1. JOURNAL CLUB

2. Minimal Invasive Procedures in TA
• Thyroid surgery (lobectomy/hemithyroidectomy)
is one of the modalities of choice in the
management of large thyroid adenoma
• Owing to the cosmetic and clinical morbidity
associated with thyroid surgery, many new
minimally invasive procedures have been
developed for patients who refuse surgery or
who do not qualify for surgery

3. Alternatives for surgery
• ethanol ablation (EA)
• radiofrequency ablation (RFA)
• percutaneous laser ablation (PLA)
• high-intensity focused ultrasound
• microwave ablation

4. • Laser ablation has been reported to be an effective
option in treating thyroid nodules
• Principle: -focused laser energy causes
coagulative necrosis of the tissue in
focus (i.e. a toxic adenoma)
-gradually causes a reduction in the
tissue volume with reabsorption of
the necrosed tissue
-simultaneously leads of the resolution
of hyperfunctional state of the adenoma

6. OBJECTIVE
• to assess the efficacy of combined laser
ablation treatment (LAT) and radioiodine 131
(131I) treatment of large thyroid toxic nodules
• rapidity of control of local symptoms
• hyperthyroidism
• reduction of administered 131I activity
- patients at refusal or with
contraindications to surgery

7. DESIGN AND SETTING
• Pilot study at a single center specializing in
thyroid care
• Fifteen patients were treated with LAT,
followed by 131I (group A) (10 males, 62±16 y)
• series of 17 matched consecutive patients
were treated by 131I only (group B) (11 males,
59±15 y)

9. INTERVENTIONS
• LAT: Laser energy was delivered with an
output power of 3 W (1800 J per fiber per
treatment) through two 75-mm, 21-gauge
spinal needles
• 131I: Radioiodine activity was calculated to
deliver 200 Gy to the hyperfunctioning nodule

10. MAIN OUTCOME MEASURES
• Thyroid function
• Thyroid peroxidase antibody
• Thyroglobulin antibody
• Ultrasound
• local symptoms
- at baseline
- up to 24 months

11. NODULE VOLUME ASSESSMENT
• US evaluation was conducted at baseline and 1,
12, and 24 months after LAT or 131I with a
commercially available US scanner (Mylab 70;
Esaote) equipped with a 7.5- to 13.0-MHz linear
transducer
• Volume was calculated with the ellipsoid formula
as the mean of two measurements
• In patients with coexistent cold nodules,
malignancy was ruled out by US-guided FNAC

12. ASSESSMENT OF LOCAL SYMPTOMS
• Arbitrary visual analog scale (symptom score
[SYS]) developed on occasion of a previous study
in cold nodules by the same study group (Papini
et al, Thyroid. 2007;17:229 –235)
• Ranged between 1 and 5 (1, absent; 5, constant
cervical symptoms and dysphagia)
• calculated at entry and at 1, 12, and 24 months
after LAT or 131I

13. LASER ABLATION TREATMENT
• Two 75-mm, 21-gauge spinal needles (Becton-Dickinson)
were inserted into thyroid lesions under US guidance
• Energy was delivered with an Nd:YAG laser with output
power of 3W and an illumination period of 10 minutes
(total energy delivery of 1800 J per fiber per treatment)
• The total amount of energy delivered to the nodules ranged
from 1800 to 3600 J
• Monitored for 60 minutes in the outpatient clinic and had a
subsequent US control
• Patients were given an im injection of betamethasone
(4mg) to limit edema and possible pain

15. RAIU + THYROID SPECT
• At the time of treatment and during follow-up,
patients underwent thyroid SPECT 20 minutes
after iv injection of 185 MBq of 99mTcO4-
• Studies were performed with a dual-head gamma
camera system equipped with LEHR, parallel-hole
collimators (Forte; Philips)
• RAIU was measured using a gamma probe(l’ACN)
6 and 24 hours after the oral administration of
370 kBq of 131I

16. RADIOIODINE THERAPY
• In patients treated with MMI, this was discontinued to
obtain suppressed levels of TSH at the time of 131I
administration
• 131I therapeutic activity was aimed at delivering 200 Gy to
the hyperfunctioning nodule
• Group A patients underwent 131I treatment 1 month after
LAT
• Group B patients received radioiodine after preliminary
evaluation with the same modalities

17. STATISTICAL ANALYSIS
• Results are expressed as mean ± SD
• Student’s t test for paired data was used to
compare data within the same group
• Student’s t test for unpaired data was used to
compare data between groups

19. RESULTS
• Baseline characteristics were not significantly
different in the two groups
• No complications occurred, as assessed by
post-procedure neck US, and discomfort was
minimal (mild cervical pain)

20. NODULE VOLUME
• Laser-induced nodule reduction depended on
energy delivered with no relation to nodule
volume
• Volume reduction was faster in group A
• Two years after LAT, nodule volume showed a
reduction of 71.3±13.4% (10.1±8.3 mL) in group A
vs 29.4±10.6% (15.3±5.1 mL) in group B

21. TSH
• showed a progressive increase, reaching normal values
after 12 months in all patients in both groups
• Group A: normalization occurred in 9/15 patients (60%)
already 1 month after LAT; 3 did not require 131I
(Nodule: 3.8, 4, 5 cm)
• No relapse of hyperthyroidism
• second 131I activity was not needed
• No increase of TPOAb
• Late hypothyroidism in one patient

22. RAIU AND 131I THERAPY
• Group A: 6% reduction in 24 hr RAIU%
21.1±8.1% in 131I activity after LAT
activities < 600 MBq (480.1±119.6)
• Group B: higher activities were required
(622.8±147.7 MBq; P=0.01)
8/17 required hospitalization(> 600 MBq)

23. DISCUSSION
• 131I is effective for the treatment of toxic thyroid
nodules with a good outcome profile and has been a
tried and tested non-surgical treatment modality
• Volume reduction, however, is a slow process that is
wholly obtained 6 to 36 months after treatment
• Large TTNs are frequently considered a relative
contraindication to the use of 131I because the risk of
local symptoms due to radioiodine therapies is
increased

24. REVIEW OF LITERATURE

25. • In most patients, 1 to 3 sessions of PLA or a single
session with multiple fibers induces a clinically
significant decrease in nodule volume and
amelioration of local symptoms
• Because of the novelty of the PLA technique,
longterm follow-up studies are lacking
• should be restricted to patients with pressure
symptoms or cosmetic concerns who decline
surgery or are at surgical risk

27. PERCUTANEOUS ETHANOL WITH 131I
• US-guided percutaneous ethanol injection
(PEIT) combined with 131I treatment was
reported to be effective in patients with large
toxic thyroid nodules (Zingrillo et al, JNM
2003)
• However, presents limitations in solid nodules
and is currently recommended for cystic
lesions only (Guglielmi et al, Thyroid 2004)

28. ADVANTAGES OF LAT WITH 131I
• LAT can be done on a day-care basis; prevents
morbidity associated with surgery
• Reduction in the volume of thyroid nodule is more as
compared to 131I alone
• Reduction the dosage of the 131I administered
• Can be a feasible adjunct along with 131I in patients
with large toxic nodules who do not qualify for/who
refuse surgery

29. Disadvantages of LAT
• Repeated sessions may be necessary
• Increased cost and discomfort
• Only 3/15 patients required only LAT for
completion resolution of symptoms; the
remaining patients required 131I treatment as an
adjunct
• Feasibility in toxic MNG?

30. THANK YOU