Thyroid cancer - Radiofrequency - Puncture - Diagnosis - Treatment
THERMOABLATION OF THYROID NODULES
The thyroid nodule is a frequent pathology and benign in the majority of cases without rapid increase in volume and does not require any treatment.
The prevalence of thyroid pathology is higher in women and in the elderly, it is estimated that 50% of the population after 50 years have thyroid nodules (8 women / 2 men).
Large thyroid nodules can become responsible for discomfort in the neck, or aesthetic problems.
Partial or total thyroid surgery is so far the only therapeutic approach.
Thyroid cancer represents 7% of operated nodules and the risk of thyroid cancer in the population is 0.5 to 10 per 100,000.
Since 2004 in South Korea and since 2014 in France radiofrequency thermoablation of thyroid nodules offers an innovative alternative in the management of benign thyroid nodules while preserving normal thyroid function.
At the CHU de Nîmes since 2019 patients with a large nodule that locally interferes with an increase in volume or patients with autonomous thyroid nodules in a context of hyperthyroidism may benefit from radiofrequency thermoablation as an alternative treatment to surgery or ARI therapy.
Surgery remains in Europe the only treatment offered for thyroid cancer.
Guidelines of the Korean Society of Radiology recommendations in 2017 and 2018.
Recommendations concerning the place of radiofrequency thermoablation in the management of thyroid nodules were updated in 2017 and then in 2018 by the Korean Society of Thyroid Radiology.[1]
Two clearly established indications for this technique, according to well-defined criteria:
The treatment of bulky benign nodules at the origin of a gene, expressed by the patient and that of toxic nodules responsible for clinical hyperthyroidism.
Large symptomatic benign nodules
The first established indication for thyroid RF concerns large benign nodules responsible for local or aesthetic discomfort and/or growth > 1 cm/year.
Before any radiofrequency treatment, it is necessary to carry out a complete ultrasound exploration and a cytopuncture by an expert in thyroid pathology in order to screen for possible thyroid cancer.
The nodule that can benefit from the treatment must be confirmed benign by cytology (Bethesda II) twice.
Bethesda Cytology Classification: Six cytology categories based on specific cytology criteria. Each cytological category is associated with a risk of cancer and a course of treatment.
Definition of radio frequency
Radiofrequency is a technique of percutaneous tumor destruction using heat under guidance.
The principle is to locally deposit an energy inducing a rise in temperature by ionic agitation.
When a temperature of 60° is reached in a biological tissue, the proteins are irreversibly denatured resulting in cell death.
Document by Professor Jung Hwan BAEK, Asan medical center.
Active end.
Nîmes University Hospital, Dr Haitham Sharara.
The electrode action zone located only at the distal end sur 7 to 10 mm depending on the electrode used (arrow) and the rest of the electrode is equipped with a cooling system to avoid heating the tissues in the path of the electrode.
Ablation technique.
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Local anesthesia
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Hydrodissection of organs if necessary (carotid, vagus nerve, recurrent nerve, middle sympathetic ganglion, trachea)
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Trans-isthmic treatment
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Technical moving shot
1. Local anesthesia
Injection of xylocaine around the thyroid capsule.
Nîmes University Hospital, Dr Haitham Sharara.
the virtual helmet is a valuable aid to participate in the smooth running of the intervention.
the patient chooses his film
asepsie avant l'intervention _cc781905 -5cde-3194-bb3b-136bad5cf58d_ _cc781905-5cde-3194- bb3b-136bad5cf58d_ document Dr Haitham Sharara CHU DE NIMES
anesthesia locale avant l'intervention _cc781905- 5cde-3194-bb3b-136bad5cf58d_ _cc781905-5cde-3194-bb3b -136bad5cf58d_ _cc781905-5cde- 3194-bb3b-136bad5cf58d_document Dr Haitham Sharara CHU DE NIMES
ongoing treatment document Dr Haitham Sharara CHU DE NIMES
2. Hydrodissection
The objective of avoiding complications due to the proximity of the nodule to critical structures.
The neck is relatively narrow, containing many critical structures (the carotid, vagus, trachea and recurrent nerve, middle sympathetic ganglion), so it is difficult to fully treat a nodule without securing the procedure with hydrodissection.
