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Papini Enrico. L'alcolizzazione del nodulo cistico. ASMaD 2011
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Papini Enrico. L'alcolizzazione del nodulo cistico. ASMaD 2011

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  • Cambiare gruppi group 1 and 2
  • Transcript

    • 1. HOW TO SCLEROSE THYROID CYSTS AND HOW TO ABLATE SOLID THYROID NODULES WITH LASER Enrico Papini Department of Endocrinology, Regina Apostolorum Hospital - Albano, Roma Azienda Ospedaliera Sant’Eugenio La Patologia Nodulare della Tiroide Roma, 5 Novembre 2011
    • 2. Current problems in the management of benign thyroid nodules: Solid lesions
      • Ultrasonography (US) and Fine Needle Aspiration (FNA) have greatly decreased the use of diagnostic thyroidectomy.
      • Most thyroid nodules are currently managed with clinical and US follow-up.
      • What should we do when a benign nodule increases steadily?
    • 3.  
    • 4. P 0.61 JCEM 1998 P=0.001 P=0.61
    • 5.  
    • 6. Current problems in the management of benign thyroid nodules: Cysts
      • Most palpable cystic nodules of the thyroid gland are benign
      • They can be easily drained with the same US-guided FNA that confirms the absence of malignant cells
      • Most of them recur after drainage and usually show a slow but progressive growth
      • Local pressure symptoms and patient concern frequently lead to a surgical treatment.
    • 7.  
    • 8. Is a benign FNAB as reliable in cystic as in solid nodules?
      • The answer is Yes
      • FNA is performed in two stages during the same session:
      • fluid is first completely drained from the cystic cavity and submitted for cytocentrifugation
      • an US-guided FNA is subsequently performed on the cyst wall and on the remaing complex tissue (take care of the hubs with vascular signals).
    • 9. Prevalently cystic nodule: FNA Recurrence one month after complete drainage
    • 10. PEI: materials
      • immagine sonda per ecoguidata
    • 11.  
    • 12. Macroscopic appearance of an AFTN resected two days after PEI treatment
    • 13. PEI treatment: histological changes
    • 14. Pre-treatment Vol: 17.6 ml After ethanol infusion Vol: 10 ml 1 month after PEI Vol: 3.6 ml 12 months Vol: 0.4 ml Thyroid cysts: volume changes after PEI
    • 15. Pre-treatment: Vol: 13.7 ml After ethanol infusion: Vol: 9.1 ml 12 months: Vol: 3.3 ml Reduction: 76% Complex nodules: volume changes after PEI
    • 16.
      • Five-year Follow-up
      • 58 cystic thyroid nodules, recurred at least twice after percutaneous drainage
      • 95 solitary nontoxic AFTN (suppressed TSH, normal FT3 and FT4)
      • 17 patients with toxic AFTN (thyrotoxicosis).
    • 17. Efficacy of PEI treatment Thyroid Cysts
      • cases treated by PEI: 58
      • 5-year follow-up
      • median number of treatments: 2
      • effective : volume decrease > 75% and improvement of local symptoms
      • ineffective : volume decrease < 75% and/or persistence of local symptoms
    • 18. Efficacy of PEI treatment: AFTN detectable serum TSH at a 5-yr follow-up AFTN > 5 ml AFTN < 5 ml 40% 60% 20.4% 79.6% 95 cases
    • 19. baseline baseline 5 years 5 years cysts AFTN Solid nodules showed a lower volume reduction and an increased risk of side-effects due to ethanol seeping. P<0,0001 P<0,001
    • 20. Limits of PEI: Solid Nodules
      • The volume of thyroid tissue ablated by each injection is small and the injection of a large amount of ethanol in solid lesions increases the risk of extracapsular diffusion.
      • the number of ethanol injections, discomfort and risk of the procedure increase while the probability of persistent therapeutic efficacy decreases.
    • 21. US-guided PEI: training & costs
      • Operators’ experience
        • operator: training on US-FNABs ( > 200 FNA/yr for at least 2 years)
        • sonographer: US training > 200 hours/yr
