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Vorländer C. [Local ablative procedures for treatment of thyroid nodules]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02101-1. [PMID: 38772926 DOI: 10.1007/s00104-024-02101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/23/2024]
Abstract
Thyroid nodules are very frequent in the iodine deficiency regions of central Europe and some of the affected patients are referred for definitive treatment, such as surgery and radioiodine treatment. In recent years nonsurgical and non-radioiodine techniques have been introduced to treat thyroid gland pathologies. These techniques include the probe-based techniques of radiofrequency, microwave and laser application. The only noninvasive technique is high-intensity focused ultrasound. All mentioned techniques have the goal to reduce the volume of the thyroid nodule by application of energy/heat. The knowledge of all techniques and their advantages and risks is necessary to help physicians and patients in making decisions for the appropriate method of treatment of thyroid nodules.
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Affiliation(s)
- Christian Vorländer
- Klinik für Endokrine Chirurgie, Bürgerhospital und Clementine Kinderhospital gemeinnützige GmbH, Nibelungenallee 37-41, 60318, Frankfurt am Main, Deutschland.
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2
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Bojunga J, Trimboli P. Thyroid ultrasound and its ancillary techniques. Rev Endocr Metab Disord 2024; 25:161-173. [PMID: 37946091 DOI: 10.1007/s11154-023-09841-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
Ultrasound (US) of the thyroid has been used as a diagnostic tool since the late 1960s. US is the most important imaging tool for diagnosing thyroid disease. In the majority of cases a correct diagnosis can already be made in synopsis of the sonographic together with clinical findings and basal thyroid hormone parameters. However, the characterization of thyroid nodules by US remains challenging. The introduction of Thyroid Imaging Reporting and Data Systems (TIRADSs) has improved diagnostic accuracy of thyroid cancer significantly. Newer techniques such as elastography, superb microvascular imaging (SMI), contrast enhanced ultrasound (CEUS) and multiparametric ultrasound (MPUS) expand diagnostic options and tools further. In addition, the use of artificial intelligence (AI) is a promising tool to improve and simplify diagnostics of thyroid nodules and there is evidence that AI can exceed the performance of humans. Combining different US techniques with the introduction of new software, the use of AI, FNB as well as molecular markers might pave the way for a completely new area of diagnostic accuracy in thyroid disease. Finally, interventional ultrasound using US-guided thermal ablation (TA) procedures are increasingly proposed as therapy options for benign as well as malignant thyroid diseases.
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Affiliation(s)
- Joerg Bojunga
- Department of Medicine I, Goethe University Hospital, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | - Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana (USI), Lugano, Switzerland
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3
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Richter JP, Richter CP, Gröner D. [Ultrasound-guided ablation techniques for thyroid lesions]. Laryngorhinootologie 2023; 102:916-927. [PMID: 37734389 DOI: 10.1055/a-2144-4132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Ultrasound-guided ablation techniques have been increasingly introduced into routine treatment of thyroid lesions as a complement to existing surgical therapies and radioiodine treatment. In cystic or predominantly cystic lesions instillation therapy (ethanol/polidocanol ablation) has yielded good results. Novel thermal ablation techniques, including radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation (LA) and high intensity focused ultrasound (HIFU), induce irreversible cellular effects by locally applying temperatures ≥ 60 °C to the targeted thyroid region. Lesions causing local symptoms or focal hyperfunctionality can thus be selectively treated under continuous sonographic monitoring. While a considerable body of evidence supports the efficacy and safety of various local ablative techniques, future challenges lie in initiating comparative prospective trials and in standardizing clinical practice, training and continuous quality assessment on a regional and superregional level. In the future, it shall be indicated to include local ablative techniques - so far not known to all patients in Germany - into the informed decision-making process as a suitable alternative or supplement to existing therapies.
