Download 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 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
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 Med ical Center, 4 Depar tment 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, 7Department 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)
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
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)
Symptom
Scan
Hormone
Nodule
Extranodular
T3 / fT4
TSH
CC
-
↓
N
N
N
PC
-
↑/→
N
N
N
HR
-
↑/→
↓
N
↓
F
+
↑
↓
↑
↓
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
Pre-RFA
1M
3M
6M
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 (%)
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.
Changes in T3, fT4 and TSH
Hormone†
Pre-RFA
1M
3M
6M
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.
Changes in Scintigraphy
Pre-RFA
1M
3M
6M
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†
2.3 ± 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.
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
0
10<20
9
6
3
0
0
20<30
4
1
2
1
0
≥30
7
1
4
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
Symptom
Hormone
T3
fT4
TSH
Volume
Volume
Reduction (%)
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
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)
Symptom
Hormone
T3
fT4
TSH
Volume
Volume
Reduction(%)
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
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
Thank You!