LA CONSULTA SEMANAL

CONSULTA

1: J Clin Ultrasound  2002 Sep;30(7):445-9

Sonographically guided percutaneous ethanol treatment of a symptomatic complex nodule with a large cystic component in a patient with thyroid hemiagenesis.

Braga-Basaria M, Basaria S, Mesa C Jr, Stolf AR, Graf H.

Servico de Endocrinologia e Metabologia do Hospital de Clinicas da Universidade Federal do Parana, Rua Padre Camargo, 262, Curitiba 80.060, Brazil.

Thyroid hemiagenesis is a rare anomaly that is usually discovered incidentally during the evaluation of unrelated thyroid disorders. We present the case of a patient with hemiagenesis of the left thyroid lobe and a large, recurrent, symptomatic complex nodule with a large cystic component that occupied most of the right lobe. She had previously undergone multiple unsuccessful aspirations of the cyst. The patient was successfully treated with an intranodular injection of ethanol under sonographic guidance. The success of this procedure resulted in the resolution of symptoms and avoidance of surgical resection of the right lobe, with resulting hypothyroidism. We recommend that ethanol injections be considered for treatment of symptomatic cystic or benign solid nodules in patients with thyroid hemiagenesis and in those who have undergone hemithyroidectomy and have symptomatic nodules.

2: Pathol Int  2002 May;52(5-6):406-9

Histological study of papillary thyroid carcinoma treated with percutaneous ethanol injection therapy.

Akasu H, Shimizu K, Kitagawa W, Naito Z, Kawanami O, Tanaka S.

Department of Surgery, Nippon Medical School, Tokyo and Department of Pathology, Nippon Medical School, Tokyo and Department of Molecular Pathology, Nippon Medical School, Kawasaki, Japan.

An 86-year-old male patient was treated by percutaneous ethanol injection therapy (PEIT), following tumorectomy of a papillary thyroid carcinoma and a modified radical neck dissection for its metastasis. After seven treatments with PEIT, the patient was admitted to hospital for a tracheotomy to treat progressive severe dyspnea. Seven days later the patient died from acute renal failure caused by diabetic ketoacidosis. At autopsy, tumor masses were found to comprise mostly scar tissue, and the remaining neoplastic cells often showed anaplastic changes. Fresh coagulation necrosis and hemorrhages were scattered throughout the tumor lesions and their microvessels were occasionally occluded by thrombus. These changes were seen prominently, especially at the central areas of PEIT treatment. Given these findings, we believe that PEIT may be useful in providing local control for the progression of thyroid cancer, especially in cases of unresectable malignant thyroid tumors.

3: APMIS  2002 Feb;110(2):172-6

Histologic changes in thyroid nodules after percutaneous ethanol injection in patients subsequently operated on due to new focal thyroid lesions.

Pomorski L, Bartos M.

Clinic of Endocrinological and General Surgery, Institute of Endocrinology, Medical University of Lodz, Poland.

This paper reports macro- and microscopic changes in hyperfunctioning thyroid nodules (HTN), initially diagnosed as solitary, in patients treated with percutaneous ethanol injection (PEI). In 78 patients, benign solitary HTN were diagnosed by clinical and hormonal examination. High resolution ultrasonography confirmed the solitary nodule. The results of fine needle aspiration biopsy (FNAB), performed twice, ruled out malignancy of the nodule. The patients were referred for PEI treatment. At 1-year follow-up, newly formed thyroid nodules, whose volumes increased, were detected in five patients (6.4%) with HTN, initially diagnosed as solitary. Therefore, these patients were operated on. Subtotal thyroidectomy was performed. At the intraoperative macroscopic evaluation, a hard fibrous solid mass was found in place of three nodules (n1, n2, n3) following PEI treatment. The middle area of the cut surface of PEI-treated nodules (n4 and n5) in the other two patients was firm and haemorrhagic, surrounded by a fibrous mass. Histolopathologic examination of n1, n2 and n3 revealed fibrosis and hyalinosis. Examination of n4 and n5 showed haemorrhagic necrosis in the middle of the nodules surrounded by fibrous tissue.

