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激光治疗可使良性甲状腺结节明显缩小

Laser shrinks benign thyroid nodules
来源:EGMN 2013-06-08 11:20点击次数:469发表评论

凤凰城——根据一项为期2年的意大利随机试验结果,多数接受激光切除的良性甲状腺结节萎缩一半以上,且这种操作的并发症发生率很低。


之前由Papini医生(Thyroid 2007;17:229-35)和其他欧洲研究小组(Thyroid 2006;16:763-8)发表的研究显示,激光切除甲状腺冷结节具有良好预后。但治疗甲状腺良性或恶性结节的微创手术尚未在美国专科医生中得到广泛采用,包括经皮注射酒精(PEI)、射频切除(RFA)和激光切除(LA)。


罗马Regina Apostolorum医院的Enrico Papini医生及其同事在接受随访的患者中评估了超声引导下LA治疗良性甲状腺结节的临床和超声变化,同时比较了不同中心使用这种技术的不良反应和疗效。该研究共纳入在4个甲状腺中心就诊的连续200例实体甲状腺结节体积为5~18 ml的患者,并将其随机分配到单纯LA治疗(n=101)或随访组(n=100)。对于治疗组患者,临床医生使用双光纤1.064 nm钕钇铝石榴石激光实施LA,输出能量为3瓦特。对于不超过13 ml的结节,传输能量为3,600焦耳(J),对于大于13 ml的结节,传输能量为7,200 J。治疗在门诊进行,耗时不超过30分钟,且耐受性较好。在LA之后1、6、12和24个月,评估体积和局部症状的变化。操作中不需要进行全身麻醉。Papini医生指出:“患者能够告诉您是否感觉疼痛是非常重要的。因为仅在甲状腺囊遇到高温时才会感觉到疼痛,此时,你可以停用可能靠近结节边缘的那根光纤。”对照组不接受任何影响甲状腺的治疗。基线以及之后每6个月进行临床、实验室和超声检查,共随访3年时间。


结果显示,治疗组患者的甲状腺结节在6个月(–50.7%)和24个月(–57.3%)时呈进行性缩小(P<0.001)。在73.6%的病例中观察到体积缩小超过50%(P<0.001)。LA治疗后,结节体积在12个月内进行性缩小,至24个月保持稳定。4个中心的24个月平均体积缩小比例分别为41.6%、63.2%、61.5%和58.7%。每次操作的一次性用品费用约为400美元,不同中心的疗效和不良反应相似。诉称压迫症状的患者比例由31%减至1%。共发生4例并发症,包括1例自行缓解的声带麻痹、1例感染和2例发热。同时,对照组患者24个月时结节体积增加21.9%,不过局部症状无显著变化。


研究者总结认为,激光切除治疗可使甲状腺结节显著缩小,耐受性较好,并且操作中不需要全身麻醉,费用较为合理。


Papini医生披露无相关利益冲突。


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By: NASEEM S. MILLER, Clinical Endocrinology News Digital Network


PHOENIX – The majority of benign thyroid nodules treated with laser ablation shrunk by more than half and the procedures had a low complication rate, according to a 2-year randomized trial in four centers in Italy.


The 200-patient study showed that the procedure was fairly well tolerated without general anesthesia, and cost about $400 in disposables per procedures, Dr. Enrico Papini said at the annual meeting of the American Association of Clinical Endocrinologists.


Previous published studies by Dr. Papini (Thyroid 2007;17:229-35) and other European groups (Thyroid 2006;16:763-8) have shown good outcomes for laser ablation of cold thyroid nodules. However, minimally invasive procedures for treating benign or malignant thyroid nodules, including percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), and laser ablation (LA), have not been widely adopted by U.S. specialists, said Dr. Hossein Gharib, president-elect of the American Thyroid Association and past-president of AACE. And experience matters.
 
"PEI should be first-line therapy for symptomatic, benign cysts," said Dr. Gharib, who was not involved in the study. "It is easy to do, safe and very effective. LA and RFA are more complicated and should be performed only by personnel with experience and equipment."


Dr. Papini said that the procedure is performed by interventional radiologists or endocrinologists "who are fairly experienced in percutaneous injections, or at least in the use of fine-needle aspiration biopsy." He added that it takes about a month of training to be effective in the procedure.


Dr. Papini and colleagues compared the clinical and ultrasound changes in benign thyroid nodules by ultrasound-guided LA with those who were follow-up only. They also assessed side effects and the efficacy of the technique in different centers.


Two hundred consecutive patients with a solid thyroid nodule with a volume of more than 5 mL and less than 18 mL were referred to four thyroid centers and randomly assigned to a single LA treatment (101 patients) or follow-up (100 patients).


In the treatment group, clinicians performed LA with a 1.064-nm neodymium yttrium-aluminum garnet laser with 2 fibers, and an output power of 3 watts. Energy delivery was 3,600 Joules for nodules up to 13 mL, and 7,200 J for nodules larger than 13 mL. The treatment was outpatient, took less than 30 minutes, and was fairly well tolerated, said Dr. Papini. Volume and local symptoms changes were evaluated 1, 6, 12, and 24 months after LA.


There was no need for general anesthesia.


"You don’t need anesthesia," said Dr. Papini of Regina Apostolorum Hospital, Rome. "It’s very important that the patient can tell you if he feels pain. Because you have pain only if the high temperature approaches the thyroid capsule, so you can stop one of the fibers that may be closer to the border of the nodule."


The control group received no treatment affecting the thyroid gland. Clinical, laboratory, and ultrasound control were performed at baseline and every 6 months thereafter for 3 years.


Results showed that a progressive nodule volume reduction was found at 6 months (–50.7%), 12 (–57.3%), and 24 (–60.9%) months (P < .001). A reduction of more than 50% was observed in 73.6% of the cases (P < .001).


Volume reduction in LA was progressive until 12 months and remained stable until 24 months. The 24-month mean volume reduction in the difference centers was 41.6%, 63.2%, 61.5%, and 58.7%.


Cost of disposables was about $400 for each procedure, and efficacy and side effects were similar in different centers, Dr. Papini reported.


The presence of pressure symptoms complaint decreased from 31% to 1% of the cases. There were four complications, including one case of self-resolving vocal cord paresis, one infection, and two fevers.


Meanwhile, the control group showed a 21.9% volume increase in 24 months, but local symptoms did not change significantly.


Although the procedure had several advantages, including no cosmetic damage and no risk of hypothyroidism, it’s not without drawbacks. Dr. Papini said that the nodules are persistent and need careful cytologic evaluation and follow-up. Also, the operator needs to be well trained, as complications can be severe during the learning period. There’s also a potential for regrowth, although none were reported during the trial’s 3-year follow-up.


"Currently, RFA is used in some centers for hepatic but not thyroid lesions," said Dr. Gharib, who practices at Mayo Clinic, Rochester, Minn. "It is likely that in the near future we will see the application of these techniques for thyroid masses."


Dr. Papini and Dr. Gharib had no relevant disclosures.


学科代码:内分泌学与糖尿病 外科学   关键词:激光切除 良性甲状腺结节
来源: EGMN
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