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Affiliation(s)
- Johannes-Paul Richter
- Klinik für Nuklearmedizin, Universitätsklinikum Magdeburg, Otto-von-Guericke-Universität, Magdeburg
| | - Carl-Philip Richter
- Chirurgische Klinik am Rathenauplatz, Schilddrüsenzentrum Baden-Württemberg, Heilbronn
| | - Daniel Gröner
- Klinik für Nuklearmedizin, Universitätsklinikum Frankfurt am Main, Frankfurt am Main
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Klimek K, Mader N, Happel C, Sabet A, Grünwald F, Groener D. Heat sink effects in thyroid bipolar radiofrequency ablation: an ex vivo study. Sci Rep 2023; 13:19288. [PMID: 37935715 PMCID: PMC10630443 DOI: 10.1038/s41598-023-45926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023] Open
Abstract
The study aimed to investigate heat sink effects in radiofrequency ablation (RFA) under thyroid-specific conditions. In an ex vivo model, bovine thyroid lobes were ablated using bipolar RFA with 2.0 kJ energy input at a power level set to 10 W (n = 35) and 25 W (n = 35). Glass vessels (3.0 mm outer diameter) placed within the ablation zone were used to deliver tissue perfusion at various flow rates (0, 0.25, 0.5, 1, 5, 10, 20 ml/min). Temperature was measured in the proximity of the vessel (Tv) and in the non-perfused contralateral region of the ablation zone (Tc), at equal distances to the ablation electrode (d = 8 mm). Maximum temperature within the perfused zone was significantly lowered with Tv ranging from 54.1 ± 1.5 °C (20 ml/min) to 56.9 ± 1.5 °C (0.25 ml/min), compared to Tc from 63.2 ± 3.5 °C (20 ml/min) to 63.2 ± 2.6 °C (0.25 ml/min) (10 W group). The cross-sectional ablation zone area decreased with increasing flow rates from 184 ± 12 mm2 (0 ml/min) to 141 ± 20 mm2 (20 ml/min) at 10 W, and from 207 ± 22 mm2 (0 ml/min) to 158 ± 31 mm2 (20 ml/min) in the 25 W group. Significant heat sink effects were observed under thyroid-specific conditions even at flow rates ≤ 1 ml/min. In thyroid nodules with prominent vasculature, heat dissipation through perfusion may therefore result in clinically relevant limitations to ablation efficacy.
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Affiliation(s)
- Konrad Klimek
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Nicolai Mader
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Christian Happel
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Amir Sabet
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Daniel Groener
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany.
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5
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Del Rio P, Polistena A, Chiofalo MG, De Pasquale L, Dionigi G, Docimo G, Graceffa G, Iacobone M, Medas F, Pezzolla A, Sorrenti S, Spiezia S, Calò PG. Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2023; 75:1393-1417. [PMID: 37198359 PMCID: PMC10435599 DOI: 10.1007/s13304-023-01522-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/23/2023] [Indexed: 05/19/2023]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.
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Affiliation(s)
- P Del Rio
- Unit of General Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - A Polistena
- Department of Surgery Pietro Valdoni, University of Rome Sapienza, Rome, Italy
| | - M G Chiofalo
- Department Head and Neck, Thyroid Surgery Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - L De Pasquale
- Thyroid and Parathyroid Service, Otolaryngology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - G Dionigi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Division of Surgery, Istituto Auxologico Italiano Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - G Docimo
- Division of Thyroid Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - G Graceffa
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - M Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
| | - A Pezzolla
- Division of Videolaparoscopic Surgery, Department of Emergency and Organ Transplanatation, University of Bari "A. Moro", Bari, Italy
| | - S Sorrenti
- Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - S Spiezia
- Department of Endocrine and Ultrasound-guided Surgery, Ospedale del Mare, Naples, Italy
| | - P G Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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6
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Ahn D. Ultrasound-Guided Ethanol Ablation for Thyroglossal Duct Cyst: A Review of Technical Issues and Potential as a New Standard Treatment. J Clin Med 2023; 12:5445. [PMID: 37685512 PMCID: PMC10487699 DOI: 10.3390/jcm12175445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
The thyroglossal duct cyst (TGDC) is the most common congenital neck mass, accounting for 70-75% of all congenital neck masses. Although the Sistrunk operation has been used as a standard of treatment, it is accompanied by a considerable surgical burden, including the need for general anesthesia, a visible surgical scar on the neck surface, and postoperative complications. Ultrasound-guided ethanol ablation (US-EA) is a minimally invasive and office-based technique that is widely used as a non-surgical treatment for several benign cystic lesions, particularly benign thyroid cysts. Recently, US-EA has also been gaining popularity as a good alternative for TGDC treatment, which is associated with high feasibility, a high safety profile, and favorable treatment outcomes. To our best knowledge, seven studies on the use of EA as a primary treatment option for TGDC have been published since 2011. Although these studies have reported promising results, there is a lack of consensus on several issues regarding the application of EA for TGDC, particularly its detailed techniques and role as a primary treatment. This article aims to provide a comprehensive review of EA for TGDC, addressing technical issues and its possible role as a new standard of treatment for TGDC.