4: Clin Radiol  2001 Nov;56(11):895-901

Percutaneous ethanol injection of autonomous thyroid nodules with a volume larger than 40 ml: three years of follow-up.

Del Prete S, Russo D, Caraglia M, Giuberti G, Marra M, Vitale G, Lupoli G, Abbruzzese A, Capasso E.

Unita Operativa di Oncologia, Ospedale S. Giovanni di Dio, Frattamaggiore, Italy.

AIM: Autonomous thyroid nodules are conventionally treated by surgery or radioiodine. Percutaneous ethanol injection is a recognized alternative approach. An assessment of the long-term success and safety was conducted. MATERIALS AND METHODS: Thirty-four patients (seven men and 27 women; age range: 32-80 years; mean: 56 +/- 13 years) with an autonomous thyroid nodule (ATN) > 40 ml (volume range 41-180 ml; mean: 63.6 +/- 34.5 ml) were treated with ultrasound-guided percutaneous ethanol injection (PEI). All patients were hyperthyroid with increased radionuclide uptake in the nodule at scintigraphy. Serial serum (free T3, free T4 and thyroid-stimulating hormone (TSH)) and ultrasound studies were performed at 3, 6, 12, 18, 24 and 36 months after the first PEI session. Scintigraphy was performed before treatment and 1 month after the serum TSH became detectable or alternatively after 6 months, even if the TSH was still undetectable. RESULTS: Each patient had 1-11 sessions of PEI, with an injection of 3-14 ml of ethanol per session (total amount of ethanol per patient: 20-125 ml). Within 3 months from the end of the treatment, the recovery of extranodular uptake on isotope scan and the normalization of TSH levels were observed in 30/34 patients. A reduction (average: 62.9%) of nodule volume was recorded in all patients and only 4/34 patients were refractory to PEI. The responsiveness of ATN to PEI appeared to be dependent on the initial nodule volume (3/4 failures in patients had nodule volumes > 60 ml). Side-effects were always self-limiting. During follow-up (6-36 months) no recurrence was observed. CONCLUSION: In conclusion, the treatment of ATN > 40 ml with PEI would appear to be a valid alternative approach to traditional methods of treatment. It is safe, well tolerated and inexpensive. Its acceptability when compared with surgery and radiodioine has still to be assessed.

5: Acta Radiol  2001 Sep;42(5):477-81

Treatment of autonomous and toxic thyroid adenomas by percutaneous ultrasound-guided ethanol injection.

Brkljacic B, Sucic M, Bozikov V, Hauser M, Hebrang A.

Department of Radiology, University Hospital Merkur, Zagreb, Croatia.

PURPOSE: To evaluate the feasibility and efficacy of US-guided percutaneous ethanol injection (PEI) in the treatment of autonomous and toxic thyroid adenomas. MATERIAL AND METHODS: PEI was performed in 42 patients with solitary, scintigraphically "hot" nodules (n=37) or toxic nodular goiter (n=5). The nodular volume ranged from 2.5 to 38 cm3 (mean volume, 20.7+/-14.1 cm3). Ethanol was injected using a free-hand technique, usually in multiple sessions, using color and power Doppler US guidance. Treatment success was evaluated following 3-4 months after PEI by scintigraphy, hormonal status, and US findings. RESULTS: The procedure was technically successful in 39 patients (93%). Three patients were lost to follow-up. Minor complications were pain (all patients), subcutaneous hematoma (n=6), and transitory dysphonia (n=1). A complete cure was achieved in 22 patients (52%), and a partial cure in 10 patients (24%). In 4 cases (9%), the result was unsatisfactory since only moderate hormonal remission was observed. A satisfactory results was thus achieved in 32/42 patients (76%). Significant nodular volume reduction was observed in all cases. Better results were observed in smaller nodules and in cases of autonomous adenomas. There were no cases of recurrent hyperthyreosis. CONCLUSION: US-guided PEI is an efficient and safe method in the treatment of autonomous thyroid nodules and it enables inactivation of nodules with minimal or transitory complications.

