Thyroid nodules are formations in the thyroid gland, which can be single or multiple. These distinct masses, separated from the surrounding thyroid tissue, are a common finding in clinical practice and there is no shortage of ways to treat them nowadays. For three years now, Santa Clínicas has been using an advanced, minimally invasive and effective procedure – microwave ablation.
Irregular pathology
Dr. A.Kalninš shared his experience about dTRA procedures in his daily practice, and then the participants were invited to watch several live procedures under the supervision of Dr. A.Kalninš. During the internship, three complex surgeries were performed by Vilmantas Smalinskas, Head of the Interventional Angiology Department of the Šiauliai Republican Hospital, in collaboration with A. Kalninš, MD. Although all three cases were complex, the operations were successful thanks to the experienced specialists.
According to Dr Romena Laukienė, an endocrinologist at Santaros Clinics, thyroid nodules are caused by both benign and malignant diseases, but patients should not be alarmed if they find nodular lesions in the thyroid gland, as 90-95% of the thyroid nodules are benign. thyroid nodules are benign – asymptomatic.
“The prevalence of thyroid nodules on palpation is 5-7%, while on echocardiography it can be as high as 67%.Moreover, thyroid nodules are often found accidentally during various imaging examinations such as computed tomography, magnetic resonance imaging, positron emission tomography, etc.,” says Dr R. Laukienė.
She said that thyroid nodules are found in people of all ages, both women and men, but are much more common in older people, especially women. However, the causes of this neoplasm, like other benign or malignant neoplasms of other organs, are not entirely clear.
“Iodine deficiency, ionising radiation, use of certain medications and diet are thought to play a role in the development of thyroid nodules. Genetic causes are also important in the development of thyroid nodules,” says the endocrinologist.
When to worry?
Although, as mentioned above, thyroid nodules often do not cause any clinical symptoms, large nodules, especially if they are located in the lower parts of the thyroid gland, can compress adjacent structures in the neck, such as the trachea, oesophagus, and blood vessels of the neck, as they descend deeper into the chest.
“Such nodules can cause discomfort in the neck, a pinched voice, breathing or swallowing problems, as well as cosmetic problems by deforming the neck. A hormone-producing nodule causes the thyroid gland to activate, which is manifested by frequent heart palpitations, heart rhythm disturbances, sweating, weight loss, etc.”, – says Dr Laukienė.
Therefore, when nodules are detected in the thyroid gland, according to her, there are three main questions to be answered: is the nodule benign or malignant; does the nodule cause thyroid dysfunction; and does the nodule cause symptoms of pressure on surrounding structures? Depending on the answers to these questions, it is decided whether and how treatment is needed.
At Santara Clinics, all patients with thyroid nodules detected by CT scanning are recommended to have an ultrasound or, if the nodules are large, a CT scan.
“High-resolution ultrasound is the most sensitive imaging method used to detect and measure nodular lesions in the thyroid gland and to differentiate thyroid nodules from other pathological structures in the neck. If the thyroid nodules are very large, descending into the chest wall, then a CT scan is performed to objectively assess the signs of pressure of the thyroid nodules on the adjacent organs”, – says Dr R. Laukienė.
If a nodule is suspected of being malignant, a nodal aspiration puncture can be performed later – a fine needle is used to remove material for cytological examination.
“This is the ‘gold standard’ and the most important test method to differentiate benign from malignant nodules. Thyroid hormone blood tests are used to assess thyroid function. After the activation of thyroid gland activity is detected, thyroid scintigraphy is performed to assess the functional activity of the nodes, which allows to determine whether the node is hyperfunctioning – “hot” or hypofunctioning – “cold”, – explains Dr. R. Laukienė.
If the nodule is benign, does not cause pressure symptoms due to its size and does not interfere with thyroid function, it is not treated. However, if the nodule causes the thyroid gland to become active, it is treated with radioactive iodine or removed surgically.
“If the nodes cause symptoms of pressure on surrounding structures or cosmetically deform the neck, they are removed surgically,” says the endocrinologist.
An alternative to surgical treatment
As an alternative to surgery, minimally invasive techniques such as radiofrequency, laser or microwave ablation have been widely used in recent years, both in Europe and in the USA and some Asian countries, for the treatment of benign thyroid nodules that cause pressure and cosmetic symptoms.
According to Juozas Jarašūnas, a radiologist at Santaros Clinics, the above-mentioned treatment methods are not widely used in Lithuania, but their hospital uses microwave ablation to treat benign, symptom-causing nodules – an innovative and minimally invasive technique that will be available in 2020. Europe and 2023 The American Thyroid Specialist Organisations have already provided detailed guidelines on who and in what cases it is proposed.
“Thyroid node ablation is a new procedure in Lithuania, where a needle is used to destroy the viable tissue of the thyroid node using heat. The heat-destroyed thyroid nodule tissue shrinks and becomes significantly smaller within a year after surgery. The European Thyroid Specialists Organisation recommends this procedure for patients with a benign thyroid nodule that causes visual changes or pressure or discomfort in the neck,” explains J. Jarašūnas.
According to the radiologist, microwave tissue destruction is a long-standing technology used in other fields of medicine, but has only recently been applied to the treatment of thyroid diseases.
“The sudden popularity of the procedure is attributed to the fact that it achieves a similar result to surgery, while at the same time having less impact on thyroid function and surrounding tissues. According to the literature, the volume of a thyroid nodule is reduced by 75-90% one year after the procedure, while further follow-up studies have shown that only 5% of nodules have regrown again 4 years after the procedure,” says Jarasunas, who adds that if the effect of the treatment is insufficient or if a nodule has grown back, it is always possible to repeat the procedure, or to opt for surgical treatment only afterwards.
Preparation, course and healing period
Patients being considered for microwave ablation, says J. Jarašūnas, receive a live consultation, an ultrasound examination to assess their thyroid nodule, and an assessment of whether there are indications for the procedure and whether it can be safely performed.
“Sometimes a thyroid biopsy and blood tests are needed before treatment to make sure the nodule is not malignant. The general preparation is the same as for any surgical procedure – certain laboratory blood tests must be carried out, and patients must arrive fasting on the day of the procedure. Upon arrival at the hospital, patients are given a ward and undergo the procedure the same morning,” says the radiologist.
Microwave ablation of the thyroid gland, as the doctor explains, is performed using a fine needle, so there is no scarring of the neck, unlike the surgical method, which involves making an incision.
“This procedure leaves only a small needle mark, which is sometimes one of the reasons why people choose this method of treatment. This is most relevant for women, for whom cosmetic appearance is very important,” he says.
In addition, this procedure is performed under local anaesthesia with partial sedation. Patients remain alert throughout the procedure, minimising the risks associated with anaesthesia. After this procedure, patients can go home in the afternoon.
“After the procedure, you may have a swollen neck for a few days, a feeling of discomfort and a little pain when swallowing. Pain killers are given for a few days, but most of the time patients do not feel any discomfort in the neck and do not need medication. After the procedure, we evaluate the effect of the treatment during a repeat ultrasound examination, and patients come for follow-up visits after 1, 3, 6, 12 and 24 months,” says J. Jarašūnas.
According to the literature, complications after this procedure are rare, at just 4%.
“The most common complications are related to thermal damage and the resulting voice impaction, thyroid dysfunction, and burns to the surrounding tissues. However, in three years of microwave ablation, we have had no complaints – the results seem really good,” says the doctor.
