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Jin Yong Sung 1 , Jung Hwan Baek 1,3 , So Lyung Jung 5 , Ji-hoon Kim 6 , Kyu Sun Kim 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 ,

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Jin Yong Sung 1 , Jung Hwan Baek 1,3 , So Lyung Jung 5 , Ji-hoon Kim 6 , Kyu Sun Kim 1 ,

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  1. 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, KyuSun 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

  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) atrialfibrillation 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

  4. Treatment options • Radioactive iodine therapy • Surgery Gharib H. J ClinEndocrinolMetab 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. 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 ClinEndocrinolMetab 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. Surgery, drawbacks • Scar formation • Hypothyroidism • Anesthetic risk • Long recovery time • Voice change • Hypoparathyroidism

  7. Radiofrequency Ablation for AFTN 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

  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 suppressionof 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 0.5-1.5 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: 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)  

  18. US and Clinical Findings *P < 0.001 vs pre-RFA.

  19. Changes in T3, fT4 and TSH † Normal range (T3 : 61-173, fT4 : 0.89-1.76, TSH : 0.4-4). *P < 0.001 vs pre-RFA.

  20. Changes in Scintigraphy * 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.

  21. Treatment Effects: Nodule Volume  Success Rate (CC+PC; Normalized TSH level) : 37/44 (84.1%) • * CC (Complete Cure), PC (Partial Cure), HR (Hormonal Remission), F (Failure).

  22. 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) Complications

  23. Cases

  24. 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)

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

  26.  Single Session, Complete Cure

  27. 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)

  28. 6 Mo : Cold 1.4 x 2.6 x 3.3 cm (vol. 11.2 ml) 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

  29.  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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