Combination of Ultrasound-Guided Percutaneous Microwave Ablation and Radioiodine Therapy in Benign Thyroid Disease: A 3-Month Follow-Up Study

Abstract

Purpose: Pilot studies of combined therapies treating benign nodular goiters reported promising results. The aim of this study was to investigate the effectiveness of combined microwave ablation (MWA) and radioiodine therapy (RIT) with a special focus on thyroid function at the 3-month follow-up.

Materials and Methods: 15 patients (median age: 55 years) with a large goiter and benign thyroid nodules or Graves’ disease were treated with the combined therapy. Serum levels of triiodothyronine (T3), thyroxine (T4), thyrotropin (TSH), thyroglobuline (Tg) and, additionally, antibody levels against thyroglobulin (TgAb), thyrotropin receptors (TRAb) and thyroid peroxidase (TPOAb) were measured at enrollment, post MWA and at the 3-month follow-up (3MFU). Furthermore, the goiter volume, I-131 dose and hospitalization time were analyzed to evaluate effectiveness. MWA was operated under local anesthesia with a system working in a wavelength field of 902 to 928 MHz.

Results: TSH, T4, T3 and Tg did not change at 3MFU, except for in two patients in whom the initial TSH levels improved to normal thyroid functioning levels at follow-up. One of the patients developed a high TRAb-level that receded back into the normal range. At 3MFU, the combined therapy showed a mean thyroid volume reduction of 26.4 ml ± 7.9 ml (30.5 % ± 4.6 % (p < 0.05)). By utilizing the combined therapy, administered activity could be reduced by 26.6 % ± 4.8 % (p < 0.05) and hospitalization time by 30.9 % ± 19.9 % (p < 0.05).

Conclusion: The data confirmed the effectiveness of the combination of MWA with RIT. The combined therapy is an innovative and conservative approach and could become a safe alternative to surgery for the treatment of very large benign nodular goiters. Due to the short follow-up and the limited number of patients, further studies will be necessary.

Key Points:

• The combined therapy shows a significant volume reduction in benign nodular goiters

• Initial MWA improves the RIT results by reducing the required therapy activity

• Thyroid function is preserved after combined therapy

Citation Format:

• Korkusuz H, Happel C, Koch DA. et al. Combination of Ultrasound-Guided Percutaneous Microwave Ablation and Radioiodine Therapy in Benign Thyroid Disease: A 3-Month Follow-Up Study. Fortschr Röntgenstr 2016; 188: 60 – 68

Zusammenfassung

Ziel: Erste Studien zu verschiedenen Kombinationstherapien zur Behandlung benigner nodulärer Strumen überzeugten mit vielversprechenden Ergebnissen. Ziel der Studie war die Effektivität der kombinierten Mikrowellenablation (MWA) und Radiojodtherapie (RIT) zu prüfen, wobei die Schilddrüsenfunktion nach 3 Monaten im Fokus stand.

Material und Methoden: Fünfzehn Patienten (medianes Alter 55 Jahre) mit großen Strumen und Morbus Basedow oder benignen Schilddrüsenknoten erhielten die Kombinationstherapie. Im Serum wurden Triiodthyronin (T3), Thyroxin (T4), Thyreotropin (TSH), Thyreoglobulin (Tg) und Antikörper gegen Thyreoglobulin- (TgAK), Thyreotropin-Rezeptoren (TRAK) und Thyreoperoxidase (TPO-AK) bei der Voruntersuchung, post-MWA und bei der 3-monatigen Kontrolle (3MKU) untersucht. Um die Effektivität zu ermitteln, wurden zusätzlich Schilddrüsenvolumen, benötigte I-131-Therapieaktivität und Krankenhausliegedauer analysiert. Für die unter Lokalanästhesie durchgeführte MWA wurde ein System im Wellenlängenbereich von 902 bis 928 MHz eingesetzt.

Ergebnisse: TSH, T4, T3 und Tg veränderten sich bei der 3MKU gegenüber den Initialwerten nicht; die Patienten blieben euthyreot, außer zwei Patienten, wo eine Verbesserung der initialen TSH-Werte in den Normbereich beobachtet werden konnte. Ein Patient entwickelte einen hohen TRAK-Wert, der sich jedoch wieder normalisierte. Die 3MKU ergab eine mittlere Volumenreduktion der SD um 26,4 ml ± 7,9 ml (30,5 % ± 4,6 % (p < 0,05)). Die benötigte Therapieaktivität konnte um 26,6 % ± 4,8 % (p < 0,05) und die Krankenhausliegedauer um 30,9 % ± 19,9 % (p < 0,05) gesenkt werden.

