{"id":382577,"date":"2024-07-17T22:03:39","date_gmt":"2024-07-17T20:03:39","guid":{"rendered":"https:\/\/medizinonline.com\/?p=382577"},"modified":"2024-07-17T22:41:52","modified_gmt":"2024-07-17T20:41:52","slug":"ablacao-termica-guiada-por-ultra-sons-2","status":"publish","type":"post","link":"https:\/\/medizinonline.com\/pt-pt\/ablacao-termica-guiada-por-ultra-sons-2\/","title":{"rendered":"Abla\u00e7\u00e3o t\u00e9rmica guiada por ultra-sons"},"content":{"rendered":"\n

V\u00e1rios m\u00e9todos de abla\u00e7\u00e3o de tecidos utilizando efeitos t\u00e9rmicos, a termoabla\u00e7\u00e3o, t\u00eam sido utilizados na pr\u00e1tica cl\u00ednica de rotina desde a d\u00e9cada de 1970. A termoabla\u00e7\u00e3o \u00e9 uma terapia alternativa para n\u00f3dulos benignos sintom\u00e1ticos da tir\u00f3ide e quistos sintom\u00e1ticos da tir\u00f3ide. A taxa de hipotiroidismo ap\u00f3s a abla\u00e7\u00e3o t\u00e9rmica de um n\u00f3dulo hiperfuncional da tir\u00f3ide \u00e9 inferior a 0,01%.<\/strong><\/p>\n\n\n\n\n\n\n\n

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Inicie o teste CME<\/a><\/div>\n<\/div>\n\n\t<\/div>\n\t<\/div>\n\n\n\n

V\u00e1rios procedimentos de abla\u00e7\u00e3o de tecidos por efeitos t\u00e9rmicos, a termoabla\u00e7\u00e3o, j\u00e1 t\u00eam sido utilizados na rotina cl\u00ednica desde os anos 70, e s\u00e3o actualmente considerados terapias estabelecidas no tratamento de tumores do f\u00edgado, pulm\u00e3o, ba\u00e7o, osso e pr\u00f3stata, at\u00e9 certo ponto. O princ\u00edpio funcional \u00e9 a destrui\u00e7\u00e3o ablativa do tecido pelo calor. A abla\u00e7\u00e3o t\u00e9rmica dos n\u00f3dulos da tir\u00f3ide n\u00e3o compete com os procedimentos estabelecidos para o tratamento de doen\u00e7as benignas da tir\u00f3ide, tais como terapia medicamentosa, radioterapia ou tiroidectomia, mas deve ser vista como um complemento \u00fatil \u00e0s modalidades terap\u00eauticas existentes.<\/p>\n\n\n\n

Aspectos b\u00e1sicos da abla\u00e7\u00e3o t\u00e9rmica<\/h3>\n\n\n\n

O objectivo da abla\u00e7\u00e3o t\u00e9rmica dos n\u00f3dulos da tir\u00f3ide \u00e9 a necrose irrevers\u00edvel da coagula\u00e7\u00e3o do n\u00f3dulo da tir\u00f3ide com subsequente redu\u00e7\u00e3o do volume. Ao termoablatar os n\u00f3dulos da tir\u00f3ide, o objectivo \u00e9 atingir uma temperatura de pelo menos 60\u00b0C na zona de abla\u00e7\u00e3o. A temperaturas de abla\u00e7\u00e3o de 60\u00b0C, o efeito t\u00e9rmico ocorre quase imediatamente e danos irrevers\u00edveis no n\u00f3 ocorrem subsequentemente. Os recipientes com um di\u00e2metro inferior a 3 mm s\u00e3o destru\u00eddos pelo calor (“emboliza\u00e7\u00e3o t\u00e9rmica” dos recipientes). Este \u00e9 um efeito desejado, uma vez que destr\u00f3i os vasos intrathyroidal que abastecem o n\u00f3. Este efeito n\u00e3o se verifica em vasos com mais de 4 mm de di\u00e2metro. Nestes casos, h\u00e1 uma perda de energia, tamb\u00e9m chamada “dissipador de calor”.<\/p>\n\n\n\n

