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Ducky Lee2, Jeong Hyun Lee3, Young Kee Shong4, Dong Kyu Na7

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Presentation on theme: "Ducky Lee2, Jeong Hyun Lee3, Young Kee Shong4, Dong Kyu Na7"— Presentation transcript:

1 Ducky 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 Na7 Thank 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 and Metabolism, University of Ulsan College of Medicine, Asan Medical Center, 5Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 6Department of Radiology, Seoul National University College of Medicine, 7Department of Radiology, Human Medical Imaging & Intervention Center

2 Definition of AFTN Scintigraphy : increased uptake in the nodule
compared with surrounding normal thyroid parenchyma Hormone TSH: low or undetected Scintigraphically, the AFTN shows increased uptake in the nodule compared with surrounding normal thyroid parenchyma and the TSH level is low or undetected.

3 Problems of AFTN Malignancy
: Papillary, follicular, medullary, poorly differentiated Large nodule volume 1) symptomatic 2) cosmetic Functional problem: Thyrotoxicosis 1) decreased bone density -- osteoporosis 2) atrial fibrillation Problems 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):1971-7 Hegedus L. N Engl J Med 2004; 351:1764–1771 Toft AD. N Engl J Med 2001; 345:512–516

4 Treatment options Radioactive iodine therapy Surgery
Conventional treatment options are iodine therapy and surgery. Gharib H. J Clin Endocrinol Metab 2005; 90:581–587 Hegedus L. N Engl J Med 2004; 351:1764–1771 Toft AD. N Engl J Med 2001; 345:512–516

5 Radioactive iodine treatment
Effect/Side effect is dose dependant 10mCi: mild symptom, less than 3cm nodule TSH normalize in 6 months 20mCi: 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; 90:581–587 Hegedus L. N Engl J Med 2004; 351:1764–1771 Toft AD. N Engl J Med 2001; 345:512–516

6 Surgery, drawbacks Scar formation Hypothyroidism Anesthetic risk
Long recovery time Voice change Hypoparathyroidism As you know, surgery has been used to treat AFTN, but there are several drawbacks.

7 Radiofrequency Ablation for AFTN
Author (Year) Cases Normalized TSH (%) Volume Reduction at last follow-up (%) Follow up periods (Mo) Baek et al. (2008 and 2009) 10 60 72.2 12 Deandrea et al. (2008) 23 21.7 52.6 6 Some 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):1971-7 Deandrea et al. Ultrasound Med Biol 34:784–791

8 To evaluate the efficacy and safety of RFA for the treatment of AFTN
Objectives To evaluate the efficacy and safety of RFA for the treatment of AFTN The objective of this study is to evaluate the efficacy and safety of RFA for the treatment of AFTN.

9 Materials and Methods

10 Patients Multicenter study, Korean Society of Thyroid Radiology
5 institutions, from August 2007 to July 2011 Selection Criteria Hot nodule with / without suppression of normal thyroid Low TSH Benign lesion: FNAB or CNB Refused or not suitable for Op. or iodine therapy 44 patients [M:F=2:42, 43 ± 14.7 (range, 17-70) years] 25 (56.8%) toxic nodules, 19 (43.2%) pre-toxic nodules KSThR 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.

11 Pre-Ablation Assessment
Clinical sign / symptom : Symptom (Visual Analogue Scale, 0-10cm) and cosmetic grading score (grade 1-4) T3, fT4, TSH, TSH-R-Ab US – gray scale and color doppler : Diameter, volume and vascular grade FNAB and/or CNB Thyroid scan with 99mTc pertechnetate Clinical signs and symptoms, laboratory, US findings, FNA or CNB results and thyroid scan were assessed prior to RFA.

12 RFA Procedure Internally cooled electrode: 18 G 0.5-1.5 cm active tip
Trans-Isthmic Approach and Moving-Shot Technique Termination 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.

13 Patient 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 score Complication T3, fT4 and TSH US : diameter, volume and vascularity Thyroid scan : nodule and surrounding thyroid gland We evaluated complications and observed patients for 1-2 hours after RFA procedure. At each follow up periods, we evaluated findings as shown.