A solution of saline or xylocaine is injected between the nodule and the adjacent critical structures allowing effective hydrodissection before treating the nodules.
Vagus nerve
Carotid
Electrode
hydrodissection
Hydrodissection which creates a safety zone between the nodule and the critical structures (the carotid and the vagus nerve) (CHU de Nîmes, Dr Haitham Sharara)
Nîmes University Hospital, Dr Haitham Sharara
In the event of direct contact between the nodule and the trachea a hydrodissection of the trachea makes it possible to avoid tracheal perforation and treat the nodule more effectively.
It is recommended to use saline to perform hydrodissection to avoid recurrent (transient) nerve paralysis when using xylocaine.
Insertion of the needle between the stain and the thyroid capsule (CHU de Nîmes, Dr Haitham Sharara)
Start of injection
Tracheal hydrodissection with saline
Safety zone between the nodule and the trachea (Nîmes University Hospital, Dr Haitham Sharara)
3. Trans-isthmic treatment
The Korean Society of Radiology and Professor Jung Hwan BAEK published in the Korean Journal of Radiology in 2012 a recommendation to treat nodules transisthmically by applying the moving shot technique, in order to secure interventions and effectively treat nodules and reduce complications.
Radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: consensus statement and recommendations (Prof Jung Hwan BAEK)
4. Moving shot technique
Documents (Prof Jung Hwan BAEK) Asan medical center (Seoul)
When the nodule is in a deep position close to the recurrent nerve, the treatment is done in two stages 3 months apart to avoid damaging the recurrent nerve during the operation.
The moving shot technique allows a better result in the treatment of thyroid nodules
In 2014 Professor Jung Hwan BAEK published in the Korean Journal of Radiology a study with two treatment techniques by fixed electrode and by an electrode using the moving shot technique
Prof. BAEK demonstrated superior efficacy in the treatment of thyroid nodules by the moving shot technique
Documents of Prof. JUNG Hwan BAEK (Asan medical center, Seoul)
Nîmes University Hospital, Dr Haitham Sharara
After three months of treatment:
Volumetric reduction of 73.65% with disappearance of the local gene.
Nîmes University Hospital, Dr Haitham Sharara
Results
The expected reduction in nodular volume, found in different studies after a single RF session, is a reduction of 60% to 90% of the initial volume.
In a 5-year study, Deandrea et al. showed significant early nodule volume reduction from 3 months to 12 months, with a median volume reduction of 66.9% at 5 years, after a single radiofrequency ablation session.
An Austrian study conducted by Dobnig and Amrein showed superimposable results since the reduction in nodular volume was measured on average at 68% and 82%, respectively at 3 months and 12 months, accompanied by a subjective improvement in functional and aesthetic genes.
This study also showed a more marked efficacy of RF on the smallest nodules and cystic nodules.
57-year-old patient with right lobe nodule, local gene, benign on cytology, normal biological assessment, refusal of surgery
Before treatment
39-year-old patient with a local gene right isthmic nodule without biological abnormality
benign on cytology twice, thermoablation due to local gene and refusal of surgery
Nîmes University Hospital, Dr Haitham Sharara
Control 4 months post RF volumetric decrease 88%
Nîmes University Hospital, Dr Haitham Sharara
79-year-old patient, bulky benign nodule increased in volume, local discomfort.
Nîmes University Hospital, Dr Haitham Sharara
Nodule 3 months post-treatment, volumetric reduction of 58.59% Disappearance of the local and aesthetic gene.
Nîmes University Hospital, Dr Haitham Sharara
Toxic benign nodules
The second validated indication for thyroid radiofrequency treatment concerns toxic or pre-toxic nodules responsible for clinical hyperthyroidism and/or aesthetic problems.
In this situation also, the benignity of the nodule must be proven, but in this case a single cytopuncture reporting a Bethesda score 2 is necessary (a toxic nodule being only very exceptionally malignant).
The objective of the treatment is, here, twofold: to obtain the euthyroidism of the patient and a reduction in the nodular volume of 50 to 70%.