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Affiliation(s)
- Dongbin Ahn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea
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Gao K, Dai W, Wang F, He S. Efficacy Assessment and Analysis of Related Factors of Ultrasound-Guided Percutaneous Lauromacrogol Injection for Cystic Thyroid Nodules. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1093-1101. [PMID: 36401842 DOI: 10.1002/jum.16123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/08/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES This study aimed to investigate the factors influencing the short-term and long-term efficacy of sclerotherapy for cystic thyroid nodules. METHODS Ninety-nine cystic thyroid nodules that underwent ultrasound-guided fine-needle aspiration biopsy, detection of thyroglobulin in fine needle aspirate (Tg-FNA), and ultrasound-guided percutaneous lauromacrogol injection were retrospectively enrolled from July 2018 to July 2021. All nodules were followed up at 3 and 12 months after the procedure. Factors related to lauromacrogol injection efficacy, including initial volume, vascularity, pathological types, and Tg-FNA level, were analyzed. The nodules were classified as non-effective (VRR <50%) and effective groups (VRR ≥50%) at 3 months to evaluate short-term prognosis, and non-cured (VRR <90%) and cured groups (VRR ≥90%) at 12 months to evaluate long-term prognosis. RESULTS The volume of cystic thyroid nodules tended to shrink during follow-up. The resolution rate was 79.80% (79/99) at 3 months and 96.91% (94/97) at 12 months. The cure rate was 80.41% (78/97) at 12 months. Independent factors for the long-term prognosis included Tg-FNA level and vascularity (P < .05). Only Tg-FNA level was an independent factor for the short-term prognosis (P < .05). The area under the receiver operating characteristic curve for assessing the efficacy at 3 months was 0.79 (95% confidence interval [CI]: 0.65-0.89). With a cutoff value of Tg-FNA 126.92 ng/mL, the specificity was 0.70, and the sensitivity was 0.85. CONCLUSIONS Ultrasound-guided percutaneous lauromacrogol injection is an effective treatment option for cystic thyroid nodules. It is less effective in viscous or vascular predominantly cystic nodules.
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Affiliation(s)
- Kan Gao
- Department of Ultrasound, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Weide Dai
- Department of Ultrasound, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Feiliang Wang
- Department of Ultrasound, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Shurong He
- Department of Pathology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
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8
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Ben Hamou A, Ghanassia E, Muller A, Ladsous M, Paladino NC, Brunaud L, Leenhardt L, Russ G. SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Thermal ablation. ANNALES D'ENDOCRINOLOGIE 2022; 83:423-430. [PMID: 36306894 DOI: 10.1016/j.ando.2022.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with thermal ablation, which may constitute an alternative to thyroid surgery in selected patients.
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Affiliation(s)
- Adrien Ben Hamou
- Thyroid and Endocrine Tumors Department, Institute of Endocrinology, Pitié-Salpêtrière Hospital AP-HP, Sorbonne University, 75013 Paris, France; American Hospital of Paris, Thyroid Unit, 92200 Neuilly-sur-Seine, France
| | - Edouard Ghanassia
- American Hospital of Paris, Thyroid Unit, 92200 Neuilly-sur-Seine, France; Polyclinique Sainte-Thérèse, 34200 Sète, France
| | - Arnaud Muller
- Department of Imaging, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, 69495 Pierre Bénite, France; Imagerie Médicale Val d'Ouest - Charcot, 53 Rue du Commandant Charcot, 69110 Sainte-Foy-Lès-Lyon, France
| | - Miriam Ladsous
- CHU Lille, Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, Hôpital Claude Huriez, 59000 Lille, France
| | - Nunzia Cinzia Paladino
- Aix Marseille Univ, APHM, Department of General Endocrine and Metabolic Surgery, Conception University Hospital, 13005 Marseille, France
| | - Laurent Brunaud
- Department of Gastrointestinal, Metabolic and Cancer Surgery (CVMC), CHRU Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | - Laurence Leenhardt
- Thyroid and Endocrine Tumors Department, Institute of Endocrinology, Pitié-Salpêtrière Hospital AP-HP, Sorbonne University, 75013 Paris, France; Institute of Cancer IUC Sorbonne University GRC N°16, 75013 Paris, France.
