Thyroid No Surgery 101: Thyroid Nodule Treated by RF Instead of Surgery.
Dr. Roberto Valcavi’s Case Presentation.
ABLATION BY RADIOFREQUENCY OF A BENIGN, NORMALLY FUNCTIONING THYROID NODULE: CLINICAL AND ULTRASOUND FOLLOW-UP
November 2018. The patient introduces herself
Woman, yrs. 35. Visible left lobe thyroid nodule, causing predominantly cosmetic damage. At a prestigious Italian institution, recommended left hemithyroidectomy. Two previous aspirations at another prestigious Italian institution: Tir 2. Nodule volume about 11 ml.
TSH-reflex 1.57 µU/ml (n.v. 0.25-4.40), anti-TPO antibodies <1.0 µU / ml (positive> 6), anti-Tg antibodies <1.0 µU/ml (positive> 10). Clinically euthyroid.
Repeated thyroid aspiration (3rd) at the Centro Palmer, Reggio Emilia, Italy: confirmed Thy 2. Discussed the treatment options with the patient. After accurate information the patient opts for RFA surgery.
November 2018. Preoperative ultrasound images
Fig 1. B-mode axial scan of the left thyroid lobe nodule. Solid non-homogeneous nodule, with cystic micro-areas, demarcated by a clear halo. The “danger triangle” (site of the recurrent laryngeal nerve) is clearly visible, well cleaved by the nodule.
Fig 2. Power Doppler axial scan. Peri- and intranodular vascularization.
Fig 3. B-flow axial scan. The “basket” and intranodular vascularization is confirmed.
Fig 4. Axial and sagittal scans of the left thyroid lobe nodule. Measurements of the 3 diameters are visible. Volume of the nodule calculated by the ultrasound 10.23 ml; correct volume, calculated with the ellipsoid formula is ml 11.06.
January 2019. Radiofrequency ablation intervention (RFA) at the Centro Palmer
Ultrasound-guided thyroid pericapsular local anesthesia with lidocaine 2% + ropivacaine 7.5 mg / ml. Anesthesiologist: sedation with midazolam 2.5 mg i.v. + small i.v. propofol 10 mg/ml repeated boli. STARmed generator, power used 40-60 Watts. 18G monopolar RF electrode needle internally cooled by sterile saline solution at 5 ° C, length 7 cm, exposed tip 1 cm. Under continuous ultrasound control, the electrode needle is inserted into the nodular thyroid parenchyma via trans-isthmic approach. Using the “moving shot” technique, total RF thermoablation of the left thyroid nodule is completed. Delivered 6.46 kCal in an ignition time of 11’48 “. Total intervention time for field set-up and awakening of the patient: 35 min’. No side effects. Euphonic patient.
January 2019. Postoperative ultrasound images (day after RFA)
Fig 5. Power Doppler axial scan. After RFA intervention hypoechoic nodule, totally devoid of intranodular vasculature, conserved perinodular vasculature, undamaged thyroid capsule, undamaged “danger triangle”. Total ablation of the nodule.
Fig 6. B-flow axial scan. Complete intranodular devascularization confirmed, perinodular vasculature preserved.
Fig. 7. Power Doppler sagittal scan. Left lobe thyroid hypoechoic nodule, perinodular vasculature, no intranodular vasculature.
July 2019. Six months after RFA thyroid procedure
TSH-reflex 1.84 µU / ml (n.v. 0.25-4.40), anti-TPO antibodies 2.3 µU/ml (positive>6), anti-Tg antibodies 1.7 µU/ml (positive>10). Clear subjective improvement reported by the patient. At the left side ultrasonography shows the ablated thyroid nodule reduced to about 2.3 ml, hypo-echogenic at the periphery, isoechoic at the center, avascular. The nodule now falls within the thyroid gland profile. The patient is well and says she is satisfied.
July 2019. Ultrasound images at six months of RFA procedure on left thyroid lobe nodule
Fig 8. B-Mode axial scan. Left hypo-echogenic solid nodule at the periphery, isoechogenic in the center, site of previous RFA intervention. Preserved thyroid capsule. Isthmic, paratracheal and paracarotid viable parenchyma. The nodule is within the glandular profile, no longer causing any bulk.
Fig. 9. Power Doppler axial scan. Intranodular vascularization, perinodular vasculature preserved.
Fig. 10. Power Doppler sagittal scan. Intranodular devascolarization, preserved thyroid capsule and capsular vasculature. Undamaged extranodular thyroid parenchyma.
Fig. 11. Axial and sagittal scans of the left thyroid lobe nodule 6 months after RF ablation. Measurements of the 3 diameters are visible. Volume of the nodule calculated by the ultrasound system 2.29 ml; correct volume, calculated with the ellipsoid formula, is ml 2.49. Volumetric reduction of approximately 77% at six months from RFA.
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