14 Treatment Effects Complete Cure (CC) : Partial Cure (PC)
Normal hormone level & Hot nodule converted to cold or invisible nodule Partial Cure (PC) Hormonal Remission (HR) Failure (F) Symptom Scan Hormone Nodule Extranodular T3 / fT4 TSH CC - N PC ↑/→ HR F + 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.

15 Statistical Analysis Wilkoxon signed rank test : At each follow up periods The nodule volume change and % volume reduction Changes of T3, fT4 and TSH Changes in thyroid scan (nodule and extranodular area) Changes of cosmetic and symptom grading scores Significance : P < 0.05 The statistical significance was assigned for p value less than 0.05.

16 Results

17 RFA 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.

18 US and Clinical Findings
Pre-RFA 1 M 3 M 6 M Last F/U Diameter (cm) 3.8 ± 1.4 3.1 ± 1.4* 2.8 ± 1.6* 2.5 ± 1.4* 2.1 ± 1.2* Volume (ml) 18.5 ± 30.1 11.8 ± 26.9* 12.2 ± 28.2* 7.0 ± 14.7* 4.7 ± 10.1* Volume Reduction (%) 28.6 ± 109.6 64.1 ± 18.4 61.5 ± 77.2 70.8 ± 69.9 Vascularity Grade 3.1 ± 0.7 0.9 ± 1.0* Symptom Grade Score 3.3 ± 2.1 Cosmetic Grade Score 3.8 ± 0.5 1.8 ± 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 below Vascular grade, symptom score and cosmetic score were significantly decreased at last follow up. * P < vs pre-RFA.

19 Changes 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* fT4 1.94 ± 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.

20 Changes in Scintigraphy
Pre-RFA 1 M 3 M 6 M Last F/U Nodule* 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.

21 Treatment Effects: Nodule Volume
Pre-RFA Vol. (ml) Nodule number (n=44) CC* (n=21) PC* (n=16) HR* (n=5) F* (n=2) < 10 24 13 7 4 10<20 9 6 3 20<30 1 2 ≥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%)

22 Complications During RFA
Most complaining of mild pain and/or heat sense in the neck, sometimes radiating to the head, shoulders, teeth and chest. None to stop the procedure by symptom No 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.

23 Cases Let me show you two cases.

24 CASE 1, F/17 Palpable Thyroid Nodule
Sx/Sg: Fatigue FNA: Bethesda Category II Pre-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.

25 6 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 : Hot 2.2 x 2.0 x 2.7cm (vol. 6.4 ml) C3, S4, V2 6 Mo F/U : Cold x 1.2 x 1.5cm (vol. 1.7 ml), C2, S1, V0 RFA : 1cm electrode, 70 W, 6 min (12 min)

26  Single Session, Complete Cure
Symptom Hormone Volume Volume Reduction (%) T3 fT4 TSH Pre RFA 114 1.69 0.048 6.22 6 Mo - 71 1.48 1.55 1.91 69.0 12 Mo 78 1.34 1.62 1.88 70.0 TSH 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

27 CASE 2, F/66 Palpable Thyroid Nodule
Sx/Sg: Palpitation, weight loss, dyspnea FNA: Bethesda Category II Toxic 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.

28 Index : 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) min 6 Mo : Cold 1.4 x 2.6 x 3.3 cm (vol ml)

29  Two Sessions, Complete Cure
Symptom Hormone Volume Volume Reduction(%) T3 fT4 TSH Pre RFA + 319 > 6.0 < 0.004 49.1 3 Mo - 106 1.38 1.37 15.6 68.2 6 Mo 110 1.15 0.78 11.2 77.2 Thyrotoxic 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

30 Limitations Small number of patients
Retrospective study Small number of patients Short 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.

31 Conclusion RFA appears an effective and safe alternative procedure to surgery or radioiodine therapy for AFTN In conclusion, RFA appears an effective and safe alternative procedure to surgery and radioiodine therapy for AFTN.

32 Thank You! Thank you for your attention!


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