| | - Gilles Russ
- Thyroid and Endocrine Tumors Department, Institute of Endocrinology, Pitié-Salpêtrière Hospital AP-HP, Sorbonne University, 75013 Paris, France; Institute of Cancer IUC Sorbonne University GRC N°16, 75013 Paris, France; Centre de Pathologie et d'Imagerie, 14, Avenue René-Coty, 75014 Paris, France
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9
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Li L, Qiu X. Safety and Efficacy of Ultrasound-Guided Radiofrequency Ablation for Benign Nonfunctional Thyroid Nodules in Children: A Retrospective Study of 62 Patients with Over Four Years of Follow-Up. Thyroid 2022; 32:525-535. [PMID: 34915754 DOI: 10.1089/thy.2021.0454] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: Image-guided radiofrequency ablation (RFA) for benign nonfunctional thyroid nodules in adults has been shown to be effective and safe, but few trials address the use of RFA in children. Therefore, this study was designed to assess the efficacy and safety of RFA application to benign nonfunctional thyroid nodules in children. Methods: A retrospective study of RFA for 70 benign nonfunctional thyroid nodules in 62 children with four-year follow-up was conducted. Volume reduction ratio (VRR), technique efficacy, regrowth rate, symptom score, and cosmetic score were calculated to evaluate the efficacy. Complications and side effects were recorded. Logistic regression analysis was performed to identify risk factors, and subgroup analyses were performed. Results: Patients were followed up for at least four years (59.1 ± 10.5 months, range 48-85 months). After RFA treatment, the VRR and technique efficacy rates were highest at the first year* (77.5% and 91.4%, respectively) but decreased by four years (55.1% and 81.4%, respectively). The symptom score decreased from 4.0 ± 2.1* to 0.8 ± 1.6 (Z = -6.82, p < 0.001), and the cosmetic score decreased from 3.3 ± 0.7 to 1.3 ± 0.9 (Z = -7.0, p < 0.001).* The nodule regrowth rate was 22.9%, of which 56.3% of cases represented loss of efficacy. In the cases of loss of efficacy, 66.7% had greater volume than their initial presentation. Patients who received a second RFA treatment due to loss of efficacy lost efficacy again. Bilateral nodules, low vascularity, and low cystic components were independent risk factors correlating with technique efficacy. Bilateral nodules correlated with low VRR, low efficacy rate, and high regrowth rate. Nodules with a higher proportion of cystic components had higher VRR. The overall complication rate was 4.8%. Conclusions: RFA was effective in reducing the volume of benign nonfunctional thyroid nodules in children, providing significant symptomatic relief with a good safety profile during short- and long-term follow-up. RFA is a good minimally invasive treatment modality for selected pediatric patients, and it may not be appropriate for the treatment of bilateral thyroid nodules in children.
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Affiliation(s)
- Liwen Li
- Department of Thyroid surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
| | - Xinguang Qiu
- Department of Thyroid surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
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10
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Stan MN, Papaleontiou M, Schmitz JJ, Castro MR. Nonsurgical Management of Thyroid Nodules: The Role of Ablative Therapies. J Clin Endocrinol Metab 2022; 107:1417-1430. [PMID: 34953163 PMCID: PMC9016471 DOI: 10.1210/clinem/dgab917] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/02/2022]
Abstract
CONTEXT After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma surgery or radioactive iodine (RAI) (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (eg, scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks. CASES We present 4 cases of thyroid lesions causing concern (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients' attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation [RFA] being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects, and conclude with a simplified description of how these procedures are performed. CONCLUSION Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules, while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.
