Abstract
Objective
Ultrasound-guided percutaneous ethanol injection therapy (US-PEIT) is used in patients with recurrent symptomatic thyroid cysts as a credible alternative to surgery. Young patients commonly do not wish to undergo surgery and prefer ethanol ablation, if available. The effect of this approach on quality of life is an essential factor in deciding on the treatment options, especially in the young with a long life expectancy and no comorbidity.
Methods
We performed US-PEIT in a cohort of young patients, 15–30 years, from 2015 to 2020. The patients’ general quality of life (QoL), self-reported compression symptoms and neck appearance were evaluated.
Results
The cohort comprised 59 patients with 63 cysts, more women than men, with a mean age of 23.8 years. About 1.5 mL of injected alcohol were needed to reach a 90.7% mean cyst volume reduction ratio in 12 months. The method did not fail in any of the patients; a single US-PEIT session was undertaken in 46% of them. The procedure significantly improved each of the patients’ symptoms with a significant total score difference (P < 0.001). The total symptom score correlated with the initial cyst volume (P = 0.002; r = 0.395). The mean QoL score by SF-36 6 months after the last US-PEIT was significantly different for physical component summary 56.5 (P < 0.001) but not different for mental component summary 47.7 (P = 0.125), compared to age-corresponding norms.
Conclusions
US-PEIT is a safe and effective method for the young, leading to improvements in cosmetic and subjective complaints, and should also be considered as first-line treatment in the young.
Introduction
The incidence of thyroid nodules found by palpation is 4–7%, while the prevalence of nodules in the thyroid gland observed by ultrasonography (US) can attain 67% (1). Complex nodules with a cystic component arise from haemorrhage or degenerative changes and are present in 18–35% of surgical specimens (2). Nodules with a predominantly cystic component are categorised into complex cysts, where the fluid component makes up 60–90% of the volume, and pure cysts, where the fluid volume exceeds 90% (3). The fraction of predominantly cystic or cystic nodules is 15–25% (4). The estimated risk of malignancy is <1% for pure cysts and <3% for spongiform and complex nodules with a cystic component (5).
About 5% of the patients with thyroid nodules have local mechanical problems from compression or perceive the appearance of the neck as a cosmetic problem (6). If the cause of the complaints is a cystic thyroid nodule, fine needle aspiration biopsy (US-FNAB) is performed as the diagnostic and therapeutic procedure. Simple evacuation is largely not a solution, even for small and medium cysts. The recurrence of large complex cysts is common. The recurrence rate is high, 58–80%, depending on the cyst volume, content and number of previous aspirations (4, 7, 8).
Ultrasound-guided percutaneous ethanol injection therapy (US-PEIT) or ethanol ablation (EA) is currently globally considered the first choice for treating benign cystic nodules in the thyroid gland and is recognised as a credible alternative to surgery (9, 10, 11). We, and others, have previously reported its high effectiveness, long-lasting effect and overall safety (4, 12, 13). The method’s success rate was reported in the relevant publications as between 68% and 100% (14, 15). Absolute alcohol has a local effect on the cyst cavity wall. It primarily causes coagulation necrosis of the cells (dehydration and denaturation of the cell proteins) and disturbs microcirculation (endothelium damage, thrombotisation and ischemisation). Reactive tissue fibrosis and slow cyst cavity crinkling follow (16).
The effect of thyroid cysts and their therapy on patients’ subjective symptoms and health-related quality of life (QoL) is commonly evaluated by patient-reported outcome measures (PROMs). The SF-36 questionnaire is a multipurpose, short-form health survey based on PROMs widely used to assess patients’ health-related QoL in clinical practice. Patients with thyroid cysts often face unique problems, both compression and cosmetic. Therefore, several questionnaires were created and validated for patients with thyroid cysts (17, 18). Young patients are usually not influenced by any other serious comorbidity, and a thyroid cyst could be the first serious medical condition they have to face. Therefore, knowledge of the effect of US-PEIT on this population could be important.
