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Radiofrequency Ablation for Autonomously Functioning Thyroid Nodules (AFTN): Multicenter Study of Korean Society of Thyroid Radiology (KSThR) Jin Yong.

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Presentation on theme: "Radiofrequency Ablation for Autonomously Functioning Thyroid Nodules (AFTN): Multicenter Study of Korean Society of Thyroid Radiology (KSThR) Jin Yong."— Presentation transcript:

1 Radiofrequency Ablation for Autonomously Functioning Thyroid Nodules (AFTN): Multicenter Study of Korean Society of Thyroid Radiology (KSThR) Jin Yong Sung 1, Jung Hwan Baek 1,3, So Lyung Jung 5, Ji-hoon Kim 6, Kyu Sun Kim 1, Ducky Lee 2, Jeong Hyun Lee 3, Young Kee Shong 4, Dong Kyu Na 7 1 Department of Radiology, Thyroid Center, Daerim St. Mary's Hospital, 2 Department of Internal Medicine, Thyroid Center, Daerim St. Mary's Hospital, 3 Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 4 Department of Endocrinology and Metabolism, University of Ulsan College of Medicine, Asan Medical Center, 5 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 6 Department of Radiology, Seoul National University College of Medicine, 7 Department 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

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 Baek et al. Thyroid 2008;18(6): Baek et al. World J Surg 2009; 33(9): 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 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 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) Radioactive iodine treatment 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 Scar formation Hypothyroidism Anesthetic risk Long recovery time Voice change Hypoparathyroidism Surgery, 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) Deandrea et al. (2008) 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): Deandrea et al. Ultrasound Med Biol 34:784–791

8 Objectives 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

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

12 RFA Procedure Internally cooled electrode: 18 G cm active tip Trans-Isthmic Approach and Moving-Shot Technique Termination of ablation: Whole nodule changed to transient hyperechoic

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

14 Treatment Effects Complete Cure (CC) : Normal hormone level & Hot nodule converted to cold or invisible nodule Partial Cure (PC) Hormonal Remission (HR) Failure (F)

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

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, ± )

18 US and Clinical Findings Pre-RFA1 M3 M6 MLast F/U Diameter (cm)3.8 ± ± 1.4*2.8 ± 1.6*2.5 ± 1.4*2.1 ± 1.2* Volume (ml)18.5 ± ± 26.9*12.2 ± 28.2*7.0 ± 14.7*4.7 ± 10.1* Volume Reduction (%) ± ± ± ± 69.9 Vascularity Grade 3.1 ± ± 1.0* Symptom Grade Score 3.3 ± ± 1.0* Cosmetic Grade Score 3.8 ± ± 0.9* * P < vs pre-RFA.

19 Changes in T3, fT4 and TSH Hormone Pre-RFA1 M3 M6 MLast F/U T3 (ng/dL) ± 102.5*124.4 ± 44.5*121.4 ± 43.6*143.8 ± 69.1*132.4 ± 63.3* fT4 (ng/dL) 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* Normal range (T3 : , fT4 : , TSH : 0.4-4). * P < vs pre-RFA.

20 Changes in Scintigraphy Pre-RFA1 M3 M6 MLast F/U Nodule* 1.0 ± ± ± ± ± 0.8 Extranodular area** 1.4 ± ± ± ± ± 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.

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) < < < Success Rate (CC+PC; Normalized TSH level) : 37/44 (84.1%) * CC (Complete Cure), PC (Partial Cure), HR (Hormonal Remission), F (Failure).

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)

23 Cases

24 Sx/Sg: Fatigue FNA: Bethesda Category II Pre-toxic nodule: T3/fT4/TSH (114/1.69/0.148) CASE 1, F/17 Palpable Thyroid Nodule

25 RFA : 1cm electrode, 70 W, 6 min (12 min) 6 Mo F/U : Cold 1.8 x 1.2 x 1.5cm (vol. 1.7 ml), C2, S1, V0 Index : Hot 2.2 x 2.0 x 2.7cm (vol. 6.4 ml) C3, S4, V2

26 Sympto m Hormone Volume Volume Reduction (%) T3fT4TSH Pre RFA± Mo Mo Single Session, Complete Cure Single Session, Complete Cure

27 Sx/Sg: Palpitation, weight loss, dyspnea FNA: Bethesda Category II Toxic nodule: T3/fT4/TSH (319/>6.0/<0.004) CASE 2, F/66 Palpable Thyroid Nodule

28 Index : Hot 3.8 x 4.3 x 5.6 cm (vol ml) 2 sessions of RFA : 1.5cm, 100W, 12(15) & 10(13) min 6 Mo : Cold 1.4 x 2.6 x 3.3 cm (vol ml)

29 Sympto m Hormone Volume Volume Reduction(%) T3fT4TSH Pre RFA+319> 6.0< Mo Mo Two Sessions, Complete Cure Two Sessions, Complete Cure

30 Limitations Retrospective study Small number of patients Short follow-up period (16.1 ± 12.5 months)

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

32 Thank You!


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