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Radiofrequency Ablation for Autonomously Functioning Thyroid
Nodules (AFTN): Multicenter Study of Korean Society of Thyroid Ra-
diology (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
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
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Definition of AFTN
Scintigraphy : increased uptake in the nodule
compared with surrounding normal thyroid parenchyma
Hormone TSH: low or undetected
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Problems of AFTN
Malignancy : Papillary, follicular, medullary, poorly differen-
tiated
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):1971-7Hegedus L. N Engl J Med 2004; 351:1764–1771Toft AD. N Engl J Med 2001; 345:512–516
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Treatment options
Radioactive iodine therapy
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
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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 treat-ment
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
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Scar formation
Hypothyroidism
Anesthetic risk
Long recovery time
Voice change
Hypoparathyroidism
Surgery, drawbacks
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Radiofrequency Ablation for AFTN
Author (Year) Cases
Normal-ized TSH
(%)
Volume Reduc-tion at last fol-
low-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
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):1971-7Deandrea et al. Ultrasound Med Biol 34:784–791
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Objectives
To evaluate the efficacy and safety of
RFA for the treatment of AFTN
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Materials and Methods
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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
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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
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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
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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
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Treatment Effects
Complete Cure (CC) : Normal hormone level & Hot nodule converted to cold or invisible nodule
Partial Cure (PC) Hormonal Remission (HR) Failure (F)
SymptomScan Hormone
Nodule Extran-odular
T3 / fT4 TSH
CC - ↓ N N N
PC - ↑/→ N N N
HR - ↑/→ ↓ N ↓
F + ↑ ↓ ↑ ↓
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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
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Results
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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)
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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 Re-duction (%)
0 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 0.9 ± 1.0*
Cosmetic Grade Score
3.8 ± 0.5 1.8 ± 0.9*
* P < 0.001 vs pre-RFA.
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Changes in T3, fT4 and TSH
Hor-mone† Pre-RFA 1 M 3 M 6 M Last F/U
T3 (ng/dL)
179.3 ± 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 : 61-173, fT4 : 0.89-1.76, TSH : 0.4-4). * P < 0.001 vs pre-RFA.
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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†
Extranodu-lar area**
1.4 ± 0.5† 2.0 ± 0.8† 2.3 ± 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 < 0.001 vs pre-RFA.
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Treatment Effects: Nodule Vol-ume
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 0
10<20 9 6 3 0 0
20<30 4 1 2 1 0
≥30 7 1 4 0 2
Success Rate (CC+PC; Normalized TSH level) : 37/44 (84.1%)
* CC (Complete Cure), PC (Partial Cure), HR (Hormonal Remission), F (Failure).
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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)
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Cases
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• 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
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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 : Hot2.2 x 2.0 x 2.7cm
(vol. 6.4 ml) C3, S4, V2
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SymptomHormone
VolumeVolume Re-duction (%)
T3 fT4 TSH
Pre RFA ± 114 1.69 0.048 6.22 0
6 Mo - 71 1.48 1.55 1.91 69.0
12 Mo - 78 1.34 1.62 1.88 70.0
Single Session, Complete Cure
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• 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
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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 : Cold1.4 x 2.6 x 3.3 cm
(vol. 11.2 ml)
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SymptomHormone
VolumeVolume Re-duction(%)
T3 fT4 TSH
Pre RFA + 319 > 6.0<
0.004 49.1 0
3 Mo - 106 1.38 1.37 15.6 68.2
6 Mo - 110 1.15 0.78 11.2 77.2
Two Sessions, Complete Cure
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Limitations
Retrospective study
Small number of patients
Short follow-up period (16.1 ± 12.5 months)
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Conclusion
RFA appears an effective and safe alternative
procedure to surgery or radioiodine therapy for AFTN
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Thank You!