The primary purpose of this prospective, single-centre study was to confirm the method’s efficacy in young, otherwise healthy patients and evaluate its effect on their QoL.
Methods
Subjects and study design
In this prospective study at a single tertiary centre, we included patients indicated to US-PEIT with 96% alcohol at University Hospital Olomouc from 2015 to 2020. Inclusion criteria were as follows: symptomatic cysts recurring after simple evacuation (one to four times), otherwise healthy patients <30 years old, with no contraindications to surgery if relevant. Surgery as an alternative option was previously offered to all patients. All the patients demonstrated normal thyroid function (serum TSH in the reference range). Only one girl (15 years old) had Hashimoto’s disease with hypothyroidism, adequately treated with l-thyroxine. Exclusion criteria for study enrolment were as follows: previous thyroid surgery and symptoms of thyroid hormone dysfunction as they could have affected patient’s QoL.
The patients (and parents of patients under 18) were informed about the method and signed the Informed Consent Form; the study was approved by the University Hospital Olomouc Ethics Committee (ref. number 49/23). A Philips iU22 ultrasound machine with a 10 MHz probe was used for the US examination and US-PEIT procedure.
As described in our previous work, the procedure was performed and evaluated as a single puncture variant. The fluid aspiration from the cyst was followed by alcohol instillation from another syringe without removing the needle. The applied alcohol was not re-aspirated. No local anaesthesia was applied (13). The cyst volume was calculated by ultrasound software (volume of aspirated fluid was not statistically evaluated), and the volume change was evaluated as the volume reduction ratio (VRR) index: VRR (%) = [(initial cyst volume – final cyst volume)/initial cyst volume] × 100. Cysts were considered small (volume <10 mL), medium (volume 11–30 mL) and large (volume >30 mL).
A US monitoring visit followed 1 month after the procedure. If any new fluid was present in the cystic cavity, a subsequent US-PEIT was performed. If only a tiny solid residue free from any fluid was observed, the treatment was finished, and periodic US control visits were planned in 3, 6 and 12 months.
For the standardised QoL evaluation, we asked the patients to fill out the QoL SF-36 questionnaire developed by Ware and Sherbourne 1992 (translated into Czech by Sobotík) (19, 20) 6 months after the last US-PEIT procedure. This questionnaire has 36 questions assessing eight domains: physical functioning, role limitation due to physical problems, bodily pain, general health, vitality, social functioning, role limitation due to emotional issues and mental health. The described algorithm converted the raw scores to T scores (21). The physical component summary (PCS) and mental component summary (MCS) scores are calculated to review patient results quickly. Interpretation of the SF-36 Health Survey is simplified by the norm-based scoring (NBS) of its health domain scales and component summary measures. In NBS, each scale is scored to have the same average (50 points) and the same standard deviation, signifying that each point equals one-tenth of a standard deviation (13). As norms (means and standard deviations) we applied the USA (United States of America) population data with the average age of 58 (18-98) for individual subscales. In contrast, we applied the available age-adjusted norms for summary subscales (PCS and MCS) (19).
We translated and modified the multiple-choice thyroid-specific questionnaire according to Reverter, in which patients answered ten questions before and 6 months after the last US-PEIT (17). The following symptoms were reported: (i) neck enlargement, visible or palpable resistance (cosmetic complaint); (ii) feeling of a ‘foreign’ object in the neck; (iii) pressure in the throat; (iv) pain in the throat; (v) pain propagation to the jaw and ears; (vi) swallowing complaints; (vii) urge to cough; (viii) shortness of breath, sensation of heavy breathing; and (ix) hoarse voice. Question No. 10 (compressive symptoms on the trachea by chest x-ray) was scored 1 for all our patients (to enable comparison with the initial Spanish work). Chest x-rays before the procedure (Question No. 10) were not performed because none of the cysts was large enough (>100 mL) to cause a significant deviation of the trachea. The reported complaint intensity was scored between 1 (no complaints) and 5 (appreciable and lasting complaints). The maximum attainable total score was 50 (patient perceiving the symptoms most appreciably) and the minimum score was 10 (no symptoms).