6: Thyroid  2000 Dec;10(12):1087-92

Surgical and pathological changes after percutaneous ethanol injection therapy of thyroid nodules.

Monzani F, Caraccio N, Basolo F, Lacconi P, LiVolsi V, Miccoli P.

Department of Internal Medicine, University of Pisa, Italy. fmonzani@med.unipi.it

Few data exist on the operative and pathological findings in patients having undergone previous percutaneous ethanol injection (PEI) therapy of thyroid nodules. We report here our experience with 13 patients operated on by the same surgical team. Two pathologists, both blinded to the previous PEI treatment, carried out histological evaluation. Reasons for surgery included PEI failure, suspicion of malignancy, and tracheal compression. The operations did not pose any special problem from the technical point of view, and the postoperative courses were uneventful. One patient who had a second operation developed hypoparathyroidism, and laryngeal nerve palsy was never observed. The histological diagnosis was hyperplastic or adenomatous nodule in 12 cases and papillary thyroid cancer in 1. No difficulty was found in evaluating the nodule capsule and surrounding vessels. In two lesions, nuclear enlargement and clearing were identified in thyroid follicles immediately adjacent to necrotic or scarred areas. These changes were considered reactive. In conclusion, patients previously treated by PEI were operated on without special technical problems. Histological diagnosis was not hindered, and there was no difficulty in ruling out malignant lesions. PEI, however, should be performed only by skilled operators, and incidental ethanol seepage throughout the nodule capsule must be carefully avoided.

7: Thyroid  2000 Nov;10(11):985-9

Radioiodine and percutaneous ethanol injection in the treatment of large toxic thyroid nodule: a long-term study.

Zingrillo M, Torlontano M, Ghiggi MR, Frusciante V, Varraso A, Liuzzi A, Trischitta V.

Divisione ed Unita di Ricerca di Endocrinologia, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Fg, Italy. mzingrillo@isnet.it

Surgery is generally recommended for large thyroid toxic nodules (TTNs). When surgery is not applicable, both radioactive iodine (RAI) and percutaneous ethanol injection (PEI) are alternative treatments. In this retrospective study, the long-term efficacy of nonsurgical treatments was evaluated in 43 patients with TTN, selected on the basis of presence of hyperthyroidism and a fairly large nodule (3- and 4-cm in diameter) completely inhibiting controlateral lobe captation during scintigraphy. Twenty-one patients were treated by RAI (administered dose 670+/-160 MBq; range 555-925) and twenty-two were treated by PEI (6+/-1 sessions; range 5-9). FT4, FT3, thyrotropin (TSH), and nodule volume were assessed before and at fixed intervals after treatment. Median follow-up was 36 months (range, 12-84). Compared to baseline values, with both therapies, serum FT4, FT3, and nodule volume were decreased (p < 0.01) and serum TSH was increased (p < 0.01), after 3 months and during the entire follow-up. Nodule volume reduction percentage was 66.8+/-22.0 and 78.4+/-18.0, in the RAI- and PEI-treated groups, respectively. At the end of follow-up, 34 patients were euthyroid (16 RAI- and 18 PEI-treated). Four RAI-treated patients (19%) showed slightly high TSH levels (4.2-5.3 mU/L), whereas three PEI-treated patients (13.6%) still had suppressed TSH levels, although being clinically asymptomatic. One RAI-treated patient (4.8%) showed overt hypothyroidism during the follow-up period and was then treated with L-thyroxin. One patient (4.6%), who was initially cured by PEI, became newly hyperthyroid during the follow-up period. Both treatments were well-tolerated. In conclusion, both of these nonsurgical treatments are effective and may be chosen also for relatively large TTNs. Specifically, RAI seems to be more effective for treating hyperthyroidism but has minimal sequelae of subclinical or clinical hypothyroidism, while, after PEI treatment the possibility of stable subclinical hyperthyroidism or hyperthyroidism relapse should be taken into account.

