Presentation on theme: "Ducky Lee2, Jeong Hyun Lee3, Young Kee Shong4, Dong Kyu Na7"— Presentation transcript:
1Ducky Lee2, Jeong Hyun Lee3, Young Kee Shong4, Dong Kyu Na7 Radiofrequency Ablation for Autonomously Functioning Thyroid Nodules (AFTN): Multicenter Study of Korean Society of Thyroid Radiology (KSThR)Jin Yong Sung1, Jung Hwan Baek1,3, So Lyung Jung5, Ji-hoon Kim6, Kyu Sun Kim1,Ducky Lee2, Jeong Hyun Lee3, Young Kee Shong4, Dong Kyu Na7Thank you, Chairperson. I’m Dr. Jin Yong Sung from Daerim St. Mary’s Hospital.1Department of Radiology, Thyroid Center, Daerim St. Mary's Hospital, 2Department of Internal Medicine,Thyroid Center, Daerim St. Mary's Hospital, 3Department of Radiology and Research Institute of Radiology,University of Ulsan College of Medicine, Asan Medical Center, 4Department of Endocrinology andMetabolism, University of Ulsan College of Medicine, Asan Medical Center, 5Department of Radiology, SeoulSt. Mary's Hospital, College of Medicine, The Catholic University of Korea, 6Department of Radiology, SeoulNational University College of Medicine, 7Department of Radiology, Human Medical Imaging & Intervention Center
2Definition of AFTN Scintigraphy : increased uptake in the nodule compared with surrounding normal thyroid parenchymaHormoneTSH: low or undetectedScintigraphically, the AFTN shows increased uptake in the nodule compared with surrounding normal thyroid parenchyma and the TSH level is low or undetected.
3Problems of AFTN Malignancy : Papillary, follicular, medullary, poorly differentiatedLarge nodule volume1) symptomatic2) cosmeticFunctional problem: Thyrotoxicosis1) decreased bone density -- osteoporosis2) atrial fibrillationProblems of AFTN that needs treatment are malignancy, compressive symptom and cosmetic problem due to large volume, and thyrotoxic symptom.Baek et al. Thyroid 2008;18(6):Baek et al. World J Surg 2009; 33(9):1971-7Hegedus L. N Engl J Med 2004; 351:1764–1771Toft AD. N Engl J Med 2001; 345:512–516
4Treatment options Radioactive iodine therapy Surgery Conventional treatment options are iodine therapy and surgery.Gharib H. J Clin Endocrinol Metab 2005; 90:581–587Hegedus L. N Engl J Med 2004; 351:1764–1771Toft AD. N Engl J Med 2001; 345:512–516
5Radioactive iodine treatment Effect/Side effect is dose dependant10mCi: mild symptom, less than 3cm noduleTSH normalize in 6 months20mCi: 38/42 (normal), 1/42 (repeat)3/42 (hypothyroidism)In iodine therapy, the therapeutic effect and side effect are dose dependent. With increment of the dose, hypothyroidism can be occurred.Gharib H. J Clin Endocrinol Metab 2005; 90:581–587Hegedus L. N Engl J Med 2004; 351:1764–1771Toft AD. N Engl J Med 2001; 345:512–516
6Surgery, drawbacks Scar formation Hypothyroidism Anesthetic risk Long recovery timeVoice changeHypoparathyroidismAs you know, surgery has been used to treat AFTN, but there are several drawbacks.
7Radiofrequency Ablation for AFTN Author(Year)CasesNormalized TSH (%)Volume Reduction at last follow-up (%)Follow up periods (Mo)Baek et al.(2008 and 2009)106072.212Deandrea et al.(2008)2321.752.66Some alternative therapies have been introduced like ethanol and laser ablation.Dr. Baek and Dr. Deandrea reported RFA results to treat AFTN. In two studies, different RFA techniques were used, moving shot and fixed needle techniques.So, we planned multicenter RFA study for AFTN with same RF technique using moving shot technique and larger number of cases.Small number of enrolled nodules, short F/U periods, different RFA technique (moving vs fixed)Baek et al. Thyroid 2008;18(6):Baek et al. World J Surg 2009; 33(9):1971-7Deandrea et al. Ultrasound Med Biol 34:784–791
8To evaluate the efficacy and safety of RFA for the treatment of AFTN ObjectivesTo evaluate the efficacy and safety of RFA for the treatment of AFTNThe objective of this study is to evaluate the efficacy and safety of RFA for the treatment of AFTN.
