Ultrasound-guided ethanol ablation for cystic thyroid nodules: effectiveness of small amounts of ethanol in a single session

Minimally invasive techniques for the management of benign thyroid nodules: Efficacy and impact on quality of life of percutaneous ethanol injection. Results from a high-resolution thyroid nodule unit

BACKGROUND AND OBJECTIVE

The high incidence of thyroid nodular disease has raised concerns on the therapeutic management of benign thyroid nodules. The development of minimally invasive techniques is an alternative to surgery and has a low rate of complications. Our objective was to evaluate the safety and efficacy profile of percutaneous ethanol injections (PEI) with ethanol aspiration of symptomatic cystic and predominantly cystic thyroid nodules (cystic component > 50%) treated in the thyroid nodule high-resolution unit (TNHRU) of Hospital de Tortosa Verge de la Cinta Hospital, Tarragona, Spain.

PATIENTS AND METHODS

The present work is a prospective, observational and descriptive study of 32 patients (87.5% women, mean age of 43; SD, 12) evaluated at the TNHRU from August 2022 through December 2023. Demographic data such as age, sex, previous thyroid function, diagnostic method, initial nodular volume, nodular composition and nodular location were analyzed. Using ultrasounds, measurements of diameters and thyroid nodule volume were taken. We aspirated a total of 50% of the cystic content and injected between 2 mL and 5 mL of 99% ethanol (depending on cystic volume). After letting the ethanol act inside the nodule for 5 to 10 minutes, all the cystic content and the injected ethanol were aspirated. We performed an ultrasound follow-up at 1, 3 and 6 months, calculating the total volume and the volume reduction rate (VRR). The impact on health-related quality of life (HRQoL) was assessed using the ThyPRO-39es questionnaire, which was administered before and after the PEI treatment at the 6-month follow-up.

RESULTS

The median volume reduction at the end of the 6-month follow-up was 0.23 mL (0.00-0.67), and the VRR, 98.57% (94.80-100.00). The difference between the initial volume and the mean volume at the 1-, 3-, and 6-month follow-ups was statistically significant, as was the VRR between the 1-month and the 3- and 6-month follow-ups. Six patients (18.80%) required 2 PEIs and only 2 patients (6.3%) required 3 PEIs. The overall quality of life, which was scored from 0 (good) to 4 (poor), significantly improved from 1.28; SD, 0.81 up to 0.19; SD, 0.40 (p < 0.001).

CONCLUSIONS

PEI is an effective alternative to treat cystic thyroid nodules resulting in an improved patients' HRQoL. It can be performed outpatiently with a low rate of complications, thus making it suitable for inclusion in the service portfolio of a HRTNU.

Prevalence and Management of Complications of Percutaneous Ethanol Injection for Cystic Thyroid Nodules: A Systematic Review of Literature and Meta-analysis

Background: We assessed the prevalence of complications from percutaneous ethanol injection (PEI) for benign and cystic thyroid nodules (CTNs) and their management. Methods: We conducted a systematic review with meta-analysis of data from published observational studies on PEI of CTNs. We also included unpublished retrospectively collected data on complications after PEI from all consecutive patients with cytologically benign CTNs who underwent PEI at the Unit of Endocrinology and Metabolic Diseases, AOU University of Campania Luigi Vanvitelli (Naples, Italy) between June 1, 2021, and March 31, 2024. A random effects meta-analysis was performed on the prevalence rate data. Pooled prevalence data were presented with confidence intervals (CIs). The I2 statistic index was used to quantify the heterogeneity. The details of the complications and the management were qualitatively described. Results: The literature search yielded 1189 studies, of which 48 studies were included in the systematic review and meta-analysis, in addition to our institutional experience (3670 CTNs in total). The overall quality of each included study was judged as fair. The prevalence of "Overall" complications of PEI was 32% ([CI 25-40%], I2 92.7%, 967 of 3195 thyroid nodules [TNs]). The prevalence of "Minor" complications of PEI was 32% ([CI 25-40%], I2 92.7%, 952 of 3195 TNs). The prevalence of "Major" complications of PEI was 2% ([CI 1-2%], I2 0%, 22 of 3670 TNs). Sensitivity analyses did not modify the results. The pooled prevalence rate of local pain was 21% (CI [16-27] I2 90.3). Local pain was typically transient and mild, sometimes moderate, and requiring analgesics for few days. The pooled prevalence rate of dysphonia was 1% (CI [1-2], I2 0). Dysphonia was transient and could last from several hours to 12 months after PEI. Conclusions: Complications of PEI for benign and CTNs are relatively common, but most are minor and usually transient, not requiring treatment. Dysphonia was a major complication, but it was uncommon and transient. PEI for CTNs could be considered a generally safe technique.