8: Radiology  2000 Jan;214(1):143-8 [Texto completo]

Percutaneous ethanol injection of large autonomous hyperfunctioning thyroid nodules.

Tarantino L, Giorgio A, Mariniello N, de Stefano G, Perrotta A, Aloisio V, Tamasi S, Forestieri MC, Esposito F, Esposito F, Finizia L, Voza A.

Ultrasound Service, D. Cotugno Hospital, Torre del Greco (Na), Italy.

PURPOSE: To verify the effectiveness of percutaneous ethanol injection (PEI) in the treatment of large (>30-mL) hyperfunctioning thyroid nodules. MATERIALS AND METHODS: Twelve patients (eight women, four men; age range, 26-76 years) with a large hyperfunctioning thyroid nodule (volume range, 33-90 mL; mean, 46.08 mL) underwent PEI treatment under ultrasonographic (US) guidance. US was used to calculate the volume of the nodules and to assess the diffusion of the ethanol in the lesions during the procedure. When incomplete necrosis of the nodule was depicted at scintigraphy performed 3 months after treatment, additional PEI sessions were performed. RESULTS: Four to 11 PEI sessions (mean, seven) were performed in each patient, with an injection of 3-14 mL of 99.8% ethanol per session (total amount of ethanol per patient, 30-108 mL; mean, 48.5 mL). At scintigraphy after treatment in all patients, recovery of extranodular uptake, absence of uptake in the nodule, and normalization of thyroid-stimulating hormone (thyrotropin) levels were observed. In all patients, US showed volume reductions of 30%-50% after 3 months and 40%-80% after 6-9 months. Side effects were self-limiting in all patients. During the 6-48-month follow-up, no recurrence was observed. CONCLUSION: PEI is an effective and safe technique for the treatment of large hyperfunctioning thyroid nodules.

9: Thyroid  1999 Aug;9(8):763-7

Percutaneous ethanol injection may be a definitive treatment for symptomatic thyroid cystic nodules not treatable by surgery: five-year follow-up study.

Zingrillo M, Torlontano M, Chiarella R, Ghiggi MR, Nirchio V, Bisceglia M, Trischitta V.

Division and Research Unit of Endocrinology, Scientific Institute Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy. mzingrillo@isnet.it

We present a prospective study on the long-term efficacy of percutaneous ethanol injection (PEI) treatment for thyroid cystic nodules. Among patients referred for symptomatic thyroid cystic nodules who had relapsed after two aspirations or whose nodules could not be aspirated due to the thickness of the cystic fluid, PEI was given when surgery was either refused or contraindicated. Forty-three patients were treated; the mean basal volume of the cysts was 38.4 mL. The purpose of the study was to evaluate long-term efficacy of PEI treatment on: (1) amelioration of symptoms and signs of local compression and (2) nodule volume reduction. In three subjects (7%), PEI failed to induce a significant (>50%) nodule reduction, so that surgical treatment was performed. In 40 patients (93%), an impressive nodule shrinkage was observed, reaching a plateau after 24 months (volume reduction = 91.9%+/-11.4%). A new PEI session was needed in two patients in whom a recurrence was noted within the first 6 months. After 6 months, no significant (> or =1 mL volume) nodule regrowth was observed up to 60 months. Both symptoms and tracheal displacement rapidly (within 1 month) and significantly (p<0.01) improved. After PEI, mild pain was the only side effect observed. No suspicious cytology was observed in any residual nodule greater than 1 mL 6 and 24 months after the last PEI session. Our data suggest that PEI is a first-line safe, effective, probably definitive, treatment for cystic thyroid nodules for which surgery is either refused or contraindicated.