Statistics
IBM SPSS Statistics version 23 (Armonk, NY: IBM Corp.) was used for data analysis. The Wilcoxon paired test with Bonferroni significance correction for multiple comparisons was used to evaluate the changes in cyst volumes and symptom scores. The Mann-Whitney U test was used to assess the interrelation between the cyst type and cyst volume, or the cyst volume reduction, the alcohol amounts and the alcohol-to-cyst volume ratios for the various cyst types. The Kruskal–Wallis test and the Mann–Whitney U test with the Bonferroni significance correction as a post hoc test were used to assess the interdependence between the cyst size and cyst volume reduction and the amount of alcohol used and the alcohol/cyst volume ratio. A non-parametric Spearman correlation analysis was only performed for patients with one cyst (56 patients and cysts). Data normality was evaluated using the Shapiro–Wilk test. All tests were performed at the significance level of 0.05. The graphical outputs were processed using GraphPad Prism version 8.4.3 for Windows (GraphPad Software, www.graphpad.com).
Results
Evaluation of the effect of US-PEIT on cyst volume
The cohort comprised 59 patients (63 cysts) with more women (54, 85.7%) than men (9, 14.3%). The mean age was 23.8 years (SD 4.9; median 24 years; range 15–30 years). The cohort was divided into subgroups according to the cyst content and volume. As to the content, there were 15 pure cysts (24%) and 48 complex cysts (76%) (P = 0.003). As to the size, small (59%, n = 37) or medium (33%, n = 21) cysts predominated; large cysts were found in 8% of female patients (n = 5); (P = 0.001, by ANOVA); see Table 1.
Characteristics of all cysts and the amount of alcohol depending on cyst type and size.
| Number (n) | Per cent (%) | P-value | Median ethanol amount (mL) | Range | P-value | Median ethanol vs initial volume (%) | Range | P-value | ||
|---|---|---|---|---|---|---|---|---|---|---|
| All cysts | 63 | 100 | NA | 1.5 | 0.3–13 | NA | 20 | 7.9–50.0 | NA | |
| Repetition of US-PEIT | 1 | 29 | 46 | <0.001 | 1.0 | 0.3–3.0 | <0.001 | 18.2 | 8.8–33.3 | 0.036 |
| 2 | 27 | 42.9 | 2.5 | 0.7–5.0 | 22.7 | 7.9–50.0 | ||||
| 3 | 5 | 7.9 | 3.0 | 2.5–3.5 | 27.8 | 10.9–41.7 | ||||
| 4 | 2 | 3.2 | 9.0 | 5.0–13.0 | 28.5 | 22.7–34.2 | ||||
| Cyst type | Pure | 15 | 23.8 | 0.003 | 1.0 | 0.3–5.0 | 0.057 | 12.5 | 7.9–25.0 | <0.001 |
| Complex | 48 | 76.2 | 2.0 | 0.7–13.0 | 22.7 | 9.1–50.0 | ||||
| Cyst size (volume) |
Small (vol. < 10 mL) |
37 | 58.7 | 0.001 | 1.0 | 0.3–3.5 | <0.001 | 25 | 10.0–50.0 | 0.002 |
| Medium (11–30 mL) |
21 | 33.3 | 2.5 | 1.0–5.0 | 18.2 | 7.9–27.3 | ||||
| Large (> 30 mL) |
5 | 7.9 | 3.5 | 3.0–13.0 | 10.9 | 8.8–34.2 | ||||
Ethanol, total amount of instilled ethanol per cyst; ethanol vs initial cyst volume, total ethanol-to-initial cyst volume ratio.