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Affiliation(s)
- Marius N Stan
- Correspondence: Marius N. Stan, Division of Endocrinology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John J Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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11
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Grußendorf M. [Thyrotoxicosis]. MMW Fortschr Med 2021; 163:50-59. [PMID: 34595648 DOI: 10.1007/s15006-021-0261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Eisele RM, Scherber PR, Schlüter M, Drews T, Glanemann M, Gäbelein G. Thermoablation of thyroid nodules reveals excellent results with low morbidity. Technol Health Care 2021; 30:683-689. [PMID: 34397442 DOI: 10.3233/thc-213181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thermoablation is an attractive treatment of thyroid nodules for its minimal-invasiveness. It remains unclear whether results and morbidity meet the patients' expectations. OBJECTIVE The aim of the presented study is to show data obtained after microwave thyroid ablation from a patients' perspective. METHODS Indications and preoperative diagnosis were chosen according to international guidelines. Thermoablation was achieved using a CE certified microwave system. The procedures heeded the published recommendations of the European Federation of Societies for Ultrasound in Medicine and Biology. Follow-up included ultrasound, laboratory parameters and a standardized questionnaire. RESULTS Thirty patients were enrolled into the study. All patients reported an improvement of complaints following the procedure. Scar formation occurred in 3 cases (10%) with 0.5 ± 1.3 mm length and 0.4 ± 1.0 mm width. No cosmetic, neurological, vocal or pharyngeal complication occurred. Energy required for non-functioning nodules (n= 15, 50%) was 2.56 ± 3.41 kJ/mL, for autonomous adenoma (n= 8, 27%) 0.96 kJ/mL (p< 0.05, t-test). CONCLUSION The presented data summarize an initial experience in selected patients and resemble excellent patient reported outcome with minimal morbidity. These preliminary data indicate the majority of patients satisfied with the procedure. Further trials will be required to endorse these findings.
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Affiliation(s)
| | - Philipp R Scherber
- Department of General, Visceral, Vascular and Pediatric Surgery, Medical Faculty, University of Saarland, Homburg, Germany
| | - Monika Schlüter
- Department of General, Visceral, Vascular and Pediatric Surgery, Medical Faculty, University of Saarland, Homburg, Germany
| | | | - Matthias Glanemann
- Department of General, Visceral, Vascular and Pediatric Surgery, Medical Faculty, University of Saarland, Homburg, Germany
| | - Gereon Gäbelein
- Department of General, Visceral, Vascular and Pediatric Surgery, Medical Faculty, University of Saarland, Homburg, Germany
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13
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Muhammad H, Tehreem A, Russell JO, Tufano RP. Radiofrequency Ablation and Autonomous Functioning Thyroid Nodules: Review of the Current Literature. Laryngoscope 2021; 132:906-914. [PMID: 34375454 DOI: 10.1002/lary.29811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Haris Muhammad
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, Maryland, U.S.A
| | - Aniqa Tehreem
- Department of Internal Medicine, Sinai Hospital, Baltimore, Maryland, U.S.A
| | - Jonathon O Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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14
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Bernardi S, Palermo A, Grasso RF, Fabris B, Stacul F, Cesareo R. Current Status and Challenges of US-Guided Radiofrequency Ablation of Thyroid Nodules in the Long Term: A Systematic Review. Cancers (Basel) 2021; 13:2746. [PMID: 34205994 PMCID: PMC8199252 DOI: 10.3390/cancers13112746] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/22/2021] [Accepted: 05/28/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND US-guided minimally-invasive techniques, such as radiofrequency ablation (RFA) have emerged as an alternative treatment for benign and malignant thyroid nodules. This systematic review aims to provide an overview on the long-term outcomes of US-guided RFA in patients with benign and malignant thyroid nodules. METHODS We systematically searched PubMed/MEDLINE, EMBASE, and Scopus to identify articles reporting the outcomes of thyroid RFA after a follow-up of at least 3 years. RESULTS A total of 20 studies met the inclusion criteria and were included in the review. In patients with benign thyroid nodules, RFA significantly reduced nodule volume and this was generally maintained for the following 5 years. However, a small but not negligible proportion of nodules regrew and some of them required further treatments over time. In patients with malignant nodules, RFA has been used not only to treat differentiated thyroid cancer (DTC) neck recurrences, but also to treat papillary thyroid microcarcinoma (PTMC). In most patients with PTMC, RFA led to complete disappearance of the tumor. When it was compared to surgery, RFA was not inferior in terms of oncologic efficacy but it had a lower complication rate. However, RFA did not allow for final pathology, disease staging and accurate risk stratification. CONCLUSIONS US-guided RFA significantly reduces benign thyroid nodules and destroys most PTMC, and this is generally maintained for at least 5 years after the initial treatment. Further studies addressing the risk of regrowths in patients with benign thyroid nodules, as well as the risk of recurrence in patients with PTMC are needed.
