Download - US guided thyroid ablation
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US GUIDED RF ABLATION
OF THYROID NODULES
Prof. Dr. Cem Yücel
GAZI UNIVERSITY SCHOOL OF MEDICINE
DEPARTMENT OF RADIOLOGY
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THYROID NODULES
• Nodule incidence: – Palpation: 4-8 %
– Ultrasound: 10-41 %
– Autopsy: 50 %
• Malignity rate: ≈ 10 %
• Indications for therapy in benign nodules: – Compression symptomes
• Pain, disphagia, coughing, feeling of foreign material)
– Cosmetic
– Autonomously functioning nodules
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STANDARD TREATMENT
• Malignant:
– Surgery
– Recurrent tumors:
Surgery is challenging, comp. rate ↑
• Benign:
– Levothyroxine supression?
– Surgery
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INDICATIONS FOR RF ABLATION
• Benign symptomatic cold nodules
• Autonomously functioning nodules
• Well-differentiated malignant tumor recurrences
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PRE-PROCEDURAL EVALUATIONS
• US evaluation: – Properties of the nodule(localization, neighboring
structures, size, echogenicity, presence of calcification, ratio of solid component, internal vascularity)
– Nodules with malignant characteristics are excluded
– Determination of nodule volume
• Biopsy: – Malignity should be excluded by at least two
seperate FNAB’s or one core biopsy
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PRE-PROCEDURAL EVALUATIONS
• Laboratory tests
– Complete blood count
– Coagulation parameters
– Levels of thyroid hormones, auto-antibodies,
calcitonin, T3, T4, TSH,
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PRE-PROCEDURAL EVALUATIONS
• Informed consent – Size of ablated nodules decrease in months.
– More than one sessions may be necessary.
– Treated nodule or other nodules may regrow and
additional treatment may be required.
– Patient may feel various degrees of pain during the
procedure.
– Complications.
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RF GENERATOR
• Generator: RF power between 0-200 W
– During thyroid ablation 20-50 W (max 100 W)
– Impedence
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RF ELECTRODE
• Electrode:
– Straight, internally cooled
– 19 gauge, length 7 cm, active tip: 0.5, 0.7, 1.0, 1.5 cm
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PROCEDURE
• Patient in supine position, mild neck extension
• Local anesthesia
• Approach:
– Trans-isthmic
Entire length of the electrode can be visualized
Minimal exposure of heat to danger triangle
Electode passes sufficient amount of thyroid
parenchyma(to avoid any change of needle position and
leakage of hot ablated fluid outside the thyroid)
– Craniocaudal
– Lateral
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PROCEDURE • “Moving-shot” technique (Baek et al.)
– As thyroid nodules are ellipsoid in shape, prolonged
fixation of the electrode is dangerous to surrounding
critical structures
– Initially, the electrode is positioned at the peripheral
deepest portion of the nodule
– When an echogenic area appears at the targeted area
and impedence increases, RF power ic decreased and
the electrode tip is moved back to an untreated area.
– In cystic nodules, all fluid is aspirated before ablation.
– When all nodule is ablated and transient hiperechoic
areas are observed all through the nodule, procedure
is terminated.
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FOLLOW-UP
• US follow-up:
– At 1, 3, 6 and 12. months
– Volume decrease:
1. month 33-58 %, 6. month 85 %
– Echogenicity: ↓ than before ablation
– İntranodular vascularity (-)
• TSH, T3, T4
• Resolving of complaints
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RESULTS
Baek JH et al. Korean J Radiol. 2011 Sep-Oct;12(5):525-40
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COMPLICATIONS
Baek JH et al, Radiology. 2012 Jan;262(1):335-42
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OUR EXPERIENCE
• 13 cases, 20 nodules(11F, 2 M)(Age range=33-72, med. 48)
• 10 euthyroid, 4 with hyperthyroidism
• Nodule volume = 0.6-50 cc, medium 8 cc
• Follow-up:
– 1. month(11 cases, 18 nodules): 10-83 %↓(med. 48 %)
– 3. month(5 case, 7 nodule): 34-90 %↓(med. 61 %)
– 6. month(1 case): 89 %↓
– In all cases hormone levels returned to normal
– In 1 case transient hoarseness
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50 y, F, Euthyroid
Pre-ablation: Volume=16 cc
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Post-RF 1. month: Volume=4.5 cc (72 %)
Post-RF 6. month: Volume=1.7 cc (89 %)
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42 y, M, Hyperactive
Pre-ablation: Volume=6 cc
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POST-RF 3. MONTH
Volume = 1.5 cc ( 75 % )
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38 y, F, Euthyroid
Pre-ablation: Volume=3.3 cc
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Per-RF Post-RF
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1. MONTH 3. MONTH
1.4 cc ( 58 % ) 0.7 cc ( 79 % )
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In the management of benign thyroid
nodules, RF ablation is an effective and
safe alternative to surgery in experienced
hands