Hyperthyroidism
Hyperthyroidism is a clinical picture that is caused by too much secretion of thyroid hormones. Thyrotoxicosis is an exagerated form of hyperthyroidism characterized by excessively high levels of blood thyroid hormone levels. It is a life-threatening condition and must be treated urgently.
In hyperthyroidism, thyroid hormone levels are high and TSH levels are low in the blood. Clinical manifestations of hyperthyroidism include nervousness, insomnia, sweating, tremor, flushing, alopesia, weight loss, palpitation and eye bulging (exophtalmia). The most common cause of hyperthyroidism (in more than 80% of cases) is Graves disease. In this condition, the body produces antibodies called (thyrotropin receptor antibodies, TRaB). These antibodies attach to the surface of thyroid cells and cause these cells to work too much causing overproduction of thyroid hormones. In this condition, the thyroid gland becomes enlarged and there is edema, inflammation and increased vascularity. The most prominent physical finding is eye bulging (exophtalmia), which is quite characteristic for this disease. The Graves disease is seen 7-8 times more common in women compared to men.
Embolization: a new option for Graves disease
In Graves disease, the classic treatment options are antithyroid medications, radioactive iodine (RAI) and surgery. Generally, antithyroid pills are tried first. If this fails or is not sufficient, patients are classically treated either with radioactive iodine or surgical operation. However, RAI may decrease infertility in young patients and cause secondary cancers due to high dose radiation while surgery may cause a neck scar, hypoparathyroidism and voice loss. Additionally, both treatments cause permenant hypothyroidism and the patient will have to take levothyroxine pills for life time.
Another option in the management of Graves disease is embolization, in which the feeding vessels of thyroid gland are blocked with a simple angiography procedure. After embolization, the blood supply to the thyroid tissue is decreased. As a result, the thyroid becomes smaller in size and hormonally less active but does not die. Thus, no permament hypothyroidism occurs after embolization.
In our 20 year-old patient with Graves disease, Doppler ultrasound typically shows increased number of thyroid vessels (inferno pattern). With a simple angiography procedure, thyroid arteries were occluded with small particles (embolization). Three months after the treatment, the patient has no symptoms and her hormone levels became normal.
Embolization has been successfully used in the treatment of Graves disease in some centers including ours for the last 2 decades. Studies indicate that in nearly 60-80% of the patients, hormone levels return to normal, symptoms of hyperthyroidism diminish, the size of the thyroid becomes normal and antibodies against the thyroid tissue (TRaB) decrease in the blood. The side effects of embolization procedure are generally mild and typically include neck pain, fatigue and subclinical hyperthyroidism that lasts for some weeks. The most important advantages of embolization are as follows:
There is no incision or suture in the neck
There is no high dose radiation
No general anesthesia is required
Hospital stay is only one night
It may correct hyperthyroidism without surgery and radiation
Since the thyroid gland is preserved no hypothyroidism occurs after the treatment
Laser or RF ablation of thyroid nodules
If there are multiple nodules in a patient with hyperthyroidism, percutaneous ablation can still be used. But in this case, it must be made clear which nodule(s) is toxic (responsible for hyperthyroidism). This can be done with a simple test called thyroid scintigraphy. If the toxic nodules are single or several and they can be identified using ultrasound + scintigraphy, percutaneous ablation is feasible and successfully treat both the nodules and hyperthyroidism. If the toxic nodules are too many or can not be identified with ultrasound + scintigraphy, then they can be treated with embolization, as in Graves disease.
In our 23 year-old patient with hyperthyroidism, a 33x28x27 mm toxic nodule was seen on ultrasound and treated with laser ablation. Six months after the treatment, a follow-up ultrasound shows 76% volume reduction in the nodule. The thyroid hormone (T3, T4 and TSH) levels have returned to normal and the patient is currently symptom free.
Why we prefer embolization in the thyroid?
Percutaneous ablation for toxic nodules, is it better than radioiodine?
Another cause of hyperthyroidism is toxic thyroid nodules that secrete too much hormones. These nodules are mostly single (solitary) although they may sometimes be multiple (MNG). In toxic nodules, classic treatments are RAI and surgery. However, as mentioned before, both treatments have some risks an limitations including permament hypothyroidism, high dose radiation and surgical complications.
We believe that for toxic nodules, the ideal treatment is percutaneous ablation. Because in this procedure, both the nodule and hyperthyroidism can betreated in a single session and the normal thyroid gland is preserved. Many studies in the literature clearly indicate that thermal ablations like laser, radiofrequency, microwave and cryoablation are quite successful in the treatment of toxic thyroid nodules. Because of success and safety of these methods, they should be preferred in the initial treatment of toxic nodules and classic treatments like RAI and surgery should be reserved if ablation fails.
In our patient with a 38x24x27 mm toxic thyroid nodule, percutaneous laser ablation was performed. One year after the treatment, she became asymptomatic, her thyroid hormone levels returned to normal and the volume of the nodule has reduced by 85%.
In our experience, all the ablation methods were successful in toxic thyroid nodules. However, if the nodule is large the recurrence may occur with alcohol, laser, RF and microwave ablation. In such cases, we prefer cryoablation as it may do a stronger and more complete ablation.
If there are multiple nodules in a patient with hyperthyroidism, percutaneous ablation can still be used. But in this case, it must be made clear which nodule(s) is toxic (responsible for hyperthyroidism). This can be done with a simple test called thyroid scintigraphy. If the toxic nodules are single or several and they can be identified using ultrasound + scintigraphy, percutaneous ablation is feasible and successfully treat both the nodules and hyperthyroidism. If the toxic nodules are too many or can not be identified with ultrasound + scintigraphy, then they can be treated with embolization, as in Graves disease.
CONSULTATION FORM
You can get information on our treatments via phone and e-mail as well as by filling and sending the consultation form below. Please send the reports of your thyroid ultrasound, hormones, scintigraphy and biopsy (if available) via e mail (thyroidgoiter@gmail.com) or whats up ( +90-534-551 0 551). Remember to write clearly your e mail address and phone number so that we can return to you as soon as possible.
Please send separately the results of your thyroid ultrasound, hormones, scintigraphy and biopsy (if available)