Shidlovskyi: Choice of Thyroid Nodules Treatment



Problem statement and analysis of the recent research

The literature of recent years presents reports about the successful use of minimally invasive technologies, including laser-induced interstitial thermotherapy (LITT) and sclerotherapy in the treatment of benign formations in the gland. However, some diverse reports do not provide an integral idea of their effectiveness in the treatment of various forms of nodular goiter, indications and contraindications, their safety and impact on the parenchyma and gland function. Attitude to the place and site of sclerotherapy with ethanol and laser-induced interstitial thermotherapy is ambiguous in the general therapeutic strategy of nodular goiter [1-6].

The objective of the research was toanalyse the results of minimally invasive technologies use in the treatment of thyroid nodules and develop the indications for their use.

Materials and methods

643 patients with thyroid nodules were treated from 2008 to 2016. They included 32 (4.97%) men and 611 (95.03%) women at the age of 18 to 72 years. Duration of nodule pathology history was 1-8 years. In addition to general clinical examination, thyroid ultrasound was performed, levels of TSH, T3 (a), T4 (a) and calcitonin TPOAb were determined and puncture biopsy of focal lesions was conducted.

Among 643 patients nodular goiter was detected in 421 patients, multinodular goiter was observed in 222 patients. The total number of treated patients was 886. Cystic transformation of nodules was observed in 184 cases and functional autonomy of nodule was noted in 84 cases.

Mean nodule volume constituted (2.9 ± 1.4) cm3 and ranged from 0.4 to 32.9 cm3. Cytology: benign process was stated from nodular tissue. The level of calcitonin in did not exceed the upper limit of normal in any case. Triiodothyronine thyrotoxicosis was diagnosed in patients with thyrotoxicosis symptoms of varying severity, before the treatment they underwent medication compensation.

Laser-induced interstitial thermotherapy, sclerotherapy with 70% solution of ethanol and their combinations were used for the treatment.

All nodules were divided into groups depending on nodular echostructure:

  • Group I included 412 solid nodules and 210 heterogeneous nodules with the volume of liquid component <20%. Volume of nodules in this group ranged between 0.4 and 4.8 cm3. LITT solely was used for the treatment of nodules.

  • Group II included 109 heterogeneous nodules with the volume of liquid component from 20 to 80%. Nodules volume ranged from 3.6 to 32.9 cm3. Sclerotherapy with 70% ethanol was used at the first stage of treatment, LITT was applied further.

  • Group III consisted of 75 nodules, which the percentage of liquid component exceeding 80%. Nodules volume ranged from 2.8 to 8.9 cm3. Sclerotherapy with 70% ethanol solely was used for the treatment.

  • Group IV included functionally active nodules with the volume of 0.4 to 1.0 cm3. LITT was used for their treatment.

Results and Discussion

Complete replacement of nodules with connective tissue occurred in the range of 9 to 16 months in the patients of Group I after LITT. The final volume of nodule (scar) ranged from 0.01 to 0.8 cm3. It depended on the initial volume of nodule and its echostructure. Moreover, a scar of larger volume formed after the solid nodules than after heterogeneous ones even with bigger original volume. The average number of procedures constituted 1.8 ± 0.1 and ranged from 1 to 4.

Group II patients (heterogeneous nodules with a volume of liquid component within 20-80%) underwent sclerotherapy at the first stage of treatment. Indications to LITT as the second phase of treatment included the absence of the liquid component in the tissue of the treated nodule. 16 patients of this group underwent sclerotherapy correction due to “honeycomb” structure of the liquid part of the nodule requiring repeated sclerotherapy and, ultimately, leading to the elimination of the liquid component. LITT was further prescribed to these patients. Total replacement of nodules with connective tissue occurred in the range of 14 to 22 months. The final volume of the nodule (scar) in these patients ranged from 0.6 to 1.7 cm3. The average number of sclerotherapy procedures constituted 1.9 ± 0.4 and ranged from 1 to 3, and the average number of LITT constituted 1.5 ± 0.3 and ranged from 1 to 4.

