Di Lelio A, Rivolta M, Casati M, Capra M
Diagnostic Radiology Service, Ospedale S. Gerardo, Milan, Italy.
AJR Am J Roentgenol. 1995 Jan;164(1):207-13. doi: 10.2214/ajr.164.1.7998541.
Percutaneous injection of alcohol was recently proposed as an alternative to surgical and radioiodine treatments of autonomous thyroid nodules. The purpose of this study was to determine the value of this procedure and to define its limitations and indications when used for this purpose.
Thirty-one patients with autonomous thyroid nodules underwent a cycle of treatment with percutaneous injection of ethanol in multiple sessions (three to seven) on alternate days depending on the diffusion of the ethanol in the nodule. Fifteen patients were hyperthyroid, and 16 were euthyroid but had inhibited secretion of thyrotropin. The treatment results were evaluated by thyroid scintigraphy and sonography, by triiodothyronine, thyroxine, and thyrotropin assays, and by a thyrotropin-releasing hormone stimulation test 6 months after the end of treatment. Baseline scintigraphy demonstrated exclusive radionuclide uptake in the nodule in 29 patients and partial uptake in the extranodular tissue in two. The volume of the nodules ranged from 0.8 to 34.0 ml (mean +/- SD, 11.8 +/- 8.8 ml). Patients were monitored clinically for 24 hr after each session of ethanol injection to evaluate complications. Fifteen patients underwent a second cycle of ethanol injection when the results 6 months after the first cycle were unsatisfactory. The mean +/- SD follow-up was done at 26.9 +/- 12.3 months.
Scintigraphy showed recovery of extranodular uptake of radionuclide in 72% of patients with nodules less than 13 ml in volume (maximum diameter [mean +/- SD], 2.7 +/- 0.7 cm; range, 1.4-4.0 cm) after one cycle of treatment and in 83% after two cycles. Among subjects with larger nodules, radionuclide uptake returned to normal in 9% after one cycle of treatment and in 9% after two cycles. For hyperthyroid patients, levels of thyroid hormones returned to normal in 69% after one cycle and in 77% after two cycles, and levels of thyrotropin returned to normal in 38% after one cycle and in 69% after two cycles; normal levels of thyrotropin were achieved in 93% of the euthyroid patients after one cycle of treatment and in 100% of these patients after two cycles. Symptoms resolved in 73% of the hyperthyroid subjects after the first cycle of treatment and in 93% of these subjects after the second. No important complications were observed; the most common side effects were acute pain at the injection site, referred pain, fever, transient dysphonia (< 12 hr), local hematoma, palpitations, and sinus tachycardia.
Our results show that percutaneous injection of ethanol is appropriate therapy for autonomous thyroid nodules less than 13 ml in volume. The treatment should be considered successful when levels of thyroid hormones and thyrotropin return to normal. Nodule size appears to be the most important determinant of the success of the treatment. No complications that required termination of the treatment occurred.
经皮注射酒精最近被提议作为自主性甲状腺结节手术及放射性碘治疗的替代方法。本研究的目的是确定该方法的价值，并明确其用于此目的时的局限性及适应证。
31例自主性甲状腺结节患者接受了经皮乙醇注射多疗程（三至七个疗程）的治疗，疗程间隔为隔日，具体疗程数取决于乙醇在结节内的扩散情况。15例患者为甲状腺功能亢进，16例甲状腺功能正常但促甲状腺素分泌受抑制。治疗结束6个月后，通过甲状腺闪烁扫描和超声检查、三碘甲状腺原氨酸、甲状腺素及促甲状腺素检测以及促甲状腺素释放激素刺激试验评估治疗效果。基线闪烁扫描显示，29例患者结节内有放射性核素摄取，2例患者结节外组织有部分摄取。结节体积范围为0.8至34.0毫升（平均±标准差，11.8±8.8毫升）。每次乙醇注射后对患者进行24小时临床监测以评估并发症。当第一个疗程6个月后的结果不理想时，15例患者接受了第二个乙醇注射疗程。平均随访时间为26.9±12.3个月。
闪烁扫描显示，体积小于13毫升（最大直径[平均±标准差]，2.7±0.7厘米；范围，1.4 - 4.0厘米）的结节患者，一个疗程治疗后72%的患者结节外放射性核素摄取恢复，两个疗程后83%的患者恢复。在结节较大的患者中，一个疗程治疗后9%的患者放射性核素摄取恢复正常，两个疗程后9%的患者恢复正常。对于甲状腺功能亢进患者，一个疗程后69%的患者甲状腺激素水平恢复正常，两个疗程后77%的患者恢复正常；一个疗程后38%的患者促甲状腺素水平恢复正常，两个疗程后69%的患者恢复正常；甲状腺功能正常的患者一个疗程治疗后93%的患者促甲状腺素水平恢复正常，两个疗程后100%的患者恢复正常。第一个疗程治疗后73%的甲状腺功能亢进患者症状缓解，第二个疗程后93%的患者症状缓解。未观察到严重并发症；最常见的副作用为注射部位急性疼痛、牵涉痛、发热、短暂性发音困难（<12小时）、局部血肿、心悸及窦性心动过速。
我们的结果表明，经皮注射乙醇是治疗体积小于13毫升的自主性甲状腺结节的合适方法。当甲状腺激素和促甲状腺素水平恢复正常时，该治疗应被视为成功。结节大小似乎是治疗成功的最重要决定因素。未发生需要终止治疗的并发症。