10Patients Multicenter study, Korean Society of Thyroid Radiology 5 institutions, from August 2007 to July 2011Selection CriteriaHot nodule with / without suppression of normal thyroidLow TSHBenign lesion: FNAB or CNBRefused or not suitable for Op. or iodine therapy44 patients [M:F=2:42, 43 ± 14.7 (range, 17-70) years]25 (56.8%) toxic nodules, 19 (43.2%) pre-toxic nodulesKSThR planned this study and 5 institutions participated.Enrolled patients had hot nodules, low TSH level and benign cytologic or histologic results.They refused or were not suitable for operation or iodine therapy.Overall 44 patients were enrolled and there were 25 toxic nodules and 19 pre-toxic nodules.
11Pre-Ablation Assessment Clinical sign / symptom: Symptom (Visual Analogue Scale, 0-10cm) andcosmetic grading score (grade 1-4)T3, fT4, TSH, TSH-R-AbUS – gray scale and color doppler: Diameter, volume and vascular gradeFNAB and/or CNBThyroid scan with 99mTc pertechnetateClinical signs and symptoms, laboratory, US findings, FNA or CNB results and thyroid scan were assessed prior to RFA.
12RFA Procedure Internally cooled electrode: 18 G 0.5-1.5 cm active tip Trans-Isthmic Approach and Moving-Shot TechniqueTermination of ablation:Whole nodule changed to transient hyperechoic Methimazole was prescibed to control thyrotoxicosis for 1 month before RFA.Internallly cooled electrode was used with trans-isthmic approach and moving shot technique.When whole nodule was changed to hyperechoic, the ablation was terminated.
13Patient Care and Follow up Post-treatment care: Evaluation of complications and observation for 1-2 hours Following at 1, 3, 6 months and every 6-12 months: Symptom (self-check list) and cosmetic grading scoreComplicationT3, fT4 and TSHUS : diameter, volume and vascularityThyroid scan : nodule and surrounding thyroid glandWe evaluated complications and observed patients for 1-2 hours after RFA procedure.At each follow up periods, we evaluated findings as shown.
14Treatment Effects Complete Cure (CC) : Partial Cure (PC) Normal hormone level & Hot nodule converted to cold or invisible nodulePartial Cure (PC)Hormonal Remission (HR)Failure (F)SymptomScanHormoneNoduleExtranodularT3 / fT4TSHCC-↓NPC↑/→HRF+↑Treatment effects can be classified as complete cure, partial cure, hormonal remission and failure.In complete cure, hot nodule was changed to cold nodule and symptom and hormone level were normalized.In partial cure, nodule was still hot or show similar uptake to extranodular area.In hormonal remission, merely thyroid hormone level was declined to normal level but TSH level was still subnormal.
15Statistical AnalysisWilkoxon signed rank test : At each follow up periodsThe nodule volume change and % volume reductionChanges of T3, fT4 and TSHChanges in thyroid scan (nodule and extranodular area)Changes of cosmetic and symptom grading scoresSignificance : P < 0.05The statistical significance was assigned for p value less than 0.05.
17RFA Characteristics Treatment Sessions: 1-6 (mean, 1.8 ± 0.9) Ablation Time: minutes (range, 12 ± 5.9)Ablation Power: W (range, 63.3 ± 26.3)Total Energy: J (mean, ± )Mean Energy/mL: J/mL (mean, ± ) The mean number of RFA sessions was 1.8.The mean ablation time and power were 12 minutes and 63 W.
18US and Clinical Findings Pre-RFA1 M3 M6 MLast F/UDiameter (cm)3.8 ± 1.43.1 ± 1.4*2.8 ± 1.6*2.5 ± 1.4*2.1 ± 1.2*Volume (ml)18.5 ± 30.111.8 ± 26.9*12.2 ± 28.2*7.0 ± 14.7*4.7 ± 10.1*Volume Reduction (%)28.6 ± 109.664.1 ± 18.461.5 ± 77.270.8 ± 69.9Vascularity Grade3.1 ± 0.70.9 ± 1.0*Symptom Grade Score3.3 ± 2.1Cosmetic Grade Score3.8 ± 0.51.8 ± 0.9*The mean volume reduction at last follow up was 70.8 %.Mean largest diameters and volumes at each follow up were significantly lower than pre-RFA data. All P value was belowVascular grade, symptom score and cosmetic score were significantly decreased at last follow up.* P < vs pre-RFA.
19Changes in T3, fT4 and TSH Pre-RFA 1 M 3 M 6 M Last F/U Hormone† T3 (ng/dL)179.3 ± 102.5*124.4 ± 44.5*121.4 ± 43.6*143.8 ± 69.1*132.4 ± 63.3*fT41.94 ± 1.29*1.20 ± 0.37*1.24 ± 0.27*1.32 ± 0.68*1.34 ± 0.44*TSH (uIU/ml)0.12 ± 0.12*0.72 ± 0.81*0.94 ± 0.80*1.69 ± 2.84*1.50 ± 2.15*Hormonal levels were also changed with statistical significance.† Normal range (T3 : , fT4 : , TSH : 0.4-4).* P < vs pre-RFA.