Patients of Group III were treated with sclerotherapy. Total replacement of nodules with connective tissue occurred for a long time between 5 to 11 months. The final volume of the nodule (scar) in these patients ranged from 0.1 to 0.5 cm3. The average number of procedures was 1.3 ± 0.2 and ranged from 1 to 3.

Thyreostatic medication intake was discontinued in case of functional autonomy (Group IV) immediately after treatment. Increase in T3 and decrease in TSH was not observed. Hyperthyroidism relapse was not noted during four years.

Cytology: connective-tissue fibers without epithelium were observed in all patients at the site of the nodule after the treatment.

Hypothyroidism signs or autoimmune component were not observed after the treatment of nodule pathology with minimally invasive technology.

Low effectiveness of minimally invasive techniques was observed in 8 (0.9%) patients. 3 patients in Group II had the nodules more than 11 cm3 in volume with a high degree of parenchymal part and liquid component over 22%. Solid nodule with the volume of 4.8 cm3 was detected in one patient. These patients underwent hemithyroidectomy. Benign process with single connective bands was stated in the course of histopathological examination.

Conclusions

  • Indications for the use of minimally invasive technologies included solitary nodules in the thyroid gland of benign origin according to the results of cytological investigations of punctate, the volume of which increase by more than 15% durinf the year according to case follow-up.

  • Only LITT as a complete method of treatment was used in case of solid nodules and nodules with cystic degeneration with the volume of liquid component <20%.

  • Cystic nodules with a volume of liquid component > 80% are to be treated using sclerotherapy completely.

  • Sclerotherapy should be conducted at the first stage of treatment of cystic units with a volume of liquid component within the 20-80%, and LITT should be performed at the second stage for the influence on the tissue component.

  • Minimally invasive treatment of nodular pathology does not lead to the development of hypothyroidism and autoimmune thyroiditis.

  • LITT in case of nodular toxic goiter provides a gradual normalization of hormonal function of the thyroid gland.

  • We consider contraindications to the use of minimally invasive technologies for treatment of nodular goiter to include hyperechogenic nodules with a volume over 2.0 cm3, nodular lesion volume more than 60% of the part volume, nodule on the background of autoimmune thyroiditis.

Prospects for further research

Prospects for further research involve the investigation of the reasons for the ineffectiveness of minimally invasive technologies in the treatment of thyroid nodules

References

1 

VA Oliinyk, SI Matiashchuk, YuM Naida, YeA Shelkovoi. The effectiveness of percutaneous ethanol sclerotherapy of various types of benign tumors of the thyroid gland. Klinichna imunolohiia. Alerholohiia. Infectolohiia. 2008;18-19:7-8. Ukrainian.

2 

G Amabile, M Rotondi, B Pirali, et al. Interstitial laser photocoagulation for benign thyroid nodules: time to treat large nodules. Lasers Surg Med. 2011;43 (8):797-803. doi:10.1002/lsm.21114

3 

AB Faizrakhmanov, VA Privalov, OV Seliverstov, NN Yarovoy. The effectiveness of sclerotherapy and laser-induced thermotherapy for the treatment of nodular nontoxic goiter. Sovremennye aspekty khirurgicheskoi endokrinologiyi. 2009;0:274-277. Ukrainian

4 

VG Petrov, EV Antonova. Evaluation of the effectiveness of laser-induced thermotherapy treatment of nodular colloid goiter depending on the original nodule volume. Onkokhirurgiya. 2013;5 (1):157. Ukrainian

5 

H Døssing, FN Bennedbæk, L Hegedüs. Long-term outcome following interstitial laser photocoagulation of benign cold thyroid nodules. Eur J Endocrinol. 2011;165 (1):123-128. doi:10.1530/EJE-11-0220. Cited in: PubMed; PMID 21551168

6 

L Hegedus. New treatment modalities of thyroid nodules. International guidelines in thyroid disease in daily practice. Abstract book; 2012 June 8-9. Vienna. 2012. p. 23.



Copyright (c) 2017 A. V. Shidlovskyy

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