        • nurse training: training on US-FNABs > 10 hours
        • hands-on training: 20 treatments
        • further refinements: 50 treatments/year
      • Disposables
        • 1 Chiba (or steel echoic) needle = 10 - 18 Euro
        • 1 sterile cover + sterile gel: 12 Euro
        • 95 % ethanol 10 vial: 1.5 Euro
        • syringes, connecting tubes, saline solution: 2 Euro
      • Non disposable equipment
        • US scanner + probes (everlasting): 40.000 - 120.000 Euro
        • 1 needle guiding device (not needed for US-assistance): 1000 Euro
        • 1 Cameco syringe holder for FNAB (500 Euro).
    • 22.  
    • 23.  
    • 24.
      • nine New Zealand rabbits
      • Nd:YAG laser coupled to a 600 nm quartz fibreoptic guide
      • the fibre and a thermocouple were placed in the lumen of two Chiba needles (18 G) and these were inserted into the liver 10 mm apart under US-guidance
      • laser was fired for 5 minutes at 1, 3 and 5 W power
      • all the rabbits survived for the full extent of the study
      cavitation charring coagulation zone
    • 25. Radiology, 2000 Histologic examination: central cavitation area, rim of carbonization, coagulative necrosis, peripheral edema.
    • 26. Laser ablation procedure
    • 27.  
    • 28. 62 patients randomized 12-month follow-up to 3 Groups PLA (Group 1) 42.7% decrease L-T4 (Group 2) NS decrease Follow-up (Group 3) NS increase
    • 29. Laser treatment: Single session 2 fibres-2 illuminations Total energy delivered: - 3600 Joules for nodules up to 12 ml (300 J/ml) - 7200 for nodules larger than 12 ml (400 J/ml).
      • Follow-up:
      • - No treatment affecting thyroid gland
      • Clinical, laboratory and US control at baseline and every 6 months thereafter for 3 years
      • Independent monitoring.
      GROUP 1 ACTIVE TREATMENT (101 cases)
    • 30. T0 T6 T12 T0 T6 T12 GROUP 1 GROUP 2 Volume changes (ml) at 12 months P<0,0001
    • 31. Volume Changes (percentage) T12 T12 T6 T6 GROUP 1 GROUP 2 P < 0,0001
    • 32. Changes in Simptoms Score after LA Prevalence of local symptoms decreased from 81% of cases at baseline to 26% at the 12-month control. No significant change was reported in Group 2.
    • 33. DISCOMFORT INDUCED BY LA PROCEDURE
    • 34.  
    • 35. Mini-invasive procedures: are less invasive than surgery for selected patients?
    • 36. Certainly is less expensive
    • 37. One step into a possible future?
    • 38. Other Thermoablation techniques: the “moving shot” radiofrequency ablation
    • 39. Risk and cost-benefit ratio of PEI
      • Advantages:
      • Rapid and effective nodule volume reduction
      • No cosmetic damage.
      • Mild or absent local pain.
      • No hypothyroidism
      • Negligible cost
      • No heavy technology.
      • No general anesthesia.
      • Outpatient clinics (15 minutes).
      • Disadvantages:
      • Persistence of thyroid nodule (careful cytologic evaluation & follow-up).
      • Need of an operator with experience in US-guided FNA biopsy
      • Complications rare and transitory (during the learning period, only).
      • Frequent need of repeat (from 2 to 3) PEI treatment.
    • 40. A (presumable) cost-benefit ratio of LA
      • Advantages:
      • Effective nodule volume reduction and decrease of local symptoms.
      • No cosmetic damage.
      • Mild local pain.
      • No hypothyroidism
      • Inexpensive disposables (600 Euro).
      • No heavy technology.
      • No general anesthesia.
      • Outpatient clinics (30 minutes).
      • Disadvantages:
      • Persistence of thyroid nodule (careful cytologic evaluation & follow-up).
      • Need of a well-trained operator due to the difficult definition of the margins.
      • Complications rare but potentially severe during the learning period.
      • Possible regrowth after a few years not yet established.
    • 41. Thank you

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