Abla\u00e7\u00e3o por radiofrequ\u00eancia (RFA)<\/h3>\n\n\n\n

A abla\u00e7\u00e3o por radiofrequ\u00eancia envolve a coloca\u00e7\u00e3o de uma sonda percutaneamente no caro\u00e7o. A sonda \u00e9 ligada a um gerador de corrente alternada de radiofrequ\u00eancia. Uma corrente flui entre dois el\u00e9ctrodos na \u00e1rea da ponta activa. A grande densidade de corrente local numa pequena \u00e1rea cria energia de fric\u00e7\u00e3o i\u00f3nica (calor), que forma a zona de abla\u00e7\u00e3o.<\/p>\n\n\n\n

RFA de n\u00f3dulos benignos da tir\u00f3ide<\/h3>\n\n\n\n

Nas meta-an\u00e1lises [1,2] foi investigado o efeito da RFA nos n\u00f3dulos da tir\u00f3ide. As meta-an\u00e1lises mostraram uma melhoria estatisticamente significativa nos resultados (volume, sintomatologia, cosmese, necessidade de medica\u00e7\u00e3o). A redu\u00e7\u00e3o m\u00e9dia do volume ap\u00f3s a RFA foi de 8,9 ml [2] a 9,77 ml [1]. O resultado estava dependente da morfologia nodal [3]. Nos ensaios aleat\u00f3rios monoc\u00eantricos, a redu\u00e7\u00e3o de volume dos n\u00f3dulos c\u00edsticos prim\u00e1rios da tir\u00f3ide foi de 87% a 93% [4,5] e no ensaio aleat\u00f3rio de controlo de casos de n\u00f3dulos s\u00f3lidos aos 6 meses foi de 49,1% \u00b1 19,5% em compara\u00e7\u00e3o com o grupo de controlo [6]. O estudo prospectivo randomizado mostrou que quanto menor um n\u00f3dulo tireoideano, maior \u00e9 a redu\u00e7\u00e3o relativa do volume [7]. A RFA foi realizada uma ou v\u00e1rias vezes, unilateral ou bilateralmente, para frio benigno ou n\u00f3dulos hiperfuncionais da tir\u00f3ide [3,8\u201314]. A RFA tamb\u00e9m \u00e9 poss\u00edvel ap\u00f3s a realiza\u00e7\u00e3o de uma lobectomia [15]. No caso de quistos da tiroide com coloide viscoso, a RFA pode ser realizada ap\u00f3s a aspira\u00e7\u00e3o do conte\u00fado viscoso do quisto. Ap\u00f3s a abla\u00e7\u00e3o t\u00e9rmica dos quistos da tir\u00f3ide, as recidivas s\u00e3o muito raras, os quistos da tir\u00f3ide podem ser muito bem tratados com a abla\u00e7\u00e3o t\u00e9rmica [16]. Mesmo ap\u00f3s uma injec\u00e7\u00e3o pr\u00e9via de etanol, uma nova redu\u00e7\u00e3o significativa do volume \u00e9 alcan\u00e7ada pela RFA [17,18]. A RFA monopolar de n\u00f3dulos hiperfuncionais da tir\u00f3ide com baixo TSH requer tratamentos de RFA m\u00faltiplos. [13,21,22]Ap\u00f3s uma \u00fanica RFA de n\u00f3dulos hiperfuncionais, 50% a 67% dos doentes continuavam hipertiroideos. Com RFA bipolar de n\u00f3dulos hiperfuncionais da tir\u00f3ide, apenas 10% ainda est\u00e3o hiperfuncionais ap\u00f3s um \u00fanico tratamento. Isto \u00e9 explicado pela borda restante do n\u00f3 hiperfuncional para proteger estruturas termo-sens\u00edveis. [11,19,20]A RFA bipolar \u00e9 superior \u00e0 RFA monopolar no tratamento de gl\u00e2ndulas tir\u00f3ideas hiperfuncionantes. <\/p>\n\n\n\n