The Comparison of Efficacy and Safety between Radiofrequency Ablation Alone and Ethanol Ablation Followed by Radiofrequency Ablation in the Treatment of Mixed Cystic and Solid Thyroid Nodule

Purpose

To compare the efficacy and safety of radiofrequency ablation (RFA) and ethanol ablation (EA) followed by RFA in treating mixed cystic and solid thyroid nodules.

Materials and Methods

We included 243 nodules from 243 patients who underwent RFA for mixed cystic and solid benign nodules. The nodules were divided into two groups (RFA alone and EA + RFA). We evaluated volume reduction rate (VRR), therapeutic success rate, improvement in symptomatic and cosmetic issues, complications, and adverse effects.

Results

The RFA group included 204 patients, and the EA + RFA group included 39 patients. The long-term success rates in the RFA only and EA + RFA groups were 90.2% and 97.4%, respectively. The mean VRR at the last follow-up in the RFA and EA + RFA groups were 81.6% and 87.2%, respectively. Therapeutic results were similar in both groups at the last follow-up. Cosmetic and symptomatic problems markedly improved in both groups. No major complications were observed.

Conclusion

Both RFA alone and EA + RA are safe and effective methods for treating mixed cystic and solid thyroid nodules, although EA + RFA is slightly more effective.

Ultrasound-guided ethanol ablation versus the Sistrunk operation as a primary treatment for thyroglossal duct cysts

PURPOSE

This study compared ethanol ablation (EA) with the Sistrunk operation (SO) with regard to feasibility, treatment efficacy, and cost-effectiveness. The goal was to evaluate whether EA could replace SO as a primary treatment modality for thyroglossal duct cysts (TGDCs).

METHODS

This retrospective case-control study included patients with TGDCs who were treated with either EA or SO between 2016 and 2022. The primary outcome variables evaluated were treatment efficacy (as measured by the volume reduction rate [VRR] and treatment success rate), complications, and cost-effectiveness.

RESULTS

A total of 72 patients were enrolled, with 33 in the EA group and 39 in the SO group. The procedure or operation times for the EA and SO groups were 9 and 82 minutes, respectively (P<0.001). At the final follow-up appointment, the VRR was 94.1% for the EA group and 100.0% for the SO group (P<0.001). Treatment success was achieved for 32 patients (97.0%) in the EA group and for all 39 patients (100.0%) in the SO group (P=0.458). The overall complication rates were 0.0% and 17.9% in the EA and SO groups, respectively (P=0.013). The total costs, including all treatment procedures and follow-up ultrasound examinations, were $485 and $1,081.7 for the EA and SO groups, respectively (P<0.001).

CONCLUSION

EA demonstrates superiority over SO in terms of feasibility, safety, and costeffectiveness, while maintaining comparable treatment efficacy. Despite the need for multiple treatment sessions in approximately one-quarter of patients, EA can serve as a primary treatment modality for selected patients with TGDCs, supplanting SO.

