Papini Enrico. L'alcolizzazione del nodulo cistico. ASMaD 2011Presentation Transcript
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
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?
P 0.61 JCEM 1998 P=0.001 P=0.61
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.
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).
Prevalently cystic nodule: FNA Recurrence one month after complete drainage
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Macroscopic appearance of an AFTN resected two days after PEI treatment
PEI treatment: histological changes
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
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
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).
Efficacy of PEI treatment Thyroid Cysts
cases treated by PEI: 58
median number of treatments: 2
effective : volume decrease > 75% and improvement of local symptoms
ineffective : volume decrease < 75% and/or persistence of local symptoms
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
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
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.
US-guided PEI: training & costs
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
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).
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
Radiology, 2000 Histologic examination: central cavitation area, rim of carbonization, coagulative necrosis, peripheral edema.