Como apenas a parte hiperfuncional do n\u00f3 \u00e9 destru\u00edda, a taxa de hipotiroidismo \u00e9 inferior a 1%, enquanto que a taxa de hipotiroidismo com ingest\u00e3o de levothyroxina ao longo da vida ap\u00f3s a terapia com radioiodina \u00e9 de 10% no primeiro ano.<\/p>\n\n\n\n

Num n\u00f3dulo tir\u00f3ide com a classifica\u00e7\u00e3o Thy 2 em aspira\u00e7\u00e3o de agulha fina, houve uma diminui\u00e7\u00e3o de volume de 67% no per\u00edodo de observa\u00e7\u00e3o de 24 meses. Apenas na classifica\u00e7\u00e3o Thy3 se verificou um aumento de volume em dois de seis n\u00f3dulos da tir\u00f3ide. Nos dois n\u00f3dulos da tir\u00f3ide, foram encontrados carcinoma folicular e neoplasia microfolicular histologicamente no p\u00f3s-operat\u00f3rio [23]. Num estudo a longo prazo ao longo de 4 anos, foi encontrado um aumento de volume ap\u00f3s RFA na \u00e1rea marginal do n\u00f3 com uma frequ\u00eancia de 5,6% [3]. [24]O comit\u00e9 de peritos italiano recomenda a RFA para os n\u00f3dulos hiperfuncionais da tiroide e para os n\u00f3dulos n\u00e3o hiperfuncionais da tiroide com mais de 20 ml, se os doentes recusarem a terapia cir\u00fargica ou a terapia com iodo radioativo. A Sociedade M\u00e9dica Radiol\u00f3gica Italiana recomenda a RFA para todos os n\u00f3dulos benignos da tir\u00f3ide [25]. H\u00e1 uma diminui\u00e7\u00e3o significativa da ecogenicidade e do sinal Doppler dentro da zona de abla\u00e7\u00e3o ap\u00f3s RFA bipolar com t\u00e9cnica “multi-shot” [26,27]. A Task Force Coreana (KSThR) recomenda a RFA com a t\u00e9cnica “moving-shot” para todos os n\u00f3dulos benignos da tir\u00f3ide, independentemente do tamanho, se o n\u00f3dulo da tir\u00f3ide causar sintomas cl\u00ednicos [28]. Abla\u00e7\u00e3o bem sucedida dos n\u00f3dulos da tir\u00f3ide \u00e9 poss\u00edvel tanto com t\u00e9cnicas de disparo como com sondas RFA monopolares e bipolares [26,27,29].<\/p>\n\n\n\n

Complica\u00e7\u00f5es ap\u00f3s a RFA s\u00e3o raras [8,22,25,28,30]. Na an\u00e1lise retrospectiva com quatro centros da Coreia, a taxa de complica\u00e7\u00f5es foi de 0,2% ap\u00f3s 2616 tratamentos [31], no estudo multic\u00eantrico retrospectivo com 13 centros da tir\u00f3ide, a taxa de complica\u00e7\u00f5es foi de 3,3% em geral, com complica\u00e7\u00f5es permanentes (hipotiroidismo e ruptura nodal da tir\u00f3ide) documentadas em apenas 2 pacientes. Em estudos a longo prazo ao longo de quatro anos, a taxa de complica\u00e7\u00e3o foi de 3,6% [3]. As RFA bipolares tamb\u00e9m apresentam baixas taxas de complica\u00e7\u00f5es [26,27]. [32]Em compara\u00e7\u00e3o com a tiroidectomia para n\u00f3dulos benignos multifocais da tiroide, os riscos de complica\u00e7\u00f5es da RFA s\u00e3o menores.<\/p>\n\n\n

