Nonsurgical Approaches to the Management of Thyroid Nodules

Sebastiano Filetti; Cosimo Durante; Massimo Torlontano


Nat Clin Pract Endocrinol Metab. 2006;2(7):384-394. 

In This Article

Percutaneous Ethanol Injection

Approximately 10 years ago, percutaneous ethanol injection (PEI) was proposed as an alternative to RAI for the treatment of solitary, autonomous thyroid nodules.[66] Since then, PEI has also been used to treat nonfunctioning solid and cystic nodules.[67,68,69,70,71,72,73,74] Injection of 95% ethanol produces nodule shrinkage secondary to coagulative necrosis and thrombosis of small intranodular blood vessels. An experienced operator must perform PEI; multiple injections are often necessary to achieve complete ablation, and adverse effects are not uncommon (pain, ethanol seepage outside the nodule, and rarer events, such as transient thyrotoxicosis and recurrent laryngeal nerve damage).

The vast majority of data published on PEI of thyroid nodules come from noncontrolled trials. In the multicenter study cited above,[66] 429 patients with toxic or autonomously functioning thyroid nodules were treated with PEI (2–12 sessions). At the 12-month follow-up, normalization of both TSH levels and scintiscan findings was documented in almost all patients whose nodule volumes were initially less than 15 ml.[66] A few years later, Zingrillo et al.[69] retrospectively analyzed the effects of PEI and RAI in two groups of patients with large, toxic nodules (3–4 cm in diameter). After a median follow-up of 36 months, outcomes in the two groups were similar in terms of nodule shrinkage and normalization of serum TSH.

In a randomized trial comparing PEI and TSH-suppressive doses of levothyroxine, significantly greater nodule shrinkage 12 months after treatment was found in the 25 patients treated with PEI (reductions of 47% with PEI versus 9% with levothyroxine).[73] The same authors later compared two groups of 30 patients who had small, solid nodules (mean volumes 9.9 ml and 9.4 ml, respectively). The first group was treated with a single PEI whereas three injections were administered in the second group. At the 6-month follow-up, the overall reduction in nodule volume was 51%, and there were no significant differences between the two groups.[74]

The best results have been obtained in the treatment of large or symptomatic cystic nodules.[67,68,70] In a prospective study with a mean follow-up of 5 years, nodule-volume reductions of over 50% were achieved in 40 of 43 patients with cystic nodules (mean volume 38.4 ml) treated by PEI.[68] Similar results were reported in 2002, in a study of 98 patients (mean nodule volume 35.3 ml), with a shrinkage of >50% in 88% of individuals at the 9-year follow-up.[70] The only prospective, randomized, double-blind study compared two groups of patients with cystic nodules who were treated with either ethanol or saline. The nodules were cured (i.e. residual cyst volumes ≤1 ml) in 27 of 33 PEI-treated patients, versus 16 of 33 saline-treated patients (P = 0.006).[67]

In our opinion, PEI should be proposed as first-line therapy only for symptomatic, recurrent cystic nodules. For other types of nodules, PEI should be considered only when both surgery and RAI have been refused or are contraindicated.


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