US-PEIT was successful (the cystic cavity disappeared) in all patients. No relapse occurred within the 6 and 12 months of follow-up. A single US-PEIT procedure was performed for 29 (46%) cysts. The procedure was repeated once for 27 (43%) cysts, twice for 5 (8%) cysts and thrice for 2 (3%) cysts. The mean number of US-PEIT procedures per cyst was 1.7 (SD 0.7), and the median amount of injected alcohol was 1.5 mL (Table 1). The number of repeated treatments correlated significantly with initial cyst volume (P = 0.01; r = 0.338) and cyst type (for complex cyst P = 0.005; r = 0.371). The final mean cyst volume (solid residue) 12 months after the US-PEIT intervention(s) was 0.92 mL, the attained mean VRR was 90.7% (Fig. 1).
Quartile box showing cyst volume reduction distribution based on cyst type (pure vs complex). The box shows the frist and thirdquartiles, a horizontal line within the second quartile (median), whiskers at the fifthand ninety-fifth percentile, and outliers as dots. The difference between pure and complex cysts was at 1, 3 and 6 months with P < 0.001 (***) and at 12 months P = 0.001 (**).
Citation: European Thyroid Journal 12, 5; 10.1530/ETJ-23-0085
Effect of US-PEIT on the volume of pure and complex cysts in time evaluated by volume and volume reduction ratio.
| Cyst type | Mean volume (mL) | SD | P-value | Mean VRR (%) | SD | P-value | |
|---|---|---|---|---|---|---|---|
| Initial cyst volume | Pure | 13.53 | 13.57 | 0.891 | NA | NA | NA |
| Complex | 10.31 | 7.45 | NA | NA | NA | ||
| All | 11.08 | 9.25 | NA | NA | NA | NA | |
| 1 month after US-PEIT | Pure | 0.67 | 0.97 | <0.001 | 94.4 | 3 | <0.001 |
| Complex | 1.86 | 1.69 | 80.2 | 10.5 | |||
| 3 months after US-PEIT | Pure | 0.43 | 0.74 | <0.001 | 96.6 | 2.5 | <0.001 |
| Complex | 1.31 | 1.64 | 86.8 | 9.7 | |||
| 6 months after US-PEIT | Pure | 0.35 | 0.61 | <0.001 | 97.2 | 2 | <0.001 |
| Complex | 1.13 | 1.45 | 88.4 | 9.7 | |||
| 12 months after US-PEIT | Pure | 0.34 | 0.61 | <0.001 | 97.2 | 2 | <0.001 |
| Complex | 1.1 | 1.43 | 88.6 | 9.8 | |||
| All | 0.92 | 1.32 | NA | 90.7 | 9.3 | NA |
Final cyst volume, volume of the cyst at 12 months after the completion of US PEIT; initial cyst volume, volume of cyst before US-PEIT; VRR, volume reduction ratio at intervals after the completion of US PEIT.
No significant difference was found between the baseline volumes of the pure and the complex cysts (P = 0.891). A significant (P < 0.001) cyst volume reduction against the baseline value was observed in the cohort in 1, 3, 6 and 12 months. In 12 months, the volume reduction was significantly (P < 0.001) more pronounced in the pure cysts (Table 2). The quartile box plot shows the cyst volume reduction distribution in dependence on the cyst type (Fig. 1). While the pure and complex cysts did not differ in the amounts of the initial ethanol volume applied (P = 0.057), the alcohol-to-initial cyst volume ratio was significantly higher for the complex cysts than pure cysts (22.7 vs 12.5, P < 0.001), see Table 1.
A significant difference in the cyst volume reduction was only observed between the small and medium cysts 12 months after the procedure: the VVR for the medium cysts was 93.7%, as opposed to 88.9% for the small cysts (P = 0.045). The three cyst size groups also differed significantly regarding the amount of injected alcohol: the medium and large cysts required more alcohol than the small cysts (P < 0.001 and P = 0.001, respectively). No significant difference was observed between the medium and large cysts in this respect.
Slight local pain subsiding within 48 h was reported by 22 (37%) patients after the procedure. No other complications were recorded. The procedure was free from any thyroid performance disruption (serum TSH levels remained within the reference range).
