Monzani F, Caraccio N, Goletti O, Lippolis P V, Casolaro A, Del Guerra P, Cavina E, Miccoli P
Institute of Internal Medicine 2, University of Pisa, Italy.
Clin Endocrinol (Oxf). 1997 Jan;46(1):9-15. doi: 10.1046/j.1365-2265.1997.d01-1752.x.
Percutaneous ethanol injection (PEI) has been suggested as an alternative to radioiodine and surgery for the treatment of autonomous thyroid nodules (ATN).
In this study we have defined the long-term efficacy and safety of PEI for the treatment of ATN, and we have attempted to optimize the clinical usefulness and improve the technical approach to PEI treatment.
One hundred and seventeen patients with ATN, 26 males and 91 females, aged 48 +/- 12.9 years (mean +/- SD), were offered PEI when other established treatments were refused or contraindicated. Seventy-seven patients were affected by toxic adenoma (60 with a single nodule, 17 with a multinodular goitre); 40 patients suffered from a pretoxic single nodule.
Sterile 95% ethanol was administered weekly under sonographic control by a 20-22 gauge needle without anaesthesia or pharmacological sedation. During PEI treatment, 26 toxic elderly patients were treated with methimazole and propranolol. According to hormone and scintigraphic data, three possible outcomes were identified for statistical analysis: failure (persistent suppression of extra-nodular tissue uptake, along with elevated free T4 (FT4) and free T3 (FT3) and undetectable TSH levels); partial cure (normalization of FT4 and FT3 levels, with low/ undetectable TSH levels; persistent suppression of extra-nodular uptake); complete cure (normal thyroid hormone and TSH levels; restored extra-nodular uptake).
The patients were followed for up to 5 years (median 2.5). PEI therapy was well tolerated by all patients. Complete cure was achieved in all pretoxic patients and in 60 (77.9%) patients with toxic adenoma, while partial cure was observed in 7 cases (9.1%) and failure in 10 (13%). PEI treatment proved similarly effective in toxic patients with a single nodule or with multinodular goitre (87 vs 88.2%, respectively). At the end of treatment, a significant shrinkage of nodule volume was observed in all patients (P = 0.0001). Toxic patients with pretreatment volume > 40 ml (n = 8) did not show a significant difference in treatment response rate as compared to those with volume < 40 ml. Recurrence of hyperthyroidism was never observed during follow-up, independently of thyroid status before treatment. Only one patient with significant thyroid autoantibody serum levels before PEI treatment, developed sub-clinical hypothyroidism at 3 years. The administration of methimazole and/or propranolol did not modify PEI outcome.
Our data confirm the efficacy and safety of percutaneous ethanol injection for the therapy of autonomous thyroid nodules. The very low incidence of hypothyroidism along with the absence of recurrence of hyperthyroidism suggests that percutaneous ethanol injection is the treatment of choice in patients with pretoxic thyroid adenoma. Percutaneous ethanol injection appears an effective alternative procedure in toxic patients with a high surgical risk even if they have large nodules, and in younger ones in whom radioiodine is contraindicated. Patients may be submitted to anti-thyroid drug and/or beta-blocker therapy if it is necessary, but this does not affect percutaneous ethanol injection treatment outcome. Finally, not only single autonomous thyroid nodules but also toxic multinodular goitre may be successfully treated by percutaneous ethanol injection.
经皮乙醇注射（PEI）已被提议作为放射性碘和手术治疗自主性甲状腺结节（ATN）的替代方法。
在本研究中，我们明确了PEI治疗ATN的长期疗效和安全性，并试图优化其临床实用性并改进PEI治疗的技术方法。
117例ATN患者，男26例，女91例，年龄48±12.9岁（均值±标准差），当其他既定治疗被拒绝或禁忌时接受PEI治疗。77例患者为毒性腺瘤（60例为单个结节，17例为多结节性甲状腺肿）；40例患者患有亚临床毒性单个结节。
在超声引导下，使用20-22号针头每周注射无菌95%乙醇，无需麻醉或药物镇静。在PEI治疗期间，26例老年毒性患者接受甲巯咪唑和普萘洛尔治疗。根据激素和闪烁扫描数据，确定三种可能的结果进行统计分析：失败（结节外组织摄取持续受抑制，同时游离T4（FT4）和游离T3（FT3）升高且促甲状腺激素（TSH）水平不可测）；部分治愈（FT4和FT3水平正常，TSH水平低/不可测；结节外摄取持续受抑制）；完全治愈（甲状腺激素和TSH水平正常；结节外摄取恢复）。
患者随访长达5年（中位数2.5年）。所有患者对PEI治疗耐受性良好。所有亚临床毒性患者和60例（77.9%）毒性腺瘤患者实现完全治愈，7例（9.1%）患者部分治愈，10例（13%）患者治疗失败。PEI治疗在单个结节或多结节性甲状腺肿的毒性患者中同样有效（分别为87%和88.2%）。治疗结束时，所有患者结节体积均显著缩小（P = 0.0001）。治疗前体积>40 ml的毒性患者（n = 8）与体积<40 ml的患者相比，治疗反应率无显著差异。随访期间未观察到甲状腺功能亢进复发，与治疗前甲状腺状态无关。仅1例PEI治疗前甲状腺自身抗体血清水平较高的患者在3年时出现亚临床甲状腺功能减退。甲巯咪唑和/或普萘洛尔的使用未改变PEI治疗结果。
我们的数据证实了经皮乙醇注射治疗自主性甲状腺结节的疗效和安全性。甲状腺功能减退发生率极低且甲状腺功能亢进无复发表明，经皮乙醇注射是亚临床毒性甲状腺腺瘤患者的首选治疗方法。经皮乙醇注射对于手术风险高的毒性患者（即使有大结节）以及禁忌使用放射性碘的年轻患者似乎是一种有效的替代方法。如有必要，患者可接受抗甲状腺药物和/或β受体阻滞剂治疗，但这并不影响经皮乙醇注射治疗结果。最后，不仅单个自主性甲状腺结节，而且毒性多结节性甲状腺肿也可通过经皮乙醇注射成功治疗。
