Surgical aspects of thyroid nodules previously treated by ethanol injection

Treatment of hyperfunctioning thyroid nodules by percutaneous ethanol injection

BACKGROUND: Autonomous thyroid nodules can be treated by a variety of methods. We assessed the efficacy of percutaneous ethanol injection in treating autonomous thyroid nodules. METHODS: 35 patients diagnosed by technetium-99 scanning with hyperfunctioning nodules and suppressed sensitive TSH (sTSH) were given sterile ethanol injections under ultrasound guidance. 29 patients had clinical and biochemical hyperthyroidism. The other 6 had sub-clinical hyperthyroidism with suppressed sTSH levels (<0.24 &mgr;IU/ml) and normal thyroid hormone levels. Ethanol injections were performed once every 1-4 weeks. Ethanol injections were stopped when serum T3, T4 and sTSH levels had returned to normal, or else injections could no longer be performed because significant side effects. Patients were followed up at 3, 6 and, in 15 patients, 24 months after the last injection. RESULTS: Average pre-treatment nodule volume [18.2 PlusMinus; 12.7 ml] decreased to 5.7 PlusMinus; 4.6 ml at 6 months follow-up [P < 0.001]. All patients had normal thyroid hormone levels at 3 and 6 months follow-up [P < 0.001 relative to baseline]. sTSH levels increased from 0.09 PlusMinus; 0.02 &mgr;IU/ml to 0.65 PlusMinus; 0.8 &mgr;IU/ml at the end of therapy [P < 0.05]. Only 3 patients had persistent sTSH suppression at 6 months post-therapy. T4 and sTSH did not change significantly between 6 months and 2 years [P > 0.05]. Ethanol injections were well tolerated by the patients, with only 2 cases of transient dysphonia. CONCLUSION: Our findings indicate that ethanol injection is an alternative to surgery or radioactive iodine in the treatment of autonomous thyroid nodules.

Surgical and pathological changes after percutaneous ethanol injection therapy of thyroid nodules

Few data exist on the operative and pathological findings in patients having undergone previous percutaneous ethanol injection (PEI) therapy of thyroid nodules. We report here our experience with 13 patients operated on by the same surgical team. Two pathologists, both blinded to the previous PEI treatment, carried out histological evaluation. Reasons for surgery included PEI failure, suspicion of malignancy, and tracheal compression. The operations did not pose any special problem from the technical point of view, and the postoperative courses were uneventful. One patient who had a second operation developed hypoparathyroidism, and laryngeal nerve palsy was never observed. The histological diagnosis was hyperplastic or adenomatous nodule in 12 cases and papillary thyroid cancer in 1. No difficulty was found in evaluating the nodule capsule and surrounding vessels. In two lesions, nuclear enlargement and clearing were identified in thyroid follicles immediately adjacent to necrotic or scarred areas. These changes were considered reactive. In conclusion, patients previously treated by PEI were operated on without special technical problems. Histological diagnosis was not hindered, and there was no difficulty in ruling out malignant lesions. PEI, however, should be performed only by skilled operators, and incidental ethanol seepage throughout the nodule capsule must be carefully avoided.