Evaluation of subjective symptoms before and after US-PEIT
We found a significant decrease in the total symptoms score; the total score before and after the US-PEIT was 20.7 and 10.5, respectively (P < 0.001) (see Fig. 2). A summary score of 10 (no symptoms) after the procedure was reached in 42 (71%) patients.
Cosmetic effect and subjective symptoms before and after US-PEIT. Difference before and 6 months after the last US-PEIT in (i) visible enlargement of the neck (cosmetic complaint), (ii) feeling of pressure in the neck (‘foreign body’), (iii) throat pressure, (iv) sore throat, (v) pain in the throat radiating to the ears, (vi) difficulty in swallowing, (vii) frequent throat clearing, (viii) shortness of breath, (ix) hoarseness and (x) compressive symptoms on the trachea shown in chest x-ray – not performed none of the cysts was large enough (>100 mL) to cause a significant deviation of the trachea. Each item was scored between 1 (none of the time), 2 (a little of the time), 3 (some of the time), 4 (most of the time) and 5 (all of the time). Change in Questions 1 to 6 and 8 was significant P < 0.001 (***), 7 was P = 0.002 (**), 9 was P = 0.003 (**) and the score did not differ in Question 10.
Citation: European Thyroid Journal 12, 5; 10.1530/ETJ-23-0085
The patients reported no differences in subjective perception before or after the procedure regarding the baseline cyst volume for the three cyst sizes (small, medium and large). With the more uniform distribution between the group of small cysts and the group of medium and large cysts (36 vs 18 + 5 patients), the difference in the perception of the symptoms was significant before the therapy (score 19.5 vs. 22.7, P = 0.029) but not after the therapy (P = 0.969). No effect of the cyst type on the total symptom score before or after the therapy was observed, see Table 3.
Symptom score before and after (6 months) US-PEIT according to the thyroid cyst size.
| Symptom score (size/type of cyst) | Mean | SD | Median | Minimum | Maximum | P-value |
|---|---|---|---|---|---|---|
| Before US-PEIT (all) | 20.7 | 6.4 | 20 | 11 | 37 | <0.001 |
| After US-PEIT (all) | 10.5 | 1.1 | 10 | 10 | 15 | |
| Before US-PEIT (small) | 19.5 | 6.4 | 18.5 | 11 | 34 | 0.029 |
| Before US-PEIT (medium+large) | 22.7 | 5.9 | 21 | 15 | 37 | |
| After US-PEIT (small) | 10.6 | 1.3 | 10 | 10 | 15 | 0.969 |
| After US-PEIT (medium+large) | 10.4 | 0.7 | 10 | 10 | 12 | |
| Before US-PEIT (pure) | 21.9 | 7.9 | 20.5 | 11 | 36 | 0.556 |
| Before US-PEIT (complex) | 20.4 | 5.9 | 20 | 12 | 37 | |
| After US-PEIT (pure) | 10.5 | 0.8 | 10 | 10 | 12 | 0.639 |
| After US-PEIT (complex) | 10.6 | 1.2 | 10 | 10 | 15 |
The correlation analysis of initial cyst volume to specific subjective symptoms showed that before US-PEIT there was a correlation to the visible enlargement of the neck (P < 0.001; r = 0.51), to the feeling of pressure in the neck (P = 0.004; r = 0.378) and to the throat pressure (P = 0.014; r = 0.323). The total symptom score also correlated with the initial cyst volume (P = 0.002; r = 0.395). Initial cyst volume also correlated with the change in subjective symptom score regarding the visible enlargement of the neck, feeling of pressure in the neck, and throat pressure and difficulty swallowing (P <0.001, r = 0.515; P <0.001, r = 0.447; P = 0.008, r = 0.346; resp. P = 0.047, r = 0.264). The change in the total symptom score also correlated with the initial cyst volume (P = 0.001; r = 0.445). The only observed correlation of the cyst volume outcome in 12 months after US-PEIT to any subjective symptom was to shortness of breath (P = 0.032; r = 0.284).
