5-YEAR FOLLOW-UP OF PERCUTANEOUS ETHANOL INJECTION FOR THE TREATMENT OF HYPERFUNCTIONING THYROID-NODULES - A STUDY OF 117 PATIENTS

Percutaneous ethanol injection (PEI) has been suggested as an alternat ive to radioiodine and surgery for the treatment of autonomous thyroid nodules (ATN). OBJECTIVE In this study we have defined the longterm e fficacy and safety of PEI for the treatment of ATN, and we have attemp ted to optimize the clinical usefulness and improve the technical appr oach to PEI treatment. PATIENTS One hundred and seventeen patients wit h ATN, 26 males and 91 females, aged 48 +/- 12.9 years (mean +/- SD), were offered PEI when other established treatments were refused or con traindicated. Seventy-seven patients were affected by toxic adenoma (6 0 with a single nodule, 17 with a multinodular goitre); 40 patients su ffered from a pretoxic single nodule. METHODS Sterile 95% ethanol was administered weekly under sonographic control by a 20-22 gauge needle without anaesthesia or pharmacological sedation. During PEI treatment, 26 toxic elderly patients were treated with methimazole and propranol ol. According to hormone and scintigraphic data, three possible outcom es were identified for statistical analysis: failure (persistent suppr ession of extra-nodular tissue uptake, along with elevated free T4 (FT 4) and free T3 (FT3) and undetectable TSH levels); partial cure (norma lization of FT4 and FT3 levels, with low/undetectable TSH levels; pers istent suppression of extra-nodular uptake); complete cure (normal thy roid hormone and TSH levels; restored extra-nodular uptake). RESULTS T he patients were followed for up to 5 years (median 2.5). PEI therapy was well tolerated by all patients. Complete cure was achieved in all pretoxic patients and in 60 (77.9%) patients with toxic adenoma, while partial cure was observed in 7 cases (9.1%) and failure in 10 (13%). PEI treatment proved similarly effective in toxic patients with a sing le nodule or with multinodular goitre (87 vs 88.2%, respectively). At the end of treatment, a significant shrinkage of nodule volume was obs erved in all patients (P = 0.0001). Toxic patients with pretreatment v olume >40 ml (n = 8) did not show a significant difference in treatmen t response rate as compared to those with volume <40 ml. Recurrence of hyperthyroidism was never observed during followup, independently of thyroid status before treatment. Only one patient with significant thy roid autoantibody serum levels before PEI treatment, developed subclin ical hypothyroidism at 3 years. The administration of methimazole and/ or propranolol did not modify PEI outcome. CONCLUSION Our data confirm the efficacy and safety of percutaneous ethanol injection for the the rapy of autonomous thyroid nodules. The very low incidence of hypothyr oidism along with the absence of recurrence of hyperthyroidism suggest s that percutaneous ethanol injection is the treatment of choice in pa tients with pretoxic thyroid adenoma. Percutaneous ethanol injection a ppears an effective alternative procedure in toxic patients with a hig h surgical risk even if they have large nodules, and in younger ones i n whom radioiodine is contraindicated. Patients may be submitted to an ti-thyroid drug and/or beta-blocker therapy if it is necessary, but th is does not affect percutaneous ethanol injection treatment outcome. F inally, not only single autonomous thyroid nodules but also toxic mult inodular goitre may be successfully treated by percutaneous ethanol in jection.