Nonsurgical Approaches to the Management of Thyroid Nodules

Sebastiano Filetti; Cosimo Durante; Massimo Torlontano

Disclosures

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

In This Article

Ultrasound-guided Percutaneous Laser Ablation

Ultrasound-guided percutaneous laser ablation (PLA) has been used for years in palliative treatment of advanced cancer. Since the year 2000, it has also been proposed as a minimally invasive alternative to surgery for the ablation of nonfunctioning and autonomous thyroid nodules that cause pressure symptoms or cosmetic problems.[75,76,77,78,79] The procedure is performed under ultrasonography guidance. The major drawback of PLA is that it is currently impossible to identify the true boundaries of the laser-induced tissue damage. The echogenic zone observed on real-time ultrasonography examination correlates poorly with the area of thermal necrosis. An accurate estimate of the volume of the thermal lesion can be obtained, with ultrasonography and color Doppler studies, only a few hours after the end of the procedure. Patients often experience burning cervical pain, which rapidly decreases once energy delivery ceases.

In the few patients treated to date, there have been no reports of permanent dysphonia, cutaneous burning, or damage to the vital structures of the neck. PLA is a rapid (duration around 30 min) and inexpensive procedure that can be performed on an outpatient basis. Postablation neck pain can be controlled with 1–2 days of oral analgesics or corticosteroids. Given the risk of damaging vital structures and the absence of data from large prospective trials, PLA should be performed only in specialized centers.

A 50–70% decrease in nodule volume and amelioration of local symptoms can reportedly be achieved with 1–3 sessions of PLA, or a single treatment performed with multiple optical fibers. In the only available randomized study, 15 patients with nonfunctioning nodules were managed with PLA and compared with 15 patients managed with observation only. After 6 months, a significantly greater reduction in nodule volume (from 8.2 ml to 4.8 ml) was documented in the PLA group (P = 0.001).[79]

PLA is a rapid and highly effective means for achieving clinically significant volume reductions in thyroid lesions, but currently its use in the cervical area is hampered by the lack of precision of the treatment. Complete ablation of malignant lesions is almost impossible to achieve without provoking damage to surrounding vital structures. For these reasons, only experienced operators should use PLA, and its use should be limited to the treatment of large, cytologically benign thyroid nodules that cannot be treated with surgery, RAI, or medical therapy. The number of patients treated with PLA is currently quite limited, and it is too early to consider this technique as an alternative to traditional approaches. It should not be used when the indications for treatment are purely cosmetic.

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