20Changes in Scintigraphy Pre-RFA1 M3 M6 MLast F/UNodule*1.0 ± 0.2†1.9 ± 1.0†2.0 ± 1.0†2.1 ± 0.8†2.3 ± 0.8†Extranodular area**1.4 ± 0.5†2.0 ± 0.8†2.2 ± 0.6†2.4 ± 0.5†* 1 : Hot nodule, 2 : Similar uptake to extranodular area, 3 : Cold nodule.** 1 : non-visualized, 2 : weak uptake, 3 : normal uptake.† P < vs pre-RFA.Nodular uptake were decreased and extranodular uptake were restored with statistical significance, too.
21Treatment Effects: Nodule Volume Pre-RFA Vol. (ml)Nodule number(n=44)CC*(n=21)PC*(n=16)HR*(n=5)F*(n=2)< 1024137410<2096320<3012≥30* CC (Complete Cure), PC (Partial Cure), HR (Hormonal Remission), F (Failure).This slide shows treatment effects according to nodule volume.Nodule numbers are 24, 9, 4 and 7 in each group.In groups less than 10 and 10 to 20, complete or partial cure cases were 20 and 9.2 cases were failed to cure in more than 30 group.Although fewer nodules are included in large volume group, the success rate tends to decreased according to volume increase.Overall success rate is 84.1 %. Success Rate (CC+PC; Normalized TSH level): 37/44 (84.1%)
22Complications During RFA Most complaining of mild pain and/or heat sensein the neck, sometimes radiating to the head,shoulders, teeth and chest.None to stop the procedure by symptomNo major complication(voice change, skin burn, hematoma or infection)During RFA, most patients complained of mild pain and heat sense.But, there was no case to stop ablation by these symptoms.There was no major complication.
24CASE 1, F/17 Palpable Thyroid Nodule Sx/Sg: FatigueFNA: Bethesda Category IIPre-toxic nodule: T3/fT4/TSH (114/1.69/0.148)The first case is a 17 year old female with palpable thyroid nodule and complaining fatigue.TSH is subnormal. The nodule is pretoxic.
256 Mo F/U : Cold 1.8 x 1.2 x 1.5cm (vol. 1.7 ml), C2, S1, V0 After RFA, 6.4 ml hot nodule was changed to 1.7 ml cold nodule.Index : Hot2.2 x 2.0 x 2.7cm(vol. 6.4 ml)C3, S4, V26 Mo F/U : Cold x 1.2 x 1.5cm (vol. 1.7 ml), C2, S1, V0RFA : 1cm electrode, 70 W, 6 min (12 min)
26 Single Session, Complete Cure SymptomHormoneVolumeVolume Reduction (%)T3fT4TSHPre RFA1141.690.0486.226 Mo-711.481.551.9169.012 Mo781.341.621.8870.0TSH level was elevated from to 1.62 at 12 months follow up and the final volume reduction was 70%.With single session of RFA, the pre-toxic nodule cured completely. Single Session, Complete Cure
27CASE 2, F/66 Palpable Thyroid Nodule Sx/Sg: Palpitation, weight loss, dyspneaFNA: Bethesda Category IIToxic nodule: T3/fT4/TSH (319/>6.0/<0.004)The second case is a 66 year old female with palpable thyroid nodule and complaining of palpitation, weight loss and dyspnea.T3 and free T4 were much elevated and TSH was undetected.This nodule was toxic.
28Index : Hot 3.8 x 4.3 x 5.6 cm (vol. 49.1 ml) After two sessions of RFA, 49.1 ml hot nodule was changed to 11.2 ml cold nodule.Index : Hot x 4.3 x 5.6 cm(vol ml)2 sessions of RFA : cm, 100W,12(15) & 10(13) min6 Mo : Cold 1.4 x 2.6 x 3.3 cm (vol ml)
29 Two Sessions, Complete Cure SymptomHormoneVolumeVolume Reduction(%)T3fT4TSHPre RFA+319> 6.0< 0.00449.13 Mo-1061.381.3715.668.26 Mo1101.150.7811.277.2Thyrotoxic symptoms disappeared and TSH level was elevated from undetected level to 0.78 at 6 months follow up.The final volume reduction was 77.2%.With two sessions of RFA, the toxic nodule cured completely. Two Sessions, Complete Cure
30Limitations Small number of patients Retrospective studySmall number of patientsShort follow-up period (16.1 ± 12.5 months)This study was retrospectively designed and relatively small number of patients were enrolled and follow up period was relatively short.A further prospective study may be prepared soon.
31ConclusionRFA appears an effective and safe alternative procedure to surgery or radioiodine therapy for AFTNIn conclusion, RFA appears an effective and safe alternative procedure to surgery and radioiodine therapy for AFTN.