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RFA de met\u00e1stases linfonodais ou recidivas locais de carcinoma da tir\u00f3ide<\/h3>\n\n\n\n

Em alguns casos, a cirurgia ou terapia com radioiodina ap\u00f3s a tiroidectomia n\u00e3o pode ser realizada para met\u00e1stases conhecidas de carcinoma papil\u00edfero da tir\u00f3ide bem diferenciado. Ap\u00f3s a RFA de recorr\u00eancias locais ou met\u00e1stases linfonodais, foi encontrada uma redu\u00e7\u00e3o significativa do volume das met\u00e1stases de 53% a 95% e uma diminui\u00e7\u00e3o da tiroglobulina do fabricante do tumor [33\u201337]. O controlo p\u00f3s-terap\u00eautico por biopsia n\u00e3o mostrou qualquer evid\u00eancia de tecido maligno residual e nenhuma evid\u00eancia de recorr\u00eancia do lado tratado ap\u00f3s RFA [38\u201340]. Tamb\u00e9m na s\u00e9rie de casos com recorr\u00eancias de carcinoma papil\u00edfero e folicular da tir\u00f3ide bem diferenciadas, o acompanhamento a longo prazo ap\u00f3s a RFA n\u00e3o mostrou qualquer evid\u00eancia de progress\u00e3o [41]. Tamb\u00e9m em combina\u00e7\u00e3o com a radioterapia, a RFA foi mostrada num estudo prospectivo para destruir com sucesso os restos da tir\u00f3ide ap\u00f3s a tiroidectomia [42]. Os comit\u00e9s de peritos recomendam, portanto, a RFA paliativa para as recidivas e met\u00e1stases de carcinoma da tir\u00f3ide bem diferenciadas, quando n\u00e3o \u00e9 poss\u00edvel a terapia cir\u00fargica ou a terapia com radioiod\u00edodos ou quando s\u00e3o rejeitadas pelo doente [24,25,28].<\/p>\n\n\n\n

A taxa de complica\u00e7\u00f5es de RFA de met\u00e1stases e de recidivas locais foi de cerca de 7%, n\u00e3o foram observadas complica\u00e7\u00f5es que amea\u00e7assem a vida [25,36]. Em compara\u00e7\u00e3o directa com a reopera\u00e7\u00e3o para a recorr\u00eancia local, foram encontradas taxas mais baixas de complica\u00e7\u00f5es com RFA com a mesma efic\u00e1cia [40].<\/p>\n\n\n\n

Abla\u00e7\u00e3o por micro-ondas (MWA)<\/h3>\n\n\n\n

Em MWA, uma sonda de microondas \u00e9 inserida percutaneamente no n\u00f3dulo tireoidiano. \u00c9 criado um campo de microondas na \u00e1rea da ponta activa. A onda electromagn\u00e9tica \u00e9 atenuada pela excita\u00e7\u00e3o de compostos dipolares (\u00e1gua dos tecidos, mol\u00e9culas). A atenua\u00e7\u00e3o da onda electromagn\u00e9tica \u00e9 convertida em calor (energia de abla\u00e7\u00e3o).<\/p>\n\n\n\n

