Transcript RFA for AFTN(Autonomously Functioning Thyroid Nodule)
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
Definition of AFTN
Scintigraphy
: increased uptake in the nodule compared with surrounding normal thyroid parenchyma
Hormone
TSH: low or undetected
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):675-676 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
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
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)
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
Surgery, drawbacks
Scar formation
Hypothyroidism
Anesthetic risk
Long recovery time
Voice change
Hypoparathyroidism
Radiofrequency Ablation for AFTN
Author (Year) Baek et al. (2008 and 2009) Deandrea et al. (2008) Cases Normalized TSH (%) Volume Reduction at last follow-up (%) Follow up periods (Mo) 10 23 60 21.7
72.2
52.6
12 6 Small number of enrolled nodules, short F/U periods, different RFA technique (moving vs fixed)
Baek et al. Thyroid 2008;18(6):675-676 Baek et al. World J Surg 2009; 33(9):1971-7 Deandrea et al. Ultrasound Med Biol 34:784–791
Objectives
To evaluate the efficacy and safety of RFA for the treatment of AFTN
Materials and Methods
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
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
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
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
Treatment Effects
Complete Cure (CC) : Normal hormone level & Hot nodule converted to cold or invisible nodule Partial Cure (PC) Hormonal Remission (HR) Failure (F) CC PC HR F Symptom + Nodule ↓ ↑/→ ↑/→ ↑ Scan Extranodular N N ↓ ↓ Hormone T3 / fT4 TSH N N N ↑ N N ↓ ↓
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
Results
RFA Characteristics
Treatment Sessions: 1-6 (mean, 1.8 ± 0.9)
Ablation Time: 2.5-30 minutes (range, 12 ± 5.9) Ablation Power: 20-120 W (range, 63.3 ± 26.3)
Total Energy: 4500-539460 J (mean, 76939.6 ± 87264.2) Mean Energy/mL: 1589-19014 J/mL (mean, 6417.3 ± 4318.4)
US and Clinical Findings
Diameter (cm) Pre-RFA 3.8 ± 1.4 Volume (ml) Volume Reduction (%) Vascularity Grade Symptom Grade Score Cosmetic Grade Score 18.5 ± 30.1
0 3.1 ± 0.7
3.3 ± 2.1
3.8 ± 0.5
1 M 3.1 ± 1.4
* 11.8 ± 26.9
* 28.6 ± 109.6
3 M 2.8 ± 1.6
* 12.2 ± 28.2
* 64.1 ± 18.4 6 M 2.5 ± 1.4
* 7.0 ± 14.7
* 61.5 ± 77.2
Last F/U 2.1 ± 1.2
* 4.7 ± 10.1
* 70.8 ± 69.9
0.9 ± 1.0
* 0.9 ± 1.0
* 1.8 ± 0.9
* * P < 0.001 vs pre-RFA.
Changes in T3, fT4 and TSH
Hormone † T3 (ng/dL) fT4 (ng/dL) TSH (uIU/ml) Pre-RFA 179.3 ± 102.5
* 124.4 ± 44.5
* 121.4 ± 43.6
* 143.8 ± 69.1
* 132.4 ± 63.3
* 1.94 ± 1.29
* 0.12 ± 0.12
* 1 M 1.20 ± 0.37
* 0.72 ± 0.81
* 3 M 1.24 ± 0.27
* 0.94 ± 0.80
* 6 M 1.32 ± 0.68
* 1.69 ± 2.84
* Last F/U 1.34 ± 0.44
* 1.50 ± 2.15
* † Normal range (T3 : 61-173, fT4 : 0.89-1.76, TSH : 0.4-4). * P < 0.001 vs pre-RFA.
Changes in Scintigraphy
Pre-RFA Nodule * Extranodular area ** 1.0 ± 0.2
† 1.4 ± 0.5
† 1 M 1.9 ± 1.0
† 2.0 ± 0.8
† 3 M 2.0 ± 1.0
† 2.3 ± 0.8
† 6 M 2.1 ± 0.8
† 2.2 ± 0.6
† Last F/U 2.3 ± 0.8
† 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 < 0.001 vs pre-RFA.
Treatment Effects: Nodule Volume
Pre-RFA Vol. (ml) < 10 10<20 20<30 ≥30 Nodule number (n=44) 24 9 4 7 CC * (n=21) 13 6 1 1 PC * (n=16) 7 3 2 4 HR * (n=5) 4 0 1 0 F * (n=2) 0 0 0 2 * CC (Complete Cure), PC (Partial Cure), HR (Hormonal Remission), F (Failure).
Success Rate (CC+PC; Normalized TSH level) : 37/44 (84.1%)
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)
Cases
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
)
Index : Hot 2.2 x 2.0 x 2.7cm (vol. 6.4 ml) C3, S4, V2 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
Pre RFA 6 Mo 12 Mo Symptom ± T3 114 71 78 Hormone fT4 1.69
1.48
1.34
TSH 0.048
1.55
1.62
Volume Volume Reduction (%) 6.22
1.91
1.88
0 69.0
70.0
Single Session, Complete Cure
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
)
Index : Hot 3.8 x 4.3 x 5.6 cm (vol. 49.1 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. 11.2 ml)
Pre RFA 3 Mo 6 Mo Symptom + T3 319 106 110 Hormone fT4 > 6.0
1.38
1.15
TSH < 0.004
1.37
0.78
Volume Volume Reduction(%) 49.1
15.6
11.2
0 68.2
77.2
Two Sessions, Complete Cure
Limitations
Retrospective study
Small number of patients
Short follow-up period (16.1 ± 12.5 months)
Conclusion
RFA appears an effective and safe alternative procedure to surgery or radioiodine therapy for AFTN