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Affiliation(s)
- Stella Bernardi
- Department of Medical Sciences, University of Trieste, 34149 Trieste, Italy;
- U.C.O. Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Hospital, 34149 Trieste, Italy
| | - Andrea Palermo
- Unità di Endocrinologia e Diabete, Policlinico Universitario Campus Bio-Medico, 00128 Roma, Italy;
| | - Rosario Francesco Grasso
- U.O.S. Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, 00128 Roma, Italy;
| | - Bruno Fabris
- Department of Medical Sciences, University of Trieste, 34149 Trieste, Italy;
- U.C.O. Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Hospital, 34149 Trieste, Italy
| | - Fulvio Stacul
- S.C. Radiologia, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Maggiore Hospital, 34125 Trieste, Italy;
| | - Roberto Cesareo
- U.O.S. Malattie Metaboliche, Ospedale Santa Maria Goretti, 04100 Latina, Italy;
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15
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Yang CC, Hsu Y, Liou JY. Efficacy of Ethanol Ablation for Benign Thyroid Cysts and Predominantly Cystic Nodules: A Systematic Review and Meta-Analysis. Endocrinol Metab (Seoul) 2021; 36:81-95. [PMID: 33677930 PMCID: PMC7937837 DOI: 10.3803/enm.2020.833] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/10/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Ultrasound-guided minimally invasive procedures are widely used to treat thyroid diseases. The objective of this study was to assess the efficacy and safety of ethanol ablation (EA) in comparison with other non-surgical options in the treatment of benign thyroid cystic nodules. METHODS We conducted a systematic search of studies on EA for thyroid cystic nodules, mainly in the Ovid-MEDLINE and Embase, Web of Science, and Cochrane databases. The standardized mean difference (SMD) of the volume reduction ratio (VRR) after EA versus other non-surgical treatments comprised the primary outcome, whereas the odds ratio (OR) of therapeutic success rates between the two groups comprised the secondary outcome. RESULTS The meta-analysis included 19 studies (four randomized controlled trials and 15 non-randomized studies) with 1,514 participants. The cumulative VRR of EA was 83.908% (95% confidence interval [CI], 79.358% to 88.457%). EA had a significantly higher pooled VRR (SMD, 0.381; 95% CI, 0.028 to 0.734; P=0.030), but not a significantly higher pooled therapeutic success rate (OR, 0.867; 95% CI, 0.132 to 5.689; P=0.880), than other forms of non-surgical management including radiofrequency ablation (RFA), polidocanol sclerotherapy, and simple aspiration with or without saline flush. However, the VRR and therapeutic success rate were not significantly different between EA and RFA. Major complications were recorded only in six patients (0.53%) with self-limiting dysphonia. CONCLUSION The role of EA as the first-line treatment for benign thyroid cysts and predominantly cystic nodules is supported by its high effectiveness and good safety profile compared to other currently available non-surgical options.
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Affiliation(s)
- Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
| | - Yung Hsu
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
| | - Jyun-Yan Liou
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
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16
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[The "hot" thyroid gland carcinoma and a critical look at thermal ablation]. Chirurg 2021; 92:34-39. [PMID: 32968827 PMCID: PMC7511143 DOI: 10.1007/s00104-020-01287-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hot and hyperfunctioning thyroid gland nodules are currently treated primarily by radioiodine or surgical resection. In recent years local thermal ablation as an alternative therapeutic modality is increasingly recommended. This article reports the case of a patient with a hot thyroid nodule, which was resected and turned out to be follicular thyroid cancer. In this context it appears to be necessary to critically question thermal ablation as an alternative treatment option for thyroid nodules, particularly since the current recommendations are weak with low or even very low evidence. Radioiodine or surgery remains the first-line treatment for hot and hyperfunctioning thyroid nodules but malignancy in a hot thyroid nodule also needs to be considered.