Publication Types:

Clinical Trial

10: Thyroid  1999 Mar;9(3):225-33

Percutaneous ethanol injection therapy in benign solitary solid cold thyroid nodules: a randomized trial comparing one injection with three injections.

Bennedbaek FN, Hegedus L.

Department of Endocrinology, Odense University Hospital, Denmark. finn.bennedbaek@ouh.dk

The aim of the present study was to evaluate the efficacy of percutaneous ethanol injection therapy (PEIT) with special reference to dose response and symptom score and to describe side effects in a parallel-group randomized clinical trial with 6 months of follow-up, comparing 2 different treatment strategies. Sixty euthyroid outpatients with a benign solid and scintigraphically solitary cold thyroid nodule causing local discomfort were assigned to 1 session with a single intranodular injection of sterile 98% ethanol (PEIT-1, n = 30) or 3 weekly sessions with 1 injection of sterile 98% ethanol (PEIT-3, n = 30). In the PEIT-1 group, the pretreatment nodule volume was 9.9+/-5.7 mL (mean +/- SD). It decreased to 7.0+/-4.7 mL after 1 month, and 5.6+/-5.9 mL after 6 months (p = 3.2x10(-6)), and the ethanol dose given was 24.7%+/-7.5% of the pretreatment nodule volume. The overall reduction in nodule volume was 46%. In the PEIT-3 group the pretreatment nodule volume was 9.4+/-4.2 mL. It decreased to 5.9+/-3.5 mL 1 month after the last session, and 4.6+/-2.6 mL after 6 months (p = 4.0x10(-10)), and the cumulative ethanol dose given was 47.9%+/-21.3% of the pretreatment nodule volume. The overall reduction in nodule volume was 51%, and the difference between the 2 treatment regimens was 5.3%+/-5.5% (mean +/- SE of difference, p = 0.3). A satisfactory treatment dose, defined as a total intranodular spread of ethanol visualized on the monitor screen, was achieved in only 50%-60% of the sessions. This was due to pain that necessitated premature discontinuation of the injection and was apparently severe enough in 3 patients in the PEIT-3 group that they refused additional treatment. Twenty-two of 30 (73%) patients in the PEIT-1 group and 19 of 30 (63%) in the PEIT-3 group had a marked effect on symptoms at 6-month follow-up (p = 0.6). Side effects comprised transient thyrotoxicosis in 2 patients, permanent ipsilateral facial dysesthesia and increased flow of tears in 1 patient, paranodular fibrosis impeding subsequent surgery in 1 case and various degrees of pain and tenderness related to PEIT in nearly all. Major side effects were dose dependent. We conclude that PEIT is effective in inducing necrosis and reducing the volume of benign solid cold thyroid nodules. The additive effect of 2 additional doses compared with 1 dose is insignificant. The optimum management strategy has yet to be clarified. Limitations relate to the procedure being quite painful despite local anesthesia and the fact that side effects are in no way negligible, and therefore, a word of caution in routine use is advisable. Publication Types:

Clinical Trial

11: N Engl J Med  1998 May 14;338(20):1438-47 [Texto completo]

http://content.nejm.org/cgi/content/full/338/20/1438

Treatment of benign nodular thyroid disease.

Hermus AR, Huysmans DA.

Department of Endocrinology, University Hospital Nijmegen, The Netherlands.

Publication Types:

Review

12: J Clin Endocrinol Metab  1998 Mar;83(3):830-5 [Texto completo]

Effect of percutaneous ethanol injection therapy versus suppressive doses of L-thyroxine on benign solitary solid cold thyroid nodules: a randomized trial.

Bennedbaek FN, Nielsen LK, Hegedus L.

Department of Endocrinology, Odense University Hospital, Odense C, Denmark.

