Thermal ablation of thyroid nodules

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As thermoablation referred to medical treatment methods in which tissue is destroyed by heat. They are used against various benign and malignant tumors, e.g. B. against liver metastases or against benign thyroid nodules . They are an alternative to surgery . Since the 1970s , various methods of tissue ablation through thermal effects, thermal ablation , have been used in clinical routine and are currently in some cases established therapies in the treatment of liver , lung , spleen and bone tumors as well as enlarged prostate . The functional principle is the ablative destruction of tissue by heat. The thermal ablation of thyroid nodules does not compete with the established procedures for the therapy of benign thyroid diseases such as drug therapy, radioiodine therapy or thyroidectomy , but should rather be seen as a useful addition to the existing therapy modalities.

Basics of thermal ablation

The goal of thermal ablation of thyroid nodules is irreversible coagulation necrosis of the thyroid nodule with subsequent volume reduction. During the thermal ablation of thyroid nodules, a temperature of at least 60 ° C is aimed for in the ablation zone. At ablation temperatures of 60 ° C, the thermal effect occurs almost immediately and the result is irreversible damage to the node. Vessels with a diameter of less than 3 mm are destroyed by the heat (“thermal embolization” of the vessels). This is a desired effect as it destroys the intrathyroid vessels supplying the node. This effect does not occur with vessels of more than 4 mm in diameter. In these cases there is a loss of energy, also known as a "heat sink".

Radiofrequency ablation (RFA) of thyroid nodules

In the radiofrequency ablation , a probe is placed percutaneously into the node. The probe is connected to a radio frequency alternator . In the area of ​​the active tip, a current flows between two electrodes . The high local current density in a small area creates ionic friction energy (heat) which forms the ablation zone.

Radiofrequency ablation of benign thyroid nodules

The effect of RFA on thyroid nodules was examined in metanalyses. The metanalyses showed a statistically significant improvement in the outcome (volume, symptoms, cosmetics , medication requirement ). The average volume reduction after RFA was 8.9 ml to 9.77 ml. The outcome was dependent on the nodal morphology. In the single-center randomized studies, the volume reduction of primary cystic thyroid nodules was 87% to 93% and in the randomized case-control study of solid nodules after 6 months it was 49.1% ± 19.5% compared to the control group. The randomized prospective study showed that the smaller the thyroid nodule, the greater the relative volume reduction. The RFA was performed once or several times, unilaterally or bilaterally , in the case of benign cold or hyperfunctional thyroid nodules. An RFA is also possible after a lobectomy . For thyroid cysts with viscous colloid , RFA can be performed after aspiration of the viscous cyst contents. Even after a previous ethanol injection, the RFA achieves a further significant volume reduction. In the RFA of hyperfunctional thyroid nodules with reduced TSH, several RFA treatments are necessary, this is explained by the remaining edge of the hyperfunctional node to protect thermo-sensitive structures. After a single RFA of hyperfunctional nodules, 50 to 67% of patients were still hyperthyroid . In the case of a thyroid nodule with Thy 2 classification in the fine needle aspiration, there was a decrease in volume of 67% over the observation period of 24 months. Only in the Thy3 classification was there an increase in volume in 2 out of 6 thyroid nodules. A follicular carcinoma and a microfollicular neoplasm were found postoperatively in the two thyroid nodules. In a long-term study over 4 years there was an increase in volume after RFA in the edge area of ​​the node with a frequency of 5.6%. The Italian Commission of Experts recommends RFA for hyperfunctional thyroid nodules and for non-hyperfunctional thyroid nodules larger than 20 ml if patients refuse surgical therapy or radioiodine therapy. The Italian Medical Radiological Society recommends RFA for all benign thyroid nodules. There is a significant decrease in echogenicity and the Doppler signal within the ablation zone after bipolar RFA with the “multi-shot” technique. The Korean Task Force (KSThR) recommends RFA with the "moving-shot" technique for all benign thyroid nodules regardless of size, if the thyroid nodule causes clinical symptoms. Successful ablation of thyroid nodules is possible with both shot techniques and with monopolar and bipolar RFA probes.

Complications after RFA are rare. In the retrospective analysis with 4 centers from Korea, the complication rate was 0.2% after 2616 treatments; in the retrospective multicenter study with 13 thyroid centers, the complication rate was a total of 3.3%, with permanent complications ( hypothyroidism and thyroid nodule rupture) being documented in only 2 patients . In long-term studies over 4 years, the complication rate was 3.6%. Bipolar RFA also show low complication rates. Compared to thyroidectomy for benign multifocal thyroid nodules, the risk of complications with RFA is lower.