Currently, the two reference techniques for the treatment of these toxic thyroid nodules are surgery and radioactive iodine 131.
RF treatment is indicated for toxic nodules in
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a young or old patient.
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patient refuses surgery or IRA to avoid potential complication such as post lobectomy hypothyroidism or due to reluctance to undergo radiation exposure
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surgical contraindication
In a retrospective study by Cervelli et al. Comparing the treatment of toxic nodules with radioactive iodine to radiofrequency treatment, the thermoablation technique showed an equivalent reduction in nodular volume (between 50 and 70%) and euthyroidism obtained in all patients without hypothyroidism in the course.
44-year-old patient, clinical and biological hyperthyroidism (TSH 0.015mIU/L); hot nodule on scintigraphy, benign on cytology.
Control 1 month after RF volumetric decrease 34.6% with transient hypothyroidism TSH 4.31.
Control 3 months after RF volumetric decrease 66.3% with normalization of TSH 3.21.
Control 6 months after RF volumetric decrease 69.45% with normalization of TSH 2.79.
hot nodule
Before treatment
1 month post treatment
3 months post treatment
6 months post treatment
Nîmes University Hospital, Dr Haitham Sharara
Nîmes University Hospital, Dr Haitham Sharara
58-year-old patient, biological hyperthyroidism with a TSH of 0.01
hot nodule on right lobe scintigraphy
Nodular volume before RF 6.15 cc with a TSH 0.01
Control 3 months post RF: volumetric reduction 66.07% with a TSH 0.68
Nîmes University Hospital, Dr Haitham Sharara
40 year old patienthyperthyroidism biological( TSH 0.08)
hot nodule on scintigraphy
right isthmic nodule 4.91 cc highly vascularized
Thyroid cancer
In the management of these thyroid cancers, surgery is the reference treatment.
Radiofrequency ablation represents a therapeutic alternative in patients with papillary microcarcinoma with a very low metastatic risk and who refuse surgery or there is a surgical contraindication, thermal ablations can be an alternative to surgery .
Also radiofrequency thermoablation is an alternative to surgery in local recurrence in multi-operated patients, or iodine refractors.
Recently, studies have shown effective RF tumor ablation after a 4-year follow-up period in patients with papillary thyroid microcarcinoma.
However, RF ablations appear to have limited efficacy in the treatment of regional microscopic metastases or multifocal carcinoma.
Therefore, a cervical ultrasound by an expert in thyroid pathology would be necessary before the ablation in order to eliminate the risk of lymph node metastases or multifocal micro-carcinomas within the thyroid gland.
Between March 2011 and April 2016
Prof. BAEK (Asan medical center, Seoul) evaluated the effectiveness of treatment by RF according to the type of carcinoma: des microcarcinomas, papillary macrocarcinomas and cancer anaplastic in patients with a high surgical risk.
8 patients with 9 papillary tumor lesionsin 3 groups (micro and macro carcinomas) and anaplastics were treated by radiofrequency:
Ultrasound monitoring after 1 month, 3 months, 6 months and 1 year of treatment showed that there is no efficacy on anaplastic cancer, however a decrease in tumor volume has been observed. for macro and micro carcinomas without any metastasis for microcarcinoma.
Concerning the specific case of follicular carcinoma (10 to 20% of all malignant lesions of the thyroid), RF has given good results in inoperable patients or patients refusing surgery, for the curative treatment of follicular cancers with low metastatic risk.
Follicular cancer, disappearance of the lesion after 1 year of treatment
images by Prof. Jung Hwan BAEK (Asan Medical Center, Seoul)
Between 2009 and 2011 Professor Baek and his team studied 10 follicular microcarcinomas with low metastatic risk (nodules < 2 cm) with a follow-up of 60-76 months with a single intervention for 8/10 patients and two interventions for 2/10 patients.
Surveillance showed complete disappearance of the cancer without recurrence in 80% of patients and a volumetric reduction of 97% in 20% of patients without recurrence or metastasis for 5 years.
Finally, one of the most interesting uses of RF in thyroid oncological pathology seems to be its application in the treatment of recurrent thyroid carcinomas, already treated for the first time surgically with IRA therapy.