The results of studies using suppressive doses of L-T4 on benign solitary solid cold thyroid nodules have been conflicting. Recently, intranodular injection of absolute ethanol has been proposed as an effective treatment, but has been evaluated only in uncontrolled studies. Our objective was to evaluate the effect of two alternative medical treatment modalities, percutaneous ethanol injection therapy and L-T4, on the benign solitary solid cold thyroid nodule. In a prospective randomized clinical trial, 50 euthyroid patients with a single solid colloid thyroid nodule causing local discomfort were assigned to a single intranodular injection of sterile 98% ethanol (n = 25) or suppressive doses of L-T4 (n = 25). We aimed at an ethanol dose of 20-50% of the pretreatment nodular volume. The initial daily dose of L-T4 was 1.5 microg/kg BW and was adjusted monthly during the first 6 months to reduce serum TSH to subnormal levels (<0.40 mU/L). Thyroid nodule volume and total thyroid volume were assessed by ultrasound, and thyroid function was determined by routine assays before and during follow-up. Symptom scores before and at 12 months were evaluated by a questionnaire rating pressure symptoms and cosmetic symptoms. The median ethanol dose given was 21% [95% confidence interval (CI), 18;25] of the pretreatment nodule volume. In this group, the median reduction in nodule volume was 47% (CI, 33;57; P < 0.0001) compared to 9% (CI, -7;22; P = 0.09) in the L-T4 group. The difference between the two treatment regimens was statistically significant (P < 0.0001). The median reduction in perinodular thyroid volume was 20% (CI, 11;31; P = 0.03) in the L-T4 group, whereas no change was seen in the ethanol group (-2.5%; CI, -18;11; P = 0.9). Fourteen of 25 (56%) patients treated with ethanol injection and 8 of 25 (32%) treated with L-T4 had complete relief of symptoms at 12 months of follow-up (P = 0.09). No major side-effects were seen in either group. Percutaneous ethanol injection therapy administered as a single small dose results in a satisfactory clinical response in approximately 50% of patients by halving the nodule volume. The thyroid nodule-reducing effect of L-T4 suppressive therapy is insignificant, but a subjective satisfactory clinical response is seen in a subgroup of patients, probably explained by the concomitant reduction of perinodular thyroid volume.

Publication Types:

Clinical Trial

13: Thyroid  1997 Oct;7(5):699-704

Is percutaneous ethanol injection a useful alternative for the treatment of the cold benign thyroid nodule? Five years' experience.

Caraccio N, Goletti O, Lippolis PV, Casolaro A, Cavina E, Miccoli P, Monzani F.

Department of Internal Medicine, University of Pisa, Italy.

We describe our 5-year experience with percutaneous ethanol injection (PEI) for the treatment of cold benign thyroid nodules and report its efficacy and side effects. Fifty-four euthyroid outpatients (aged 44.8+/-12.7 years, mean+/-SD) were divided into two groups matched for sex, age, and nodule volume: 27 patients treated only by PEI and 27 patients treated additionally with levothyroxine-suppressive therapy (median follow-up: 24 months, range 6-48). Mean pretreatment nodule volume was 21.0 mL (range 5.4-54.6). Ethanol (1.3+/-0.6 mL/mL nodule volume) was injected under sonographic control in 4 to 13 weekly sessions (mean 7.4). PEI therapy was well tolerated by all patients. At the end of treatment, nodule volume was 7.7+/-5.7 mL (p = .0001). A further significant shrinkage was obtained at 1-year follow-up (4.4+/-3.8 mL; p < .05). No significant differences in nodule reduction were observed between the levothyroxine treated or untreated group and between patients with pretreatment nodule volume smaller or larger than 15 mL. Our study confirms the efficacy and safety of PEI in inducing volume shrinkage of cold benign thyroid nodules. Overall our data suggest that PEI may become an interesting alternative for patients with surgical indications, if they refuse surgery or are poor surgical risks, or eventually demand treatment for aesthetic purposes. It may also be considered when levothyroxine therapy is contraindicated or ineffective.

Publication Types:

Clinical Trial