mL) solutions as well as in gel form.

RESULTS

There is extensive literature on the use of chemoablation for liver metastases; recently, chemoablation of the prostate has become an area of research. Human studies have been limited to patients who are not surgical candidates or to investigational procedures performed prior to definitive prostatic surgery. Animal studies of renal chemoablation as a sole therapy have produced mixed results. In our studies, only acetic acid provided complete necrosis.

CONCLUSIONS

To date, ethanol chemoablation has been shown to be feasible and reproducible only for metastatic hepatic carcinoma. In urology, chemoablation is still very much in the investigational stage for both the prostate and the kidney. A significant drawback is that even in the gel form, the spread of the chemoablative substance through the tissue is irregular and unpredictable. In the future, chemoablation may become a more effective modality by combining it with radiofrequency or other energy sources.

Injeção percutânea de etanol no tratamento de nódulos tiroidianos sólidos, císticos e autônomos

A injeção percutânea de etanol (IPE) guiada por ultra-som tem sido utilizada para o tratamento de nódulos tiroidianos autônomos, sólidos e císticos. Apresentamos nossa experiência em 50 pacientes tratados, sendo 26 portadores de nódulos sólidos, 17 de nódulos císticos e 7 de nódulos autônomos (NA). Avaliamos os pacientes 1 semana, 1 mês, 3 meses, 6 meses e 1 ano após a IPE. Após 1 ano, os nódulos sólidos reduziram a 74% do volume inicial, os císticos diminuíram 92% sem apresentar recidivas. Um ano após o tratamento dos nódulos autônomos, 5 pacientes estavam em eutiroidismo clínico e laboratorial e 2 em eutiroidismo mas com TSH subnormal. Não houve recorrência da tirotoxicose e a redução nodular foi de 66%. O procedimento foi bem tolerado por todos. Os resultados confirmam que a IPE é uma boa alternativa terapêutica para redução dos nódulos tiroidianos císticos e sólidos e no tratamento dos nódulos autônomos.

Management of simple nodular goiter: current status and future perspectives

The simple nodular goiter, the etiology of which is multifactorial, encompasses the spectrum from the incidental asymptomatic small solitary nodule to the large intrathoracic goiter, causing pressure symptoms as well as cosmetic complaints. Its management is still the cause of considerable controversy. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum TSH and (some kind of) imaging. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, we support the increasing use of fine-needle aspiration biopsy (cytology). Most patients need no treatment after malignancy is ruled out. In case of cosmetic or pressure symptoms, the choice in multinodular goiter stands between surgery, which is still the first choice, and radioiodine if uptake is adequate. In addition to surgery, the solitary nodule, whether hot or cold, can be treated with percutaneous ethanol injection therapy. If hot, radioiodine is the therapy of choice. Randomized studies are scarce, and the side effects of nonsurgical therapy are coming into focus. Therefore, the use of the optimum option in the individual patient cannot at present be based on evidence. However, we are of the view that levothyroxine, although widely used, should no longer be recommended routinely for this condition. Within a few years, the introduction of recombinant human TSH and laser therapy may profoundly alter the nonsurgical treatment of simple nodular goiter.

Treatment of hyperfunctioning thyroid nodules by percutaneous ethanol injection

BACKGROUND: Autonomous thyroid nodules can be treated by a variety of methods. We assessed the efficacy of percutaneous ethanol injection in treating autonomous thyroid nodules. METHODS: 35 patients diagnosed by technetium-99 scanning with hyperfunctioning nodules and suppressed sensitive TSH (sTSH) were given sterile ethanol injections under ultrasound guidance. 29 patients had clinical and biochemical hyperthyroidism. The other 6 had sub-clinical hyperthyroidism with suppressed sTSH levels (<0.24 &mgr;IU/ml) and normal thyroid hormone levels. Ethanol injections were performed once every 1-4 weeks. Ethanol injections were stopped when serum T3, T4 and sTSH levels had returned to normal, or else injections could no longer be performed because significant side effects. Patients were followed up at 3, 6 and, in 15 patients, 24 months after the last injection. RESULTS: Average pre-treatment nodule volume [18.2 PlusMinus; 12.7 ml] decreased to 5.7 PlusMinus; 4.6 ml at 6 months follow-up [P < 0.001]. All patients had normal thyroid hormone levels at 3 and 6 months follow-up [P < 0.001 relative to baseline]. sTSH levels increased from 0.09 PlusMinus; 0.02 &mgr;IU/ml to 0.65 PlusMinus; 0.8 &mgr;IU/ml at the end of therapy [P < 0.05]. Only 3 patients had persistent sTSH suppression at 6 months post-therapy. T4 and sTSH did not change significantly between 6 months and 2 years [P > 0.05]. Ethanol injections were well tolerated by the patients, with only 2 cases of transient dysphonia. CONCLUSION: Our findings indicate that ethanol injection is an alternative to surgery or radioactive iodine in the treatment of autonomous thyroid nodules.

Ultrasound-guided biopsy and ablation in the neck

Management and therapy of conditions of the thyroid, parathyroid glands, and cervical lymph nodes have evolved rapidly during the past 15 years. The development and continued improvement of high-resolution ultrasound (US) equipment, US-guided biopsy, and image-guided ablative techniques have fueled this change. These technical improvements and the knowledge and experience gained during this time have decreased the rate of unnecessary surgery in patients with thyroid nodules. They have also allowed more limited neck dissection in patients with parathyroid adenomas and have led to the development of US-guided ablative techniques that have eliminated the need for surgery in some cases. This article reviews the rationale and techniques of US-guided biopsy of the thyroid, parathyroid, and cervical lymph nodes. Established and evolving ablative techniques of these structures are also examined.