Cystic Complex Toxic Thyroid Nodule: What is the Best Therapy?

Cystic Complex Toxic Thyroid Nodule: What is the Best Therapy?

Cystic Complex Toxic Thyroid Nodule: What is the Best Therapy?

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?

Case Study:

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.

  1. He refuses surgery.
  2. He refuses radioiodine therapy.
  3.  Because of the solid areas we discussed ethanol vs RFA.
  4. Both can treat the cyst but RFA would be better to ablate the solid areas.
  5. He was advised due to his hyperthyroid state he was advised to take short term low dose Tapazole before and after the RFA.
  6. The RFA procedure: After ablation of the sold areas the electrode is placed in the center of the cyst.
  7. 02_10_5172_02a
  8. 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.
  9. 02_10_5172_02b
  10. Right after the RFA therapy he will stat on beta blockers.
  11. He will be seen at 2 weeks and monthly to monitor the acute release of thyroid hormone after the ablation.
  12. The success of the RFA therapy would be monitored by ultrasounds.
  13. A cyst volume of <1 cc is the endpoint needed.
  14. A normal TSH is the other end point needed.
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