The reference treatment at present remains surgery followed by ARI treatment and thyroid hormone therapy.
However, revision surgery can be difficult and at risk of complications due to the development of cicatricial fibrosis of the thyroid compartment after treatment.
For this reason and for patients who are contraindicated in or refuse new surgery, RF treatment proves to be an acceptable alternative for palliative patients (to improve the quality of life of patients in whom the tumor causes discomfort functional) than for curative purposes.
Mazzeo et al. demonstrated the effectiveness of RF for curative purposes, for the treatment of tumor recurrences in patients excluded from revision surgery or refusing surgery: 11 out of 16 lesions were classified as complete response (CR) according to mRECIST and 5 as partial response (PR).
The first publication in Europe concerning the treatment of papillary microcarcinomas < 10 mm appeared in 2021
A multidisciplinary study to assess the feasibility, safety and efficacy of radiofrequency thermoablation of 10 mm papillary microcarcinomas after cytological confirmation.
Three choices offered to patients
Surgery, thermoablation by radiofrequency or laser and close ultrasound monitoring.
From 2018 patients with cytologically proven microcarcinomas < 10 mm
were discussed within a multidisciplinary team and assessed the feasibility of thermoablation
Results :
Of 13 patients evaluated: 11 accepted thermoablation
(8/11 or 84.6% by radiofrequency and 3/11 or 27.3% by laser),
9 women and 2 men, average age 49.3 ± 8.7 years were treated by radiofrequency
As expected during the preoperative assessment (100% technical success), overall technical efficacy was achieved 11/11 (100%) Cas.
The volumetric decrease was from 0.87 ± 0.67 ml at the first follow-up to 0.17 ± 0.36 at the last follow-up (p = 0.003).
No abnormal thyroid function
No minor or major complications occurred.
Patient satisfaction was rated 10/10
The pain after the intervention was also noted 1.2 ± 1.1 / 10
No local recurrence or metastasis was found after a follow-up of 10.2 months (1.5 – 12 months)
The authors concluded that ultrasound-guided thermoablation of papillary microcarcinomas is a curative and non-invasive alternative to surgical resection or active surveillance.
These techniques seem to be widely preferred by patients.
Complications
The complications described by a multicenter study of 13 centers (1543 nodules in 1459 patients) studied the complications of radiofrequency treatment
The complication rate is 3%, between (0% to 10% variable depending on experience)
and between (2% at 6% for reference centers).
Complications are in two groups:
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Major Complications 1.4%
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Minor Complications 1.9%
Major Complications 1.4%
1. Recurrent paralysis: 1%
Complication related to the treatment of the posterior part of the nodule near the recurrent nerve and to avoid this complication the Korean society of radiology proposed to treat these nodules in two stages.
2. Nodular rupture 0.2%:
The records of 12 patients with a complication of post radiofrequency nodular rupture in four Korean thyroid disease centers between March 2010 and July 2017 were retrospectively reviewed.
Results :
The most common symptoms of post-RFA nodule rupture were sudden neck swelling and pain.
Based on imaging characteristics, the location of nodule rupture was classified into three types: anterior, posterolateral, and medial.
In order of frequency the nodular rupture occurs in the anterior location of the nodules followed by the postero-lateral nodules then the median location
Four patients who did not improve with conservative symptomatic treatment were treated with drainage or surgery
The majority of thyroid nodule ruptures after RFA can be managed with symptomatic treatment.
Document 2019 Korean Endocrine Society (Sae Rom Chung, Jung Hwan Baek, Jin Yong Sung, Ji Hwa Ryu, So Lyung Jung).
(HAS)A 67-year-old man, who presented with neck swelling, had received radiofrequency treatment for a predominantly solid echostructure nodule.
Sudden swelling and pain on the right side of his neck after radiofrequency treatment
(B,C,D)Computed tomography and (E, F) ultrasound show rupture of the anterior thyroid capsule with extension of the anterior extra-thyroid nodular contents (arrows) (anterior type)._cc781905-5cde-3194- bb3b-136bad5cf58d_
(D)Intra-nodular hyper-attenuating parts on CT represent intra-nodular bleeding.
