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HOW TO SCLEROSE THYROID CYSTS AND HOW TO ABLATE SOLID THYROID NODULES WITH LASER Enrico Papini Department of Endocrinology...
Current problems in the management of benign thyroid nodules: Solid lesions <ul><li>Ultrasonography (US) and Fine Needle A...
 
P 0.61 JCEM 1998 P=0.001 P=0.61
 
Current problems in the management of benign thyroid nodules: Cysts <ul><li>Most palpable cystic nodules of the thyroid gl...
 
Is a benign FNAB as reliable in cystic as  in solid nodules? <ul><li>The answer is  Yes </li></ul><ul><li>FNA is performed...
Prevalently cystic nodule: FNA Recurrence one month after complete drainage
PEI: materials <ul><li>immagine sonda per ecoguidata </li></ul>
 
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...
Pre-treatment: Vol: 13.7 ml After ethanol infusion: Vol: 9.1 ml 12 months:  Vol: 3.3 ml Reduction: 76% Complex nodules: vo...
<ul><li>Five-year Follow-up </li></ul><ul><li>58 cystic thyroid nodules, recurred at least twice after percutaneous draina...
Efficacy of PEI treatment  Thyroid Cysts <ul><li>cases treated by PEI: 58  </li></ul><ul><li>5-year follow-up </li></ul><u...
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 c...
baseline baseline 5 years 5 years cysts AFTN Solid nodules showed a lower volume reduction and an increased risk of side-e...
Limits of PEI: Solid Nodules <ul><li>The volume of thyroid tissue ablated by each injection is small and the injection of ...
US-guided PEI: training & costs  <ul><li>Operators’ experience </li></ul><ul><ul><li>operator: training on US-FNABs ( >  2...
 
 
<ul><li>nine New Zealand rabbits </li></ul><ul><li>Nd:YAG laser coupled to a 600 nm quartz fibreoptic guide </li></ul><ul>...
Radiology, 2000 Histologic examination: central cavitation area, rim of carbonization, coagulative necrosis, peripheral ed...
Laser ablation procedure
 
62 patients randomized  12-month follow-up to 3 Groups PLA  (Group 1)   42.7%  decrease L-T4  (Group 2)    NS decrease Fol...
Laser treatment:   Single session 2 fibres-2 illuminations Total energy delivered:  - 3600 Joules for nodules up to 12 ml ...
T0 T6 T12 T0 T6 T12 GROUP 1 GROUP 2 Volume changes (ml) at 12 months P<0,0001
Volume Changes (percentage)  T12 T12 T6 T6 GROUP 1 GROUP 2 P < 0,0001
Changes in Simptoms Score after LA Prevalence of local symptoms decreased from 81% of cases at baseline to 26% at the 12-m...
DISCOMFORT INDUCED BY LA PROCEDURE
 
Mini-invasive procedures: are less invasive than surgery for selected patients?
Certainly is less expensive
One step into a possible future?
Other Thermoablation techniques: the “moving shot” radiofrequency ablation
Risk and cost-benefit ratio of PEI <ul><li>Advantages: </li></ul><ul><li>Rapid and effective nodule volume reduction </li>...
A (presumable) cost-benefit ratio of LA <ul><li>Advantages: </li></ul><ul><li>Effective nodule volume reduction and decrea...
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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