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17
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He L, Zhao W, Xia Z, Su A, Li Z, Zhu J. Comparative efficacy of different ultrasound-guided ablation for the treatment of benign thyroid nodules: Systematic review and network meta-analysis of randomized controlled trials. PLoS One 2021; 16:e0243864. [PMID: 33471820 PMCID: PMC7816973 DOI: 10.1371/journal.pone.0243864] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Percutaneous ablation is currently deemed an additionally treatment option for benign thyroid nodules in the world, but possibly different effect among the ablation modalities is not clear. So we aim to evaluate the efficacy and complications of thermal/chemical ablation by network meta-analysis. MATERIALS AND METHODS In the network meta-analysis, PubMed, EMBASE and the Cochrane Library databases were searched from 1980 to 2020. Studies of adults with thyroid benign nodules under percutaneous ablation therapy were included. Percentage mean volume change, symptom score change, cosmetic score change and complications were evaluated by network meta-analysis. RESULTS In the network meta-analysis, Radiofrequency Ablation(RFA) with 2 treatment sessions group was associated with the highest reduction for the mean volume change during 6-month follow-up (MD = 79.09 and 95% CrI:48.23-89.94). There is no significant difference in the incidence of complications. Subgroup analysis showed that 2 sessions of Radiofrequency Ablation (RFA) ranks the highest probability (surface under the cumulative ranking curve (SUCRA) values 77.9) of being the most efficacious treatment for solid or predominantly solid benign nodules. Ethanol ablation (EA) ranked first (SUCRA value 81.1) in the treatment for cyst or predominantly cyst benign nodules. CONCLUSION RFA appears to be superior to other US-guided percutaneous ablation in reducing benign thyroid nodule volume during short- and long-term follow-up. In the subgroup analysis, RFA with 2 treatment sessions showed the most significant effectiveness for solid benign thyroid nodules and EA showed more effectiveness to decrease the volume of cyst benign thyroid nodules.
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Affiliation(s)
- Linye He
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wanjun Zhao
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zijing Xia
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Anping Su
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhihui Li
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jingqiang Zhu
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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18
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Hegedüs L, Miyauchi A, Tuttle RM. Nonsurgical Thermal Ablation of Thyroid Nodules: Not if, but Why, When, and How? Thyroid 2020; 30:1691-1694. [PMID: 32777983 PMCID: PMC7757570 DOI: 10.1089/thy.2020.0659] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Address correspondence to: Laszlo Hegedüs, MD, DMSc, Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 5th floor, Odense DK-5000 C, Denmark
| | - Akira Miyauchi
- Department of Surgery, Kuma Hospital, Kobe, Hyogo, Japan
| | - R. Michael Tuttle
- Department of Medicine, Endocrinology Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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19
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Rosario PW, Mourão GF. Thermal Ablation in Thyroid Nodules > 3 cm: When is a Single Benign Cytology Sufficient? Exp Clin Endocrinol Diabetes 2020; 129:849-850. [PMID: 33197947 DOI: 10.1055/a-1303-4403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Kim HJ, Cho SJ, Baek JH, Suh CH. Efficacy and safety of thermal ablation for autonomously functioning thyroid nodules: a systematic review and meta-analysis. Eur Radiol 2020; 31:605-615. [PMID: 32816198 DOI: 10.1007/s00330-020-07166-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/29/2020] [Accepted: 08/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although thermal ablation has been regarded as an alternative treatment option for autonomously functioning thyroid nodules (AFTNs), the efficacy of this treatment in patients with AFTNs has not yet been systematically evaluated. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of thermal ablation in the treatment of AFTN, and identify the factors affecting the effectiveness of the treatment. METHODS Ovid-MEDLINE and Embase databases were searched for studies reporting the efficacy and safety of thermal ablation for patients with AFTN published up until January 6, 2020. Data extraction and quality assessment were performed by two radiologists according to PRISMA guidelines. The primary and secondary outcomes were to yield the pooled proportions of thyroid-stimulating hormone (TSH) normalization and pooled estimates of volume reduction rate (VRR), respectively. Subgroup analyses were performed to identify factors affecting the treatment efficacy. RESULTS This systematic review identified 411 AFTNs treated by thermal ablation in 391 patients in 14 studies. TSH normalization was achieved in 71.2% of patients and the volume reduction rate was 69.4% at a mean follow-up period of 12.8 months. No patients experienced hypothyroidism or a life-threatening complication during follow-up. Subgroup analyses according to nodule volume did not find a significant difference in TSH normalization (p = 0.54) or VRR (p = 0.94). CONCLUSIONS Thermal ablation is an effective and safe treatment method for patients with AFTNs. The nodule volume did not affect the efficacy of thermal ablation, and this result should be considered in future thermal ablation guidelines. KEY POINTS • Thermal ablation has good efficacy and safety in the treatment of autonomously functioning thyroid nodule. • The efficacy of thermal ablation was not affected by nodule volume.
