1. Nodular thyroid disease is very common. Most nodules are asymptomatic, are benign by fine-needle aspiration, remain stable, and can be followed by observation alone in the majority of the patients.
  2. Some nodules grow or cause symptoms requiring treatment.usg-15016-f3

    Benign sponge-like thyroid nodule in a 46-year-old woman.

    A. Axial view of the left thyroid lobe shows a sponge-like nodule, >75% of the volume of which is occupied by areas with a sponge-like appearance (grade III) with a smooth margin, ovoid shape, and isoechogenicity. B. Photomicrographic section shows multiple variably sized nodular follicles filled with old colloid and cholesterol granules caused by the condensation of colloid microcrystals (H&E, ×40). This nodule was diagnosed as nodular hyperplasia.

  3. Surgery has been our main option for treatment.
  4. In large centers with experienced hands, minimally invasive approaches appear effective and safe.
  5. Percutaneous ethanol injection EI therapy is recommended for recurrent benign thyroid cysts.
  6. Either ultrasound-guided laser or radiofrequency ablation can be used for symptomatic solid nodules with normal or abnormal thyroid function. In 2017 RFA is the preferred method over laser
  7. Microwave ablation and high-intensity focused ultrasound are newer approaches that need further clinical evaluation. 2017 HIFU is not a good method and microwave is still research level only but appears to have a bulky  thick 16 gauge antenna to thick for the neck area.
  8. PEI and RFA have also been applied to recurrent locoregional cervical thyroid cancer with encouraging initial results, although still limited data. 2017 PEI and RFA have shown good results on these cancer lymph nodes.
  9. 2017 finds Both PEI and RFA being used for primary micro-papillary thyroid cancer as a third arm with surgery or active surveillance for those not wanting surgery or long term follow up with a thyroid cancer in their neck.
  10. Surgery and radioiodine remain as conventional and established treatments for nodular goiters. However, the new image-guided minimally invasive approaches appear safe and effective and can be used to treat symptomatic or enlarging thyroid masses.
  11. The problem is that whereas thyroid surgery is widely available and safe in many centers, it still carries a 2 to 10% risk of complications, it is costly, and it may not be appropriate for a surgically high-risk individual or for someone refusing surgery.
    Think twice when you pick a surgeon to remove your thyroid instead of ablation therapy.

    The risks of complications are high if the surgeon just does a few cases a year.

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  13. Percutaneous Ethanol Injection Therapy (PEI): There is abundant literature (around 150 papers since the early 1990s) on the effect on thyroid function and/or size.
  14.  Benign cysts and predominantly cystic thyroid nodules, where it has become the recommended standard therapy.
  15. Interestingly, the use in locoregional recurrence of papillary thyroid cancer, whether in the thyroid bed or in the regional lymph nodes, although heavily debated, is increasingly employed.
  16. Primary micro-papillary thyroid cancers are also being treated with PEI in 2017.

Cysts or dominantly cystic benign thyroid nodules

  1. Fifteen to 25% of solitary thyroid nodules are cystic or predominantly cystic, and most are benign.
  2. Simple aspiration is the treatment of choice for diagnostic and therapeutic purposes in symptomatic patients.
  3. However, the recurrence rate is up to 80%, depending on the number of aspirations and the cyst volume.
  4. In benign nodules, whether solid or cystic, the utensils cost is low compared to surgery or RFA in 2017.
  5. The time consumption, compared to US-fine-needle aspiration alone, increases by no more than 5 minutes and requires no additional staff.
  6. In recurrent or metastatic thyroid malignancy, time and cost increases manifold and depends on extension, localization, and number of targeted areas.
  7.  PEI is only recommended as the first-line therapy in benign recurrent thyroid cysts in 2012.
  8. PEI in 2017 is used for treatment of some solid nodules with low vascular blood flow by Doppler that can retain the ethanol in the nodules.
  9. 2017 finds PEI used for primary micro-pappilary thyroid cancers.

Smata Monica Thyroid Center’s Richard Guttler is an interventional thyroidologist doing PEI in his office, and presently training endocrinologists in Thyroid tumor RFA in preparation for FDA approval in 2018.

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Call 310-393-8860 or thyroid.manager@protonmail.com for details for non surgical therapies available.

Richard Guttler MD,FACE,ECNU

www.thyroid.com