Alcoholization of thyroid nodules

Thyroid nodules are sometimes cysts responsible for local difficulty swallowing or aesthetic discomfort.

The content of these cysts is a thick liquid corresponding sonographically to an anechoic structure with some hyperechoic images associated with comet-tail artifacts.

Posterior enhancement is present in all cystic nodules.

Indications of alcoholism:

Symptomatic cystic nodules.
Autonomous nodules.
Parathyroid adenomas.
Thyogloss duct cysts.

The simple cystic evacuation makes it possible to make the symptoms disappear but the recurrence is very frequent (greater than 60%).

The alcoholization of the nodules with 96% ethanol allows ischemic necrosis of the cystic wall and epithelial fibrosis which allows efficacy of the evacuating treatment of the nodule.

The alcoholization of thyroid nodules is an old technique but unfortunately little used in France, despite the effectiveness and speed of the gesture and its low cost.

In 2013 Professor Gharib H, and Professor Baek JH, published in: the journal of clinical endocrinology and metabolism (JCEM) an article which demonstrates that percutaneous ethanol alcoholization is very effective and recommended and alcoholization must be considered a first choice in the treatment of symptomatic nodule cysts.

And more recently for better efficiency in radiofrequency thermoablation, the alcoholization of the liquid component of a nodule allows complete evacuation of the liquid part of the nodule (liquid impossible to evacuate without alcoholization in due to the thick nature of the liquid).

As this case demonstrates;
faced with the impossibility of evacuating the liquid component with a 25 then 18 G needle during cytopuncture of the nodule (thick viscous liquid).
Decision to alcoholize the liquid area one week before the thermoablation, which made it possible to evacuate the liquid component (25 G needle) in pre-thermoablation and make the radiofrequency treatment more effective

Document Dr Haitham Sharara (CHU Nîmes)

Alcoholization of a cystic nodule

Thick colloidal liquid impossible to evacuate with a fine needle (25 and 18 G).

Injection of ethanol (1 cc of ethanol for a nodular volume of 10 cc) one week before evacuation.

Then complete evacuation with a 25 G needle.

Document Dr Haitham Sharara (CHU Nîmes)

Ultrasound-guided alcoholization is an old technique.

In 2004 a study by Valcavi R and Fraasoldati A demonstrated Cystic recurrence rate after simple evacuation without alcohol is 85.6% and the recurrence rate after alcohol is 7.3%

clinical case:

42-year-old patient consults for sudden onset right cervical swelling.

an ultrasound shows a hemorrhagic nodule of the right lobe.

evacuation performed under ultrasound guidance.

the ultrasound control carried out three months later shows a nodular recurrence with the persistence of a local gene.

the nodule is benign on cytology and the patient does not wish to undergo surgery.

therapeutic proposal chemical ablation by alcoholization

right lobe hemorrhagic nodule 25.2 cc

CHU DE NIMES Dr Haitham SHARARA

local anesthesia with pericapsular injection of xylocaine

transisthmic alcoholization

control ultrasound 3 hours after alcohol intake before patient discharge

acontrol ultrasound performed 3 months after alcoholization shows an almost complete disappearance of the hemorrhagic fluid component with a volumetric decrease of 98.37%

residual volume 0.31 cc

CHU DE NIMES Dr Haitham SHARARA

Complications:

A 2015 study to assess the complications of alcohol use in 30 patients

45% of patients were treated with a single alcoholization

31% of patients were treated with two alcoholizations

13% of patients were treated with three alcoholizations

The complications noted are mainly:

Pain during injection
The hematoma without gravity.
Transient recurrent damage for deep nodules

Alcoholization of autonomic nodules

Alcoholization of autonomic nodules can be an alternative to surgery and IRA therapy to treat hot thyroid nodules of small volume less than 1 cc and especially for small nodules in posterior position.

In the case of radiofrequency treatment, the field of action of the electrode is 0.94 cm, greater than the nodular diameter, which can be the cause of complications in the event of proximity of the nodule to the recurrent nerve, the vagus nerve and the middle sympathetic ganglion.

The effectiveness of alcoholization of hot nodules is currently being evaluated at the CHU de NIMES.

Here is the case of a 62-year-old patient with biological hyperthyroidism and a hot nodule on right lobe scintigraphy

its volume is 0.30 cc (11.8 x 9.3 x 8.4 mm).

Chemical ablation with 96% ethanol.

The removal is performed under sedation and local anesthesia.

Injection of 0.20 cc of ethanol into the nodule:

Identification of the nodule by transverse approach

Needle in the superficial part of the nodule

Document Dr Haitham Sharara (CHU Nîmes)

Start of injection; appearance of an intra-nodular hyperechoic image

Document Dr Haitham Sharara (CHU Nîmes)

Document Dr Haitham Sharara (CHU Nîmes)

Intra-nodule ethanol diffusion without posterior infiltration close to the recurrent nerve

Document Dr Haitham Sharara (CHU Nîmes)

Biological control after 3 months of ablation shows a TSH at 0.89

Ultrasound control after 3 months of ablation shows a volumetric decrease of 30%

Alcoholization of a thyroegloss duct cyst

The thyrogloss duct cyst is a cervical congenital malformation and corresponds to the remnant of the thyogloss tract.

KTTs are observed at any age with an increased frequency during the first 3 decades

More than 90% before the age of 10.

This is an anterior cervical mass, median or paramedian, close to the hyoid bone, discovered incidentally or revealed during an episode of secondary infection (local inflammatory signs with an increase in volume).

Evacuation of the cyst and alcoholization allow simple and rapid treatment of the cyst without going through surgery.

Document Kim SM, Baek JH, Kim YS, Lim HK, Choi H, et al , Efficacy and safety of ethanol ablation

Alcohol versus radiofrequency

Two comparative studies deal with "alcoholization versus radiofrequency" for the treatment of cystic nodules and mixed nodules

The two studies did not demonstrate the superiority of radiofrequency in the treatment of cystic nodules and mixed nodules

The cost of alcoholization remains significantly lower than radiofrequency.

The alcoholization of cystic nodules is an effective old technique with low cost and few complications.

Alcoholization can be at the service of radiofrequency by first treating the cystic part for a better efficiency of the nodular treatment by radiofrequency.