MWA de n\u00f3dulos benignos da tir\u00f3ide<\/h3>\n\n\n\n

J\u00e1 com o primeiro estudo prospectivo, foi alcan\u00e7ada uma redu\u00e7\u00e3o de volume de 46 \u00b1 30% ap\u00f3s 9 meses em n\u00f3dulos benignos da tir\u00f3ide utilizando MWA refrigerado [43]. No trabalho retrospectivo com 222 pacientes e 477 n\u00f3s, a redu\u00e7\u00e3o de volume foi de 41%. A redu\u00e7\u00e3o de volume dependia da morfologia nodal. Os n\u00f3dulos c\u00edsticos mostraram uma redu\u00e7\u00e3o de volume de 80%, os n\u00f3dulos equocomplexos mostraram uma redu\u00e7\u00e3o de volume de 72% e os n\u00f3dulos s\u00f3lidos mostraram uma redu\u00e7\u00e3o de volume de 27% [44]. [45,46]As sondas MWA n\u00e3o arrefecidas mostraram uma redu\u00e7\u00e3o de volume significativa de mais de 50% ap\u00f3s apenas 3 meses. Em combina\u00e7\u00e3o com a radioterapia de radioiodo, a actividade de radioiodo necess\u00e1ria para a radioterapia podia ser significativamente reduzida em estrume muito grande, a redu\u00e7\u00e3o de volume era de 30% [47,48]. A cintilografia pode ser utilizada para verificar a efic\u00e1cia da abla\u00e7\u00e3o t\u00e9rmica numa fase precoce, antes de serem poss\u00edveis controlos do progresso volum\u00e9trico [45\u201348]. MWA tem sido utilizado para tratar com sucesso o frio benigno ou n\u00f3dulos hiperfuncionais da tir\u00f3ide [49]. [43] [45]Devido \u00e0 sonda MWA mais espessa, foi detectada uma pequena hemorragia capsular da gl\u00e2ndula tiroide, inferior a 1 mm, em 4 de 11 doentes; com as sondas MWA n\u00e3o arrefecidas, foi detectado um pequeno hematoma superficial em todos os doentes. N\u00e3o ocorreram complica\u00e7\u00f5es permanentes ou com risco de vida em nenhum estudo [43\u201345,50,51].<\/p>\n\n\n\n

MWA de met\u00e1stases linfonodais ou recidivas locais de carcinoma da tir\u00f3ide<\/h3>\n\n\n\n

No estudo prospectivo de 17 pacientes com recidivas locais de carcinoma papil\u00edfero da tir\u00f3ide, foram realizados um ou at\u00e9 quatro MWAs. A redu\u00e7\u00e3o de volume ap\u00f3s 18 meses foi de 91 \u00b1 14%. [52]Em 30% dos casos, n\u00e3o foi poss\u00edvel detetar qualquer recidiva local ap\u00f3s o tratamento e n\u00e3o ocorreram complica\u00e7\u00f5es permanentes ou com risco de vida. Num outro estudo, 21 microcarcinomas papilares de fase T1N0M0 foram tratados com MWA. Todos os microcarcinomas poderiam ser completamente abalados por meio de uma sess\u00e3o MWA. Ap\u00f3s 11 meses de acompanhamento, n\u00e3o foi encontrada nenhuma recorr\u00eancia local [53]. N\u00e3o ocorreram complica\u00e7\u00f5es permanentes ou com risco de vida.<\/p>\n\n\n\n

Ultra-som de alta concentra\u00e7\u00e3o<\/h3>\n\n\n\n

Com HIFU, a abla\u00e7\u00e3o t\u00e9rmica \u00e9 realizada de forma n\u00e3o invasiva. A sonda de ultra-sons funciona a 2 MHz e \u00e9 curvada para dentro (c\u00f4ncava). Isto faz com que o ultra-som seja focalizado e direccionado atrav\u00e9s da pele para o n\u00f3dulo tireoidiano. A abla\u00e7\u00e3o envolve o aquecimento de um volume do tamanho de um gr\u00e3o de arroz at\u00e9 cerca de 85\u00b0C. A vantagem deste procedimento termoablativo n\u00e3o invasivo \u00e9 que n\u00e3o h\u00e1 risco de infec\u00e7\u00e3o. A concavidade da cabe\u00e7a do ultra-som determina simultaneamente o grau de foco e, portanto, tamb\u00e9m a profundidade em que o efeito t\u00e9rmico ocorre.<\/p>\n\n\n

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\"\"<\/a><\/figure>\n<\/div>\n\n\n