(G)Treatment: Evacuation of hemorrhagic fluid by needle with intravenous antibiotics
Regression of swelling
3. Hypothyroidism 0.07%
Post radiofrequency hypothyroidism is a rare complication, it depends on the quality of the remaining parenchyma, the thyroid volume and the duration of the hyperthyroidism before treatment.
Thyroid atrophy with an autonomic nodule increases the risk of post radiofrequency hypothyroidism.
Asymptomatic hyperthyroidism for several years necessarily puts the remaining thyroid parenchyma at rest and the treatment of the secreting nodule causes hypothyroidism to appear.
Clinical case
In a 58-year-old woman who underwent total thyroidectomy for multinodular goiter 5 years ago.
The biological check-up shows the appearance of hyperthyroidism with a TSH < 0.01.
On ultrasound a nodular recurrence at the level of the right thyroid compartment.
The scintigraphy shows a hot nodule responsible for the hyperthyroidism.
Decision: radiofrequency thermoablation of the nodule.
Nîmes University Hospital, Dr Haitham Sharara
Hypothyroidism one month after radiofrequency treatment with a TSH of 13mIU/L.
implementation of processing by Levothyrox.
the patient did not have an ultrasound check-up during the 12 months following the treatment but a biological check-up every 3 months (TSH of 0.75 - 1.35mIU/L).
the ultrasound control carried out one year after the thermoablation shows:
Significant nodular volumetric decrease (77.32%).
Absence of intra nodular vascularization.
treatment with levothyrox 112.5 µg
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hypothyroidism is related to the absence of thyroid tissue (total thyroidectomy) apart from the nodular recurrence at the level of the right thyroid lodge. and since the hot recurrent nodule was treated by radiofrequency, it was logical to observe the onset of post-treatment hypothyroidism.
4. Brachial plexus injury 0.07%
5. Claude Bernard Horner due to damage to the sympathetic plexus
Claude Bernard-Horner syndrome occurs when the cervical sympathetic pathway connecting the hypothalamus to the eye is interrupted.
The causal lesion can be primary (especially congenital) or secondary to another disorder.
Paralysis of the ocular sympathetic nerve, Claude Bernard-Horner syndrome is manifested by ptosis of the upper eyelid, narrowing of the pupil
Medium sympathetic ganglion visualized in 41% Width 3.8+- 1.5 mm, height 1.9+- 1.5 mm Length 8.7 +- 3.2 mm
Nîmes University Hospital, Dr Haitham Sharara
Location C6 level (41/43 =95%) Compared to the primitive carotid 88% lateral 12% Median
Nîmes University Hospital, Dr Haitham Sharara
middle sympathetic ganglion
6. Tracheal or esophageal performance
Very rare complication may occur in the treatment of isthmic nodules without hydrodissection.
Minor Complications 1.9%
1. Intra or peri thyroid hematoma 1%
2. Skin burn 0.3%
The frequency of complications remains rare, and isolation of adjacent cervical structures by hydrodissection immediately before thermoablation seems to be an effective method to limit these complications.
Conclusion
Radiofrequency thermoablation is a technique that has only been used since 2015 in France and since 2019 at the CHU de NIMES in the treatment of thyroid nodules and offers an innovative alternative to conventional treatments, with few complications, mainly for patients who are contraindicated in surgery or refusing the operation.
To date, the two clearly established indications for this technique are the treatment of symptomatic bulky benign nodules and that of toxic nodules responsible for clinical hyperthyroidism.
The place of radiofrequency treatment in the management of thyroid cancer remains reserved for patients with micro-carcinoma and a low metastatic risk or for patients who refuse surgery or there is a surgical contraindication, as well as in the treatment of recurrent cancers on multi-operated thyroid.
On the other hand, treatment by thermoablation offers several significant advantages compared to surgical management: the intervention takes place under sedation or local anesthesia, in a day hospital, little or no analgesia is necessary during and after the gesture, with a resumption of professional activity the day after the intervention.
Thyroid function is preserved post treatment in the event of a non-secreting nodule and normalization of thyroid function in the event of an autonomous nodule generally between 1 and 3 months post treatment