Schlussfolgerung: Die erhobenen Daten bestätigen die Effektivität der Kombination von MWA mit RIT. Die Kombinationstherapie ist ein innovativer und effektiver Ansatz und könnte in Zukunft als eine sichere Alternative zur operativen Entfernung großer benigner nodulärer Strumen gesehen werden. Aufgrund des kurzen Follow-ups und der geringen Patientenzahl müssen weitere Studien die Ergebnisse bestätigen.

Kernaussagen:

• die Kombinationstherapie weist eine signifikante Volumenreduktion bei großen benignen nodulären Strumen auf

• die initiale MWA ermöglicht durch eine Reduktion der benötigten Therapieaktivität eine effizientere RIT

• die Schilddrüsenfunktion bleibt bei der kombinierten Therapie erhalten

Key words

combined therapy - radioiodine - microwave ablation - thyroid function - nodular goiter

• References

• 1 Feng B, Liang P, Cheng Z et al. Ultrasound-guided percutaneous microwave ablation of benign thyroid nodules: experimental and clinical studies. Eur J Endocrinol 2012; 166: 1031-1037
• 2 Gharib H, Papini E, Paschke R et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and EuropeanThyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocr Pract 16: 1-43
• 3 Hegedüs L. Clinical practice. The thyroid nodule. N Engl J Med 2004; 351: 1764-1771
• 4 Weetman AP. Radioiodine treatment for benign thyroid diseases. Clin Endocrinol (Oxf) 2007; 66: 757-764
• 5 Chianelli M, Bizzarri G, Todino V et al. Laser ablation and 131-iodine: A 24-month pilot study of combined treatment for large toxic nodular goiter. J Clin Endocrinol Metab 2014; 99: 1-5
• 6 Paschke R, Hegedüs L, Alexander E et al. Thyroid nodule guidelines: agreement, disagreement and need for future research. Nat Rev Endocrinol 2011; 7: 354-361
• 7 Spiezia S, Garberoglio R, Milone F et al. Thyroid nodules and related symptoms are stably controlled two years after radiofrequency thermal ablation. Thyroid 2009; 19: 219-225
• 8 Korkusuz H, Fehre N, Sennert M et al. Early assessment of high-intensity focused ultrasound treatment of benign thyroid nodules by scintigraphic means. J Ther Ultrasound 2014; 2: 18
• 9 Brace CL. Radiofrequency and microwave ablation of the liver, lung, kidney, and bone: what are the differences?. Curr Probl Diagn Radiol 38: 135-143
• 10 Korkusuz H, Happel C, Heck K et al. Percutaneous thermal microwave ablation of thyroid nodules. Preparation, feasibility, efficiency. Nuklearmedizin 2014; 53: 123-130
• 11 Yue W, Wang S, Wang B et al. Ultrasound guided percutaneous microwave ablation of benign thyroid nodules: safety and imaging follow-up in 222 patients. Eur J Radiol 2013; 82: e11-e16
• 12 Simon CJ, Dupuy DE, Mayo-Smith WW. Microwave ablation: principles and applications. Radiographics 2005; 25: S69-S83
• 13 Yang Y, Chen C, Zhang X. Microwave ablation of benign thyroid nodules. Futur Oncol 2014; 10: 1007-1014
• 14 Yu J, Liang P, Yu X et al. A comparison of microwave ablation and bipolar radiofrequency ablation both with an internally cooled probe: results in ex vivo and in vivo porcine livers. Eur J Radiol 2011; 79: 124-130
• 15 Marinelli LD, Quimby EH, Hine GJ. Dosage determination with radioactive isotopes; practical considerations in therapy and protection. Am J Roentgenol Radium Ther 1948; 59: 260-281
• 16 Happel C, Korkusuz H, Koch DA et al. Combination of ultrasound guided percutaneous microwave ablation and radioiodine therapy in benign thyroid diseases. A suitable method to reduce the 131I activity and hospitalization time?. Nuklearmedizin 2015; 54
• 17 Dietlein M, Dressler J, Eschner W et al. Procedure guideline for radioiodine test (Version 3). Nuklearmedizin 2007; 46: 198-202
• 18 Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg 2013; 150: 249-256
• 19 Baek JH, Lee JH, Valcavi R et al. Thermal ablation for benign thyroid nodules: radiofrequency and laser. Korean J Radiol 12: 525-540