  1. 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. 2. Current problems in the management of benign thyroid nodules: Solid lesions <ul><li>Ultrasonography (US) and Fine Needle Aspiration (FNA) have greatly decreased the use of diagnostic thyroidectomy. </li></ul><ul><li>Most thyroid nodules are currently managed with clinical and US follow-up. </li></ul><ul><li>What should we do when a benign nodule increases steadily? </li></ul>
  3. 4. P 0.61 JCEM 1998 P=0.001 P=0.61
  4. 6. Current problems in the management of benign thyroid nodules: Cysts <ul><li>Most palpable cystic nodules of the thyroid gland are benign </li></ul><ul><li>They can be easily drained with the same US-guided FNA that confirms the absence of malignant cells </li></ul><ul><li>Most of them recur after drainage and usually show a slow but progressive growth </li></ul><ul><li>Local pressure symptoms and patient concern frequently lead to a surgical treatment. </li></ul>
  5. 8. Is a benign FNAB as reliable in cystic as in solid nodules? <ul><li>The answer is Yes </li></ul><ul><li>FNA is performed in two stages during the same session: </li></ul><ul><li>fluid is first completely drained from the cystic cavity and submitted for cytocentrifugation </li></ul><ul><li>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). </li></ul>
  6. 9. Prevalently cystic nodule: FNA Recurrence one month after complete drainage
  7. 10. PEI: materials <ul><li>immagine sonda per ecoguidata </li></ul>
  8. 12. Macroscopic appearance of an AFTN resected two days after PEI treatment
  9. 13. PEI treatment: histological changes
  10. 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
  11. 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
  12. 16. <ul><li>Five-year Follow-up </li></ul><ul><li>58 cystic thyroid nodules, recurred at least twice after percutaneous drainage </li></ul><ul><li>95 solitary nontoxic AFTN (suppressed TSH, normal FT3 and FT4) </li></ul><ul><li>17 patients with toxic AFTN (thyrotoxicosis). </li></ul>
  13. 17. Efficacy of PEI treatment Thyroid Cysts <ul><li>cases treated by PEI: 58 </li></ul><ul><li>5-year follow-up </li></ul><ul><li>median number of treatments: 2 </li></ul><ul><li>effective : volume decrease > 75% and improvement of local symptoms </li></ul><ul><li>ineffective : volume decrease < 75% and/or persistence of local symptoms </li></ul>
  14. 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
  15. 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
  16. 20. Limits of PEI: Solid Nodules <ul><li>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. </li></ul><ul><li>the number of ethanol injections, discomfort and risk of the procedure increase while the probability of persistent therapeutic efficacy decreases. </li></ul>
  17. 21. US-guided PEI: training & costs <ul><li>Operators’ experience </li></ul><ul><ul><li>operator: training on US-FNABs ( > 200 FNA/yr for at least 2 years) </li></ul></ul><ul><ul><li>sonographer: US training > 200 hours/yr </li></ul></ul><ul><ul><li>nurse training: training on US-FNABs > 10 hours </li></ul></ul><ul><ul><li>hands-on training: 20 treatments </li></ul></ul><ul><ul><li>further refinements: 50 treatments/year </li></ul></ul><ul><li>Disposables </li></ul><ul><ul><li>1 Chiba (or steel echoic) needle = 10 - 18 Euro </li></ul></ul><ul><ul><li>1 sterile cover + sterile gel: 12 Euro </li></ul></ul><ul><ul><li>95 % ethanol 10 vial: 1.5 Euro </li></ul></ul><ul><ul><li>syringes, connecting tubes, saline solution: 2 Euro </li></ul></ul><ul><li>Non disposable equipment </li></ul><ul><ul><li>US scanner + probes (everlasting): 40.000 - 120.000 Euro </li></ul></ul><ul><ul><li>1 needle guiding device (not needed for US-assistance): 1000 Euro </li></ul></ul><ul><ul><li>1 Cameco syringe holder for FNAB (500 Euro). </li></ul></ul>
  18. 24. <ul><li>nine New Zealand rabbits </li></ul><ul><li>Nd:YAG laser coupled to a 600 nm quartz fibreoptic guide </li></ul><ul><li>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 </li></ul><ul><li>laser was fired for 5 minutes at 1, 3 and 5 W power </li></ul><ul><li>all the rabbits survived for the full extent of the study </li></ul>cavitation charring coagulation zone
  19. 25. Radiology, 2000 Histologic examination: central cavitation area, rim of carbonization, coagulative necrosis, peripheral edema.
  20. 26. Laser ablation procedure
  21. 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
  22. 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). <ul><li>Follow-up: </li></ul><ul><li>- No treatment affecting thyroid gland </li></ul><ul><li>Clinical, laboratory and US control at baseline and every 6 months thereafter for 3 years </li></ul><ul><li>Independent monitoring. </li></ul>GROUP 1 ACTIVE TREATMENT (101 cases)
  23. 30. T0 T6 T12 T0 T6 T12 GROUP 1 GROUP 2 Volume changes (ml) at 12 months P<0,0001
  24. 31. Volume Changes (percentage) T12 T12 T6 T6 GROUP 1 GROUP 2 P < 0,0001
  25. 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.
  26. 33. DISCOMFORT INDUCED BY LA PROCEDURE
  27. 35. Mini-invasive procedures: are less invasive than surgery for selected patients?
  28. 36. Certainly is less expensive
  29. 37. One step into a possible future?
  30. 38. Other Thermoablation techniques: the “moving shot” radiofrequency ablation
  31. 39. Risk and cost-benefit ratio of PEI <ul><li>Advantages: </li></ul><ul><li>Rapid and effective nodule volume reduction </li></ul><ul><li>No cosmetic damage. </li></ul><ul><li>Mild or absent local pain. </li></ul><ul><li>No hypothyroidism </li></ul><ul><li>Negligible cost </li></ul><ul><li>No heavy technology. </li></ul><ul><li>No general anesthesia. </li></ul><ul><li>Outpatient clinics (15 minutes). </li></ul><ul><li>Disadvantages: </li></ul><ul><li>Persistence of thyroid nodule (careful cytologic evaluation & follow-up). </li></ul><ul><li>Need of an operator with experience in US-guided FNA biopsy </li></ul><ul><li>Complications rare and transitory (during the learning period, only). </li></ul><ul><li>Frequent need of repeat (from 2 to 3) PEI treatment. </li></ul>
  32. 40. A (presumable) cost-benefit ratio of LA <ul><li>Advantages: </li></ul><ul><li>Effective nodule volume reduction and decrease of local symptoms. </li></ul><ul><li>No cosmetic damage. </li></ul><ul><li>Mild local pain. </li></ul><ul><li>No hypothyroidism </li></ul><ul><li>Inexpensive disposables (600 Euro). </li></ul><ul><li>No heavy technology. </li></ul><ul><li>No general anesthesia. </li></ul><ul><li>Outpatient clinics (30 minutes). </li></ul><ul><li>Disadvantages: </li></ul><ul><li>Persistence of thyroid nodule (careful cytologic evaluation & follow-up). </li></ul><ul><li>Need of a well-trained operator due to the difficult definition of the margins. </li></ul><ul><li>Complications rare but potentially severe during the learning period. </li></ul><ul><li>Possible regrowth after a few years not yet established. </li></ul>
  33. 41. Thank you

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