Radiofrequency ablation of lymph node metastases or local recurrences of thyroid carcinoma

In some cases, surgery or radioiodine therapy after thyroidectomy cannot be performed in the case of known metastases from well-differentiated papillary thyroid carcinoma. After RFA of local recurrences or lymph node metastases, there was a significant volume reduction of the metastases from 53% to 95% and a decrease in the tumor maker thyroglobulin. The post-therapeutic control by means of biopsy showed no evidence of residual malignant tissue and no evidence of a new recurrence of the treated side after RFA. Also in the case series with well-differentiated papillary and follicular thyroid carcinoma recurrences, the long-term follow-up after RFA showed no evidence of progression. In combination with radioiodine therapy , it was possible to show in a prospective study that RFA successfully destroys remains of the thyroid gland after thyroidectomy. The expert commissions therefore recommend palliative RFA for relapses and metastases of well-differentiated thyroid carcinoma if surgical therapy or radioiodine therapy are not possible or are rejected by the patient. The complication rate of RFA of metastases and local recurrences was about 7%, no life-threatening complications were observed. In a direct comparison with reoperation for local recurrences, lower complication rates for RFA were found with the same effectiveness.

Microwave ablation (MWA)

In MWA, a microwave probe is inserted percutaneously into the thyroid nodule. A microwave field is created in the area of ​​the active tip. The electromagnetic wave is dampened by the excitation of dipole connections (tissue water, molecules ). The attenuation of the electromagnetic wave is converted into heat (ablation energy).

Microwave ablation of benign thyroid nodules

Even with the first prospective study , a volume reduction of 46 ± 30% after 9 months in benign thyroid nodules was achieved using cooled MWA . In the retrospective study with 222 patients and 477 nodes, the volume reduction was 41%. The volume reduction was dependent on the nodal morphology. In cystic nodules, there was a volume reduction of 80%, in echo-complex nodules, a volume reduction of 72%, and in solid nodules, a volume reduction of 27%. The uncooled MWA probes showed a significant volume reduction of over 50% after just 3 months. In combination with radio-iodine therapy, the radio-iodine activity required for radio-iodine therapy could be significantly reduced in the case of very large goiter, the volume reduction was 30%. Scintigraphy can be used to check the effectiveness of thermal ablation at an early stage before volumetric follow-up controls are possible. Benign cold or hyperfunctional thyroid nodules were successfully treated using MWA. Due to the thicker MWA probe, 4 of 11 patients had a small capsular hemorrhage of the thyroid gland smaller than 1 mm, while the uncooled MWA probes had a superficial small hematoma in all patients . There were no life-threatening or permanent complications in any of the studies.

Microwave ablation of lymph node metastases or local recurrences of thyroid carcinoma

One or up to four MWAs were performed in the prospective study with 17 patients with local recurrences of papillary thyroid cancer. The volume reduction after 18 months was 91 ± 14%. In 30% no local recurrence could be detected after treatment, life-threatening or permanent complications did not occur. In another study, 21 papillary microcarcinomas in stage T1N0M0 were treated with MWA. All micro carcinomas could be completely ablated in one MWA session. There was no local recurrence after 11 months of follow-up. There were no life-threatening or permanent complications.

Highly focused ultrasound (echotherapy)

With HIFU (highly focused ultrasound, echotherapy), thermal ablation is carried out non-invasively. The ultrasound head works at 2 MHz and is curved inwards (concave). This results in a focusing and targeted bundling of the ultrasound through the skin in the thyroid nodules. During ablation, a volume the size of a grain of rice is heated to around 85 ° C. The advantage of this non-invasive thermoablative procedure is that there is no risk of infection. The concavity of the ultrasonic head simultaneously determines the degree of focus and thus also the depth at which the thermal effect occurs.

Highly focused ultrasound (echotherapy) of benign thyroid nodules

In the 2011 feasibility study, 25 patients were treated for the first time with HIFU for goiter multinodosa, 16 patients showed significant changes on ultrasound and in 17 thyroid nodules, changes such as necrosis were found in the subsequent histopathological evaluation . The scintigraphy can thermoablation be used for the early review of the effectiveness before volumetric follow-ups are possible. Benign, cold, indifferent or hyperfunctional thyroid nodules were successfully treated using HIFU. The volume reduction after 3 months after a single HIFU treatment was 49 to 55%. In the only prospective study with 20 patients, the volume reduction was 49%. The median pretherapeutic nodal volume was 5 ml. In addition, the system defined safety distances so that the edge areas of the thyroid nodule were outside the ablation zone. There were no life-threatening or permanent complications after HIFU, and immunogenic autoimmune thyroid disease is also not triggered by the HIFU in the thyroid.

History of thermal ablation in Germany

  • 2012: First microwave ablation of a thyroid nodule in Europe by Hüdayi Korkusuz
  • 2013 Combination therapy of microwave ablation of a cold nodule and radioiodine therapy of a hot thyroid nodule
  • 2014 Founding of the German Center for Thermoablation eV to promote thermoablation as an alternative therapy to thyroid surgery and as an alternative therapy to radioiodine therapy.
  • 2015 First use of a bipolar radio frequency probe worldwide
  • 2017 Recognition of thermal ablation as top medicine by the Techniker Krankenkasse

bibliography

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