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Percutaneous Ethanol Injection of Large Autonomous Hyperfunctioning Thyroid Nodules¹

¹ From the Ultrasound Service, D. Cotugno Hospital, via Roma 8, 80059 Torre del Greco (Na), Italy. From the 1997 RSNA scientific assembly. Received February 9, 1998; revision requested March 3; final revision received April 15, 1999; accepted July 1. Address reprint requests to L.T. (e-mail: assanui@tin.it).

View larger version (101K): [in a new window]   Figure 1. Patient 9. (a, b) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (a) Image shows a large hyperfunctioning thyroid nodule (arrowheads) that occupies the lower portion of the right lobe (RL), isthmus, and part of the left lobe (LL). (b) Image shows that a single cycle of percutaneous ethanol injection (36 mL) was sufficient to obtain a completely cold nodule (arrowheads) and normal reuptake in the thyroid parenchyma (arrows). LL = left lobe, RL = right lobe.

View larger version (122K): [in a new window]   Figure 1. Patient 9. (a, b) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (a) Image shows a large hyperfunctioning thyroid nodule (arrowheads) that occupies the lower portion of the right lobe (RL), isthmus, and part of the left lobe (LL). (b) Image shows that a single cycle of percutaneous ethanol injection (36 mL) was sufficient to obtain a completely cold nodule (arrowheads) and normal reuptake in the thyroid parenchyma (arrows). LL = left lobe, RL = right lobe.

View larger version (122K): [in a new window]   Figure 2. Patient 1. (a-c) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (a) Image shows a huge (90-mL) hyperfunctioning thyroid adenoma (arrowheads) in the right lobe. The left lobe (LL) is suppressed. (b) After the first cycle of PEI, the image shows two-thirds of the nodule (arrowheads) is ablated. The left lobe (LL) is still suppressed. (c) After a second cycle with 33 mL of ethanol, the image shows complete necrosis in the nodule, with recovery of uptake in the left lobe (LL) and residual thyroid parenchyma in the right lobe (RL).

View larger version (85K): [in a new window]   Figure 2. Patient 1. (a-c) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (a) Image shows a huge (90-mL) hyperfunctioning thyroid adenoma (arrowheads) in the right lobe. The left lobe (LL) is suppressed. (b) After the first cycle of PEI, the image shows two-thirds of the nodule (arrowheads) is ablated. The left lobe (LL) is still suppressed. (c) After a second cycle with 33 mL of ethanol, the image shows complete necrosis in the nodule, with recovery of uptake in the left lobe (LL) and residual thyroid parenchyma in the right lobe (RL).

View larger version (102K): [in a new window]   Figure 2. Patient 1. (a-c) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (a) Image shows a huge (90-mL) hyperfunctioning thyroid adenoma (arrowheads) in the right lobe. The left lobe (LL) is suppressed. (b) After the first cycle of PEI, the image shows two-thirds of the nodule (arrowheads) is ablated. The left lobe (LL) is still suppressed. (c) After a second cycle with 33 mL of ethanol, the image shows complete necrosis in the nodule, with recovery of uptake in the left lobe (LL) and residual thyroid parenchyma in the right lobe (RL).

View larger version (110K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.

View larger version (118K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.

View larger version (121K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.

View larger version (53K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.

View larger version (103K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.

View larger version (91K): [in a new window]   Figure 3. Patient 2. (a) Sagittal color Doppler US image in the left lobe of the thyroid shows a large (65-mL) autonomous nodule (arrowheads) with multiple intralesional vascular signals (arrows). The nodule completely replaces the left lobe of the thyroid. (b-d) Anterior images of the thyroid obtained at scintigraphy with 99mTc pertechnetate. (b) Image shows exclusive uptake in the nodule (arrowheads) and complete inhibition in the normal thyroid parenchyma. (c) After one cycle of PEI (45 mL of ethanol in five sessions), the image shows the inferomedial part of the nodule (arrowheads) is still hyperfunctioning, and the thyroid parenchyma is still suppressed. (d) After a further cycle of PEI (25 mL of ethanol in four sessions), the image shows complete necrosis in the nodule (arrowheads) and normal reuptake in the right lobe (RL). LL = left lobe. (e) Sagittal (left) and transverse (right) US images obtained 3 months after treatment show that the calipers are positioned to measure the longitudinal (D1), anteroposterior (D2), and transverse (D3) diameters of the nodule (N) (52.5, 30.1, and 32.2 mm, respectively). The volume of the nodule, automatically given by the US unit, is 31.5 mL (not mm as shown in the image), which is half the pretreatment volume. (f) Sagittal (left) and transverse (right) US images obtained 6 months after treatment show that the calipers are positioned to measure the longitudinal (D1), transverse (D2), and anteroposterior (D3) diameters of the nodule (N) (42.3, 23.7, and 20.4 mm, respectively). The volume of the nodule, automatically given by the US unit, is 10.7 mL, which is less than 20% of the volume before treatment.