Cystic Complex Toxic Thyroid Nodule: What is the Best Therapy?
Is there a place for Ethanol PEI or Radiofrequency ablation RFA as alternatives to standard recommended therapy with radiation or surgery?
52 Y/O male with a large local symptomatic nodule. He appears euthyroid with none of the signs or symptoms of hyperthyroidism.
However he has abnormal Thyroid tests TSH is < 0.01, and both Free T4 and T3 are mildly elevated. There is no suigns of Graves’ disease and the TSI antibody is 118% N< 140%.
Neck ultrasound: single multiloculated cyst 3.6×4.6×7.5 cm 65 ml volume.
There are several small solid components but mostly cystic.
The FNA was consistent with a cyst with 20 ml brown fluid removed. There were no thyroid metaplastic cells even in the solid areas.
Toxic nodules do not usually need a biopsy.
What do we do with this patient.
- He refuses surgery.
- He refuses radioiodine therapy.
- Because of the solid areas we discussed ethanol vs RFA.
- Both can treat the cyst but RFA would be better to ablate the solid areas.
- He was advised due to his hyperthyroid state he was advised to take short term low dose Tapazole before and after the RFA.
- The RFA procedure: After ablation of the sold areas the electrode is placed in the center of the cyst.
- The formation of hyperechoic microbubbles throughout the cyst is a sign of a successful ablation. The heat needed varies from 20-50 watts in most cases.
- Right after the RFA therapy he will stat on beta blockers.
- He will be seen at 2 weeks and monthly to monitor the acute release of thyroid hormone after the ablation.
- The success of the RFA therapy would be monitored by ultrasounds.
- A cyst volume of <1 cc is the endpoint needed.
- A normal TSH is the other end point needed.