"Thyroid nodular disease: how to treat?" Take-home messages

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1 "Thyroid nodular disease: how to treat?" Take-home messages Andrea Frasoldati, PhD MD Endocrinology Unit Arcispedale S. Maria Nuova IRCCS Reggio Emilia I declare that neither I nor any member of my immediate family have a significant financial arrangement or affiliation with any product or services used or discussed in my presentation, nor any potential bias against another product or service.

2 Treating Thyroid Nodules: Basic Facts Most thyroid nodules are benign and small, remain stable and asymptomatic, and can be followed by observation alone. Only a minority of patients may need treatment Gharib et al., JCE&M, 2013, 98(10):

3 Indications for treatment Symptoms (other causes excluded) Neck pressure, Dysphagia, Shortness of breath, hoarseness, Pain. Significant increase in volume Hyperfunction Suspicious features in spite of a benign cytology

4 How to choose the best option? Goals of therapy Durability of cure Relief of symptoms Patient s values Risk of Complications Risk of malignancy

5 Helping patients make the right choice Clinical history Age and sex Nodule (goiter) size Nodule type Autoimmunity Local availability of treatments Risk of complications Patient s expectations and needs

6 L-thyroxine (LT4) treatment LT4 may induce a relevant (>50%) decrease of nodule size in a minority of patients. Small nodules of patients from iodine-deficient areas are more likely to respond to LT4. Long-term TSH-suppressive LT4 dosage treatment may prevent increase of thyroid nodules; yet, re-growth is usually observed after LT4 withdrawal. TSH-suppression is associated with increase morbidity and may be not indicated in many patients LT4 treatment in patients with nodular thyroid disease not recommended on routine basis.

7 Autonomously Functionig Thyroid Nodules (AFTNs) In most patients with AFTNs, RAI achieves a safe, longterm control of thyroid function, and a significant decrease of nodule size. PEI generally not indicated due to: a) the need of multiple sessions, b) the high recurrence rate and 3) the occurrence of rare, yet potentially serious, side effects. US-guided ablative treatments (LAT/RFA) may be considered in selected patients, especially in case of small, solitary nodules, and when radiation exposure is not indicated.

8 RAI is the best treatment for Small- to medium-sized benign AFTNs Patients with AFTNs at high surgical risk NB The only absolute contraindications to RAI treatment are breastfeeding and pregnancy. No consensus on a lowest age limit available.

9 131 I dose: fixed or patient-tailored? The radioiodine can be administered at a fixed dose (e.g MBq), based on nodule (goiter) size and/or uptake measurement. Alternatively, the optimal concentration of 131 I or of the retained radioactivity ( Gy) at the tissue level can be calculated on individual basis. Neither approach has been proved definitively superior to the other. The fixed dose approach is simpler, cheaper and effective. Yet, the personalized approach may help sparing unnecessary radioactivity (ALARA)

10 RAI for nontoxic goiter RAI may decrease the volume of nontoxic goiter (~ 50-60% reduction after 3-5 years). The response to RAI is quite variable and usually lower in very large (>100 ml) goiter. RAI may be considered in elderly patients at high surgical risks with large symptomatic goiters. In the clinical practice, fixed RAI doses are commonly used. Dose fractioning may be used to avoid hospitalization and potential side effects. rhtsh is a promising tool to enhance RAI uptake; yet, the optimal dose and timing of rhtsh are still to be fully elucidated.

11 US-guided ablation treatments in AFTNs AFTNs treated with LAT show initial amelioration of thyroid function. Yet, multiple LAT sessions are needed. Improvement of thyroid function, as well as nodule volume reduction, has been reported also with RFA. As for LAT, results are incomplete and hyperthyroidism may recur in parallel with nodule re-growth. LAT and RFA may be considered in selected cases as a part of a multimodal treatment strategy

12 Current Role of MITs MITs may effectively treat those benign thyroid nodules which are symptomatic and steadily growing. Their benign nature should be confirmed before treatment. Cosmetically oriented or unnecessary treatments should be discouraged.

13 Thyroid Cysts Relapsing benign thyroid cysts and complex nodules should be managed with US-guided aspiration followed by PEI as the first-line treatment LAT and RFA may be considered in benign mixed nodules with a prevalent solid component.

14 Solid Thyroid Nodules In solid non-functioning symptomatic nodules, LAT and RFA may achieve, in a single session, a nearly 50% volume decrease and control of local symptoms The improvement is apparently long-lasting. Repeat ablation or surgery may be offered when required.

15 Practicing MITs PEI is a simple, safe and cheap procedure and requires the availability of a US machine and sterile 95% ethanol vials. Operators with sufficient experience in US-guided FNA require a short period (few days) of practice. LAT or RFA employ disposable kits with an average cost ranging from 500 (LAT) to 1300 (RFA) /session Operators require a training period of a few weeks in a specialized center and, thereafter, should start their activity under supervision of an experienced tutor.

16 LT4 or minimally invasive therapies for benign thyroid nodules No study evaluated all-cause mortality, health-related quality of life or provided systematic data on the development of thyroid cancer. Nodule volume reductions were achieved by PEI, LP and RF,and to a lesser extent, by LT4. PEI, LP and RF led to improvements in pressure symptoms and cosmetic complaints. Adverse events such as light-to-moderate periprocedural pain were seen after PEI, LP and RF. Future studies should focus on patient-important outcome measures, especially health-related quality of life. RCTs with follow-up periods of several years and good-quality observational studies are needed Bandeira-Echtler E, Bergerhoff K, Richter B, The Cochrane Library, 2014

17 "Thyroid nodular disease: how to treat?" Thank you and have a nice dinner!