SF-36 questionnaire evaluation
In the health-related QoL SF-36 questionnaire, the mean T scores of the individual scales in our patient cohort varied from 47.64 to 56.46. Three of ten (3/10) individual scales were significantly above the USA norms (PF, RP and BP scales, P < 0.001, Fig. 3, panel A). The physical component summary was significantly above the USA norms, also when adjusted for age (P < 0.001), the mental component summary was not statistically different (MCS, P = 0.125), Fig. 3, panel B.
Mean T scores with 95% CIs in the Czech sample. (A) Individual scores compared to US general norms. (B) Summary scores, also with age- and sex-specific adjustment. A one-sample t-test was used to compare the Czech sample with the US norms. The dotted line shows the norm population average score. Values above the line show ‘better’ results; below the line show ‘worse’ scoring of QoL by SF-36. BP, bodily pain; GH, general health; MCS, mental component summary; MH, mental health; PCS, physical component summary; PF, physical functioning; RE, role limitations due to emotional problems; RP, role limitations due to physical health; SF, social functioning; VT, vitality; PCS_A, MCS_A, PCS and MCS sex and age adjusted.
Citation: European Thyroid Journal 12, 5; 10.1530/ETJ-23-0085
Discussion
This study prospectively evaluated the effect of US-PEIT on changes in thyroid cyst volume and its impact on subjective symptoms and the QoL in young.
The attained VRR in our cohort was 90.7%; in this 97.2% in the pure cyst group and 88.6% in the complex cyst group. No significant difference in the baseline volume was found between the pure and complex cysts. In 12 months, the volume reduction was significantly more pronounced in the pure cysts. The complex cysts required more commonly repeated treatments when compared to simple cysts (evaluated by correlation analysis). This can be explained by the larger fraction of the solid component in the complex cysts. When considering cyst size, a significant difference in the volume reduction was found between the small and medium cysts 12 months after the US-PEIT. A significantly larger volume of alcohol was applied to medium and large cysts than to small cysts in order to get a successful outcome. The number of repeated treatments correlated with initial cyst volume (P = 0.01; r = 0.338). The alcohol-to-initial cyst volume was significantly higher for complex cysts than for pure cysts 22.7% vs 12.5%, the median for the whole cohort was 20%. The instilled volume we used for the sclerotisation of a cyst was small, 1.5 mL (median), approaching that used in the Spanish Reverter’s cohort (<2 mL), and was sufficient for successful sclerotisation (17).
We use the US-PEIT variant without aspiration. The therapeutic success of the two approaches, non-aspiration and aspiration, is comparable (non-aspiration 96% vs aspiration 93%) when 8.3 mL, resp. 5.2 mL of infused alcohol is applied (16). The amounts of alcohol applied within US-PEIT were different in the various studies: while Bennedbaek and Hegedüs applied alcohol volumes equivalent to 25–50% of the fluid aspirated from the cyst but not more than 10 mL, Kim YJ et al. used approximately 50% (4, 22). Recent work, however, determined that smaller alcohol volumes, equivalent to <25% of the cyst volume are sufficient (23), with a mean need of 5.3 US-PEIT treatments. Instillation of less than 2 mL per application in any cyst appeared adequate by Reverter (17), however, 55% of patients needed repeated treatment. On the other hand, Cho et al. reported success in their study with less than 2 mL of alcohol applied to the cysts of any type and size by a single puncture followed by re-aspiration (after approx. 7 min) using a three-way valve; with this approach, only 11.5% of patients needed repeated treatment (24). We can only speculate as to whether the reduction of applied alcohol volume might lead to the need for repeated intervention. Still, we believe a smaller amount of alcohol is safer for the patient (regarding unintended alcohol leakage).