Ultrasound-Guided Ethanol Ablation for Thyroglossal Duct Cyst: A Review of Technical Issues and Potential as a New Standard Treatment

The thyroglossal duct cyst (TGDC) is the most common congenital neck mass, accounting for 70-75% of all congenital neck masses. Although the Sistrunk operation has been used as a standard of treatment, it is accompanied by a considerable surgical burden, including the need for general anesthesia, a visible surgical scar on the neck surface, and postoperative complications. Ultrasound-guided ethanol ablation (US-EA) is a minimally invasive and office-based technique that is widely used as a non-surgical treatment for several benign cystic lesions, particularly benign thyroid cysts. Recently, US-EA has also been gaining popularity as a good alternative for TGDC treatment, which is associated with high feasibility, a high safety profile, and favorable treatment outcomes. To our best knowledge, seven studies on the use of EA as a primary treatment option for TGDC have been published since 2011. Although these studies have reported promising results, there is a lack of consensus on several issues regarding the application of EA for TGDC, particularly its detailed techniques and role as a primary treatment. This article aims to provide a comprehensive review of EA for TGDC, addressing technical issues and its possible role as a new standard of treatment for TGDC.

Ethanol ablation of thyroid cysts in the young with a focus on efficacy and quality of life

Objective

Ultrasound-guided percutaneous ethanol injection therapy (US-PEIT) is used in patients with recurrent symptomatic thyroid cysts as a credible alternative to surgery. Young patients commonly do not wish to undergo surgery and prefer ethanol ablation, if available. The effect of this approach on quality of life is an essential factor in deciding on the treatment options, especially in the young with a long life expectancy and no comorbidity.

Methods

We performed US-PEIT in a cohort of young patients, 15-30 years, from 2015 to 2020. The patients' general quality of life (QoL), self-reported compression symptoms and neck appearance were evaluated.

Results

The cohort comprised 59 patients with 63 cysts, more women than men, with a mean age of 23.8 years. About 1.5 mL of injected alcohol were needed to reach a 90.7% mean cyst volume reduction ratio in 12 months. The method did not fail in any of the patients; a single US-PEIT session was undertaken in 46% of them. The procedure significantly improved each of the patients' symptoms with a significant total score difference (P < 0.001). The total symptom score correlated with the initial cyst volume (P = 0.002; r = 0.395). The mean QoL score by SF-36 6 months after the last US-PEIT was significantly different for physical component summary 56.5 (P < 0.001) but not different for mental component summary 47.7 (P = 0.125), compared to age-corresponding norms.

Conclusions

US-PEIT is a safe and effective method for the young, leading to improvements in cosmetic and subjective complaints, and should also be considered as first-line treatment in the young.

Approach to FNA of Thyroid Gland Cysts

Fine needle aspiration is a well-known procedure for the diagnosis and management of thyroid lesions, representing the first diagnostic tool for the definition of their nature. In clinical practice, a thyroid nodule can be classified as solid, cystic, and partially cystic based on its internal components. Different thyroid imaging reporting systems and cytologic diagnostic systems have focused their attention on solid nodules, which are more frequently linked with a malignant outcome. In fact, numerous papers demonstrated that nodules with microcalcifications, a taller-than-wide shape, hypoechogeneity, and irregular margins, are more likely to be malignant on histology. Nevertheless, according to the literature, the risk of malignancy in a partially cystic thyroid nodule ranges between 3.3 and 17-5%, including, for instance, the possible diagnosis of a cystic papillary thyroid carcinoma and other malignant entities. Therefore, in the current review article, we are going to discuss the approach to thyroid cystic lesions on fine needle aspiration cytology.

Minimally Invasive Techniques for the Management of Thyroid Nodules

Image-guided interventional techniques have emerged as promising treatments for thyroid disease. Percutaneous ethanol ablation, radiofrequency ablation, laser ablation, high intensity focused ultrasound, and microwave ablation have shown efficacy in treating benign thyroid disease. There is increasing evidence that these techniques may effectively treat papillary thyroid microcarcinomas, recurrent and metastatic disease, follicular neoplasms, and parathyroid lesions. They are performed in an outpatient setting, well-tolerated, with negligible risk for thyroid hormone supplementation, making them a popular alternative to surgical resection. In this comprehensive review, we discuss the devices, techniques, advantages, and disadvantages of each intervention, and summarize the published outcomes.