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Affiliation(s)
- Hyun Jin Kim
- Department of Radiology, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Se Jin Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi, Republic of Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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21
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Offi C, Garberoglio S, Antonelli G, Esposito MG, Brancaccio U, Misso C, D’Ambrosio E, Pace D, Spiezia S. The Ablation of Thyroid Nodule's Afferent Arteries Before Radiofrequency Ablation: Preliminary Data. Front Endocrinol (Lausanne) 2020; 11:565000. [PMID: 33643218 PMCID: PMC7906008 DOI: 10.3389/fendo.2020.565000] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 12/18/2020] [Indexed: 12/18/2022] Open
Abstract
Induced radiofrequency thermal ablation is the cytoreductive treatment of symptomatic benign thyroid nodules, metastatic and recurrent thyroid tumors and papillary thyroid microcarcinomas. It is a safe and effective alternative to surgery and it allows to obtain satisfactory results in terms of volumetric reduction of the nodule with significant improvement in the quality of life. The trans-isthmic approach and the moving shot technique are the two basic techniques; however, an advanced technique, artery-first feeding radiofrequency ablation, has been developed and validated. We have prospectively included 29 consecutive patients who have undergone radiofrequency ablation (Group A) or artery- first vRFA (Group B). All included patients had a diagnosis of benign nodular goiter and they underwent a single session of radiofrequency ablation. All patients followed a follow-up program at 1 month, 3 months, and 6 months. Continuous variables (age, TSH value, basal volume of nodule, used Joule, time in second of the procedure, nodules' volume at 1-, 3-, and 6- months of follow-up and percentage of volume reduction at 1-, 3-, and 6- months of follow-up) were described as mean, standard deviation and range, while categorical variables (gender, nodule structure and nodule vascularization) were described as number of cases and percentage. Independent samples t-test were performed to compare the continuous variables. A Test of Proportions was applied to the categorical variables. The Fisher's exact test was used to analyze the gender. Statistical significance was considered in case of p-value <0.05. Solid structure and spongiform structure showed statistic differences with p-values of 0.022 and 0.023 respectively between two groups. The percentage of reduction at 1 month did not show a significant difference between two groups; instead, the percentage of volume reduction was decreased mostly in the Group B at 3 months and 6 months of follow-up with a p-value of 0.003 and 0.013, respectively. The Joules/energy used showed a statistically significant difference (p-value=0.05), more energy must be used in vascular radiofrequency ablation. These data allow us to hypothesize that vRFA may improve the effectiveness of the procedure, allowing for a reduction in volume more quickly. They were preliminary but promising results, clearly a larger series of cases and prolonged follow-up are needed to clarify and confirm our observations.
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Affiliation(s)
- Chiara Offi
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Sara Garberoglio
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Antonelli
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Maria Grazia Esposito
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Umberto Brancaccio
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Claudia Misso
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Edoardo D’Ambrosio
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
| | - Daniela Pace
- Department of Endocrinology, Valmontone Hospital, Valmontone, Italy
| | - Stefano Spiezia
- Department of Endocrine and Ultrasound-guided Surgery, “Ospedale del Mare”, Naples, Italy
- *Correspondence: Stefano Spiezia,
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