QoL is a crucial consideration for selecting clinical management of thyroid lesions (25). To evaluate the change in the subjective symptoms, we modified the questionnaire by Reverter et al. (17). Our cohort’s size and age structure differed from Reverter’s (59 vs 30 patients, mean age 23.8 vs 46 years). The mean initial cyst volume was smaller in our cohort (11.1 mL) than in the Reverter’s cohort (18.6 mL) and none of the cysts caused trachea deviation. For our cohort, we deliberately selected young and otherwise healthy people, with resistance on the neck as the only significant health problem. Such patients (mainly women) presumably visited the doctor for the abnormal appearance of the neck earlier than the older subjects. This can explain the smaller initial cyst volume in our cohort. The mean age of our cohort as a whole (320 cysts treated with US-PEIT by the end of 2020) was 49.9 years (SD 18.2) and the initial cyst volume was 14.9 mL (SD 21.9), which matches the Spanish cohort in regards to the age structure and size (not-published). The symptom score before and after US-PEIT was 20.7 and 10.5, respectively, in our cohort and 22.8 and 13, respectively, in the Spanish cohort. The score of 10 (no symptoms) after the procedure was reported by 71% (39/59) of our patients and 47% (14/30) of the Spanish patients.
Our correlation analysis of subjective symptoms and symptoms of compression showed that from all the evaluated parameters (initial cyst volume, post US-PEIT volumes at 3, 6 and 12 months and VRR), the most significant correlations were found for initial cyst volume – specifically visible enlargement of the neck, feeling of pressure in the neck, throat pressure and also the total symptom score. We conclude that patients can expect the most relief from US-PEIT regarding the visible enlargement of the neck, feeling of pressure in the neck, throat pressure and difficulty swallowing. The final cyst volume only had a minor effect (one parameter) on the change of subjective symptoms, most likely because of the minimal remaining cyst volume, therefore, alleviating most symptoms.
To evaluate the potential effect of the procedure on young patients’ QoL with the ability to compare with standardised norms, we used the QoL SF-36 questionnaire. Young patients are usually not influenced by any other serious comorbidity. When looking into the QoL SF-36 questionnaire in detail, our patients significantly differed statistically from the reference norm in three subscales (PF, RP and BP), and in the physical component summary (PCS) in all of them, the QoL was better in our cohort than in the reference population. Our patients never reported statistically poorer QoL than the reference group in any of the parameters. While we dare not to say that US-PEIT improves the QoL because of the unavailability of a reference sample of the European population, we concluded from the above facts that US-PEIT has no adverse impacts on the subjective assessment of the patients’ QoL. Jeong et al. previously evaluated QoL after US-PEIT with multiple-choice thyroid-specific QoL and compared it with the effect of radiofrequency ablation; both methods improved QoL (18). Those outcomes may support the overall favourable role of US-PEIT in treating thyroid cysts on the patients’ QoL
Study limitations may be perceived in the follow-up duration (12 months), which could be seen as short, especially in young patients with long life expectancy. We follow most of the patients included in this study further; however, it is clinically impossible to continue outpatient visits for all patients. Patients should fill in the SF-36 questionnaire before the treatment to enable a more direct comparison of QoL. We used the available USA norms for the unavailability of SF-36 European QoL norms, which could affect the interpretation of the results.
Conclusion
US-PEIT reduces thyroid cyst volume and is safe and effective in decreasing perceived symptoms. Significant volume reduction can be achieved in both pure and complex cysts, however, the complex require more ethanol. Initial cyst volume affects the symptom’s severity and correlates with the symptom change after US-PEIT. The type of cyst does not affect subjective symptoms. US-PEIT should also be considered as a first-line treatment in the young and otherwise healthy patients.
Declaration of interest
None.
Funding
This work was supported by the Ministry of Health of the Czech Republic – Conceptual development of research organisation (FNOL, 00098892).
Author contribution statement
MH – designed the study and conducted the patient examination; HM – conducted the patient examination and co-authored the paper; RO – processed QoL data; RD – processed QoL data and co-authored the paper; DK – led the author’s group and co-authored the paper; JS – designed the study, processed QoL data and wrote this paper.
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