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1 Department of Diagnostic Radiology, Asan Medical Center, University of Ulsan
College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736,
Korea.
2 Department of Endocrinology, Asan Medical Center, University of Ulsan College
of Medicine, Songpa-gu, Seoul 138-736, Korea.
Received July 15, 2002;
accepted after revision November 19, 2002.
Address correspondence to H. K. Lee.
Abstract
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SUBJECTS AND METHODS. We studied 20 patients with simple or complex thyroid cysts and 22 patients with solid thyroid nodules. All lesions were confirmed by fine-needle aspiration biopsy to be benign. The mean volume of the instilled absolute ethanol (99.9%) was 62.2% of the whole tumor volume for solid nodules and 63.4% of the cystic volume for cysts. Follow-up sonography was performed 1–6 months (mean, 4.4 months for cysts and 4.6 months for solid nodules) after the procedure.
RESULTS. The mean volume reduction rate for cysts (65%) was greater than that for solid nodules (38.3%) (p < 0.01, Student's t test). The volume of the instilled ethanol correlated significantly with the volume reduction rate of cysts but not with that of solid nodules (p < 0.01, Student's t test).
CONCLUSION. Sonographically guided percutaneous ethanol injection is more effective for thyroid cysts than for solid thyroid nodules.
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However, to our knowledge, the efficacy of ethanol sclerotherapy has not been previously compared for treatment of cysts versus solid nodules. In addition, in complex cysts consisting of both cystic and solid components, the preferred area to be injected has been controversial. The purpose of this study was to compare the efficacy of ethanol injection in thyroid cysts and solid nodules.
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Our study group consisted of 36 women and six men (age range, 26–56 years; mean age, 40.7 years) with 20 thyroid cysts and 22 solid thyroid nodules. Patients complained of the cosmetic implications of the palpable mass (n = 30), local discomfort (n = 4), dysphagia (n = 2), and other symptoms (n = 6).
Sonography was performed with an HDI 3000 scanner (ATL, Bothell, WA) using 5- to 10-MHz linear probes.
The volume of a cyst or solid nodule was determined using the following
formula: length x width x height x 
/ 6
[1,
2]. We defined a cyst as having
more than a cystic component of 60% and a solid nodule as having more than a
solid component of 60%.
Using sonographic guidance, we inserted a 20- to 22-gauge needle into the cyst or solid nodule without placing the patient under local anesthesia; absolute ethanol (99.9%) was then instilled to a volume of 40–68% of the volume of the cystic or solid nodule. Ethanol was instilled into the cystic portion of the complex cyst or the solid portion of the solid nodule. In the case of a cyst, one fourth of the total amount of fluid was aspirated before the ethanol injection. The ethanol injection was stopped if ethanol leaked out of the nodule or if the patient complained of pain.
Sclerotherapy was performed once in five patients, twice in six patients, and three times in nine patients (mean, 1.8 times) for the cysts; sclerotherapy was performed once in six patients, twice in seven patients, and three times in nine patients (mean, 1.9 times) for the solid nodules.
Follow-up sonography was performed between 1 and 6 months (mean, 4.4 months for cysts and 4.6 months for solid nodules) after sclerotherapy.
The effectiveness of sclerotherapy was compared between cysts and solid nodules according to the volume-reduction rate. The volume-reduction rate was presented as follows: initial volume – final volume after treatment / initial volume x 100%. The volume of the injected ethanol was correlated to the effect of sclerotherapy in the two groups.
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The correlation between the volume of ethanol instilled and the volume-reduction rate of the cysts and solid nodules were confirmed. The larger the volume of ethanol instilled, the higher the rate of the volume reduction in the cysts (p < 0.01; Student's t test) but not in the solid nodules (Fig. 3).
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Side effects associated with sclerotherapy were reported in four patients who complained of local pain at the injection site caused by leakage of a small amount of ethanol into the subcutaneous tissue. Pain was transient in these patients, and no severe complications such as vocal cord paralysis or transient thyrotoxicosis were seen.
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Among these treatments, there has been a high recurrence rate of up to 58% with fine-needle aspiration biopsy, depending on the size of the cyst. Thyroid suppression therapy has been found to have little effect, and major complications such as osteoporosis can occur. Many investigators have suggested that sclerotherapy with agents such as ethanol or tetracycline instillation are effective. The effectiveness of ethanol instillation is similar to that of tetracycline and OK-432 but is less expensive than any other agent and is easier to repeat.
The mechanism of ethanol sclerotherapy is that ethanol induces cellular dehydration and protein denaturation, which are followed by coagulation necrosis, reactive fibrosis, and small-vessel thrombosis [4].
Our study has shown that ethanol sclerotherapy was effective in both cystic and solid nodules but that the volume reduction rate of thyroid cysts (64%) was greater than that of benign solid nodules (35%). The reason for the different effect of sclerotherapy in solid and cystic nodules is not well known. However, we propose that ethanol blocks the secretion of tumor cells and thereafter absorbs the fluid in a cystic nodule, after which the cystic components continually decrease. The solid components of thyroid nodules are thought to be more resistant to diffusion and are therefore also less effectively reduced after ablation. In addition, the abundant vascularization of solid nodules favors the drainage of ethanol, thus partially neutralizing its effect and limiting the success of the procedure [5].
Yasuda et al. [3] reported that with ethanol sclerotherapy, the cystic volumes decreased by more than half in 72% of the patients treated for recurrent thyroid cyst after fine-needle aspiration biopsy. Cho et al. [1] also reported that in 68% of their patients with cystic nodules, the volumes decreased by 50% or more. In our study, 65% of the patients with cystic nodules showed a volume decrease of 50% or more.
In addition, the volume of ethanol instilled in patients in our study correlated significantly with the volume-reduction rate of cysts but not with that of solid nodules. This finding means that complex solid and cystic nodules, requiring a larger amount of ethanol, are more likely to shrink than totally solid nodules.
In addition, the amount of aspirated fluid has an effect on the degree of ethanol ablation, but that was not quantified in our study. For example, ethanol sclerotherapy is more effective in pure serous cystic fluid than in gelatinous thick fluid. Further study of this effect is suggested.
In conclusion, percutaneous ethanol injection is an effective treatment for both solid and cystic thyroid nodules, but ethanol sclerotherapy is more effective in cystic thyroid nodules than in solid nodules and should be the treatment of choice for those benign cystic thyroid lesions large enough to induce local discomfort, cosmetic damage, or anxiety in patients.
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= cystic nodule (p <
0.01, Student's t test); 
= solid nodule (p >
0.01, Student's t test).