• 20 Amabile G, Rotondi M, Pirali B et al. Interstitial laser photocoagulation for benign thyroid nodules: time to treat large nodules. Lasers Surg Med 2011; 43: 797-803
• 21 Kim YJ, Baek JH, Ha EJ et al. Cystic versus predominantly cystic thyroid nodules: efficacy of ethanol ablation and analysis of related factors. Eur Radiol 2012; 22: 1573-1578
• 22 Korkusuz H, Sennert M, Fehre N et al. Local thyroid tissue ablation by high-intensity focused ultrasound: effects on thyroid function and first human feasibility study with hot and cold thyroid nodules. Int J Hyperthermia 2014; 30: 480-485
• 23 Korkusuz H, Nimsdorf F, Happel C et al. Percutaneous microwave ablation of benign thyroid nodules. Functional imaging in comparison to nodular volume reduction at a 3-month follow-up. Nuklearmedizin 2015; 54: 13-19
• 24 Rotondi M, Amabile G, Leporati P et al. Repeated laser thermal ablation of a large functioning thyroid nodule restores euthyroidism and ameliorates constrictive symptoms. J Clin Endocrinol Metab 2009; 94: 382-383
• 25 Spiezia S, Vitale G, Di Somma C et al. Ultrasound-guided laser thermal ablation in the treatment of autonomous hyperfunctioning thyroid nodules and compressive nontoxic nodular goiter. Thyroid 2003; 13: 941-947
• 26 Gharib H, Papini E, Paschke R et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. Endocr Pract 16: 468-475
• 27 Dottorini ME, Inglese E et al. Linee Guida. SIE-AIMN-AIFM per il Trat tamento Radiometa- bolico dell’Ipertiroidismo. book: vol. 00. 2009
• 28 Zingrillo M, Modoni S, Conte M et al. Percutaneous ethanol injection plus radioiodine versus radioiodine alone in the treatment of large toxic thyroid nodules. J Nucl Med 2003; 44: 207-210
• 29 Guglielmi R, Pacella CM, Bianchini A et al. Percutaneous ethanol injection treatment in benign thyroid lesions: role and efficacy. Thyroid 2004; 14: 125-131
• 30 Gharib H, Hegedüs L, Pacella CM et al. Clinical review: Nonsurgical, image-guided, minimally invasive therapy for thyroid nodules. J Clin Endocrinol Metab 2013; 98: 3949-3457
• 31 Happel C, Korkusuz H, Kranert WT et al. Combination of ultrasound guided percutaneous microwave ablation and radioiodine therapy for treatment of hyper- and hypofunctioning thyroid nodules. Nuklearmedizin 2014; 53: N48-N49
• 32 Jeong WK, Baek JH, Rhim H et al. Radiofrequency ablation of benign thyroid nodules: safety and imaging follow-up in 236 patients. Eur Radiol 2008; 18: 1244-1250
• 33 Monzani F, Caraccio N, Goletti O et al. Five-year follow-up of percutaneous ethanol injection for the treatment of hyperfunctioning thyroid nodules: a study of 117 patients. Clin Endocrinol (Oxf) 1997; 46: 9-15
• 34 Baek JH, Lee JH, Sung JY et al. Complications encountered in the treatment of benign thyroid nodules with US-guided radiofrequency ablation: a multicenter study. Radiology 2012; 262: 335-342
• 35 Rokni H, Sadeghi R, Moossavi Z et al. Efficacy of different protocols of radioiodine therapy for treatment of toxic nodular goiter: systematic review and meta-analysis of the literature. Int J Endocrinol Metab 2014; 12: e14424
• 36 Heck K, Happel C, Grünwald F et al. Percutaneous microwave ablation of thyroid nodules: effects on thyroid function and antibodies. Int J Hyperth 2015; 6736: 1-8
• 37 Valcavi R, Riganti F, Bertani A et al. Percutaneous laser ablation of cold benign thyroid nodules: a 3-year follow-up study in 122 patients. Thyroid 2010; 20: 1253-1261
• 38 Nygaard B, Faber J, Veje A et al. Transition of nodular toxic goiter to autoimmune hyperthyroidism triggered by 131I therapy. Thyroid 1999; 9: 477-481
• 39 Dunkelmann S, Wolf R, Koch A et al. Incidence of radiation-induced Graves’ disease in patients treated with radioiodine for thyroid autonomy before and after introduction of a high-sensitivity TSH receptor antibody assay. Eur J Nucl Med Mol Imaging 2004; 31: 1428-1434