HIFU de n\u00f3dulos benignos da tir\u00f3ide<\/h3>\n\n\n\n[54]No estudo de viabilidade de 2011, 25 pacientes foram tratados com HIFU para b\u00f3cio multinodular pela primeira vez. 16 pacientes apresentaram altera\u00e7\u00f5es significativas na ecografia e em 17 n\u00f3dulos da tiroide foram encontradas altera\u00e7\u00f5es como necrose na avalia\u00e7\u00e3o histopatol\u00f3gica subsequente. A cintilografia pode ser utilizada para verificar a efic\u00e1cia da abla\u00e7\u00e3o t\u00e9rmica numa fase precoce, antes de serem poss\u00edveis controlos do progresso volum\u00e9trico [55,56]. [55,56]A HIFU tem sido utilizada com \u00eaxito no tratamento de n\u00f3dulos benignos da tiroide, frios, indiferentes ou hiperfuncionais. A redu\u00e7\u00e3o do volume ap\u00f3s 3 meses foi de 49 a 55% ap\u00f3s um \u00fanico tratamento HIFU. [57]Num estudo prospetivo com 20 doentes, a redu\u00e7\u00e3o de volume foi de 49% .<\/p>\n\n\n\n

Preterapeuticamente, o volume m\u00e9dio do n\u00f3dulo era de 5 ml; al\u00e9m disso, as dist\u00e2ncias de seguran\u00e7a foram definidas pelo sistema, o que significava que as \u00e1reas perif\u00e9ricas do n\u00f3dulo tireoidiano estavam fora da zona de abla\u00e7\u00e3o [56\u201359]. Complica\u00e7\u00f5es permanentes ou potencialmente fatais ap\u00f3s a n\u00e3o ocorr\u00eancia da HIFU, uma tireopatia auto-imune imunol\u00f3gica tamb\u00e9m n\u00e3o \u00e9 desencadeada pela HIFU na gl\u00e2ndula tir\u00f3ide [54\u201359]. O conhecimento das diferentes t\u00e9cnicas (RFA, MWA, HIFU) com as suas vantagens e desvantagens \u00e9 elementar para uma terapia individual que utiliza abla\u00e7\u00e3o t\u00e9rmica. Estes podem ser aprendidos no DZTA – Deutsches Zentrum f\u00fcr Thermoablation e.V. (Centro Alem\u00e3o para a Termoabla\u00e7\u00e3o).<\/p>\n\n\n\n

Os custos para a terapia s\u00e3o cobertos por algumas companhias de seguros de sa\u00fade da Su\u00ed\u00e7a. Os pedidos da Su\u00ed\u00e7a podem, portanto, ser enviados para o Centro Alem\u00e3o para a Termaobla\u00e7\u00e3o e.V..<\/p>\n\n\n\n

Mensagens para levar para casa<\/strong><\/p>\n\n\n\n

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  • A termoabla\u00e7\u00e3o \u00e9 uma terapia alternativa para n\u00f3dulos benignos sintom\u00e1ticos da tir\u00f3ide e quistos sintom\u00e1ticos da tir\u00f3ide.<\/li>\n\n\n\n
  • A taxa de hipotiroidismo ap\u00f3s a abla\u00e7\u00e3o t\u00e9rmica de um n\u00f3dulo hiperfuncional da tir\u00f3ide \u00e9 inferior a 0,01%. <\/li>\n\n\n\n
  • \u00c9 necess\u00e1ria uma bi\u00f3psia conclusiva da agulha fina antes da termoabla\u00e7\u00e3o de um n\u00f3 hipofuncional. <\/li>\n\n\n\n
  • As v\u00e1rias t\u00e9cnicas RFA, MWA, LASER e HIFU podem ser utilizadas no
    Centro Alem\u00e3o de Termoabla\u00e7\u00e3o e.V. <\/li>\n<\/ul>\n\n\n\n

    <\/p>\n\n\n\n

    Literatura:<\/p>\n\n\n\n

      \n
    1. Fuller CW, Nguyen SA, Lohia S, Gillespie MB: Radiofrequency ablation for treatment of benign thyroid nodules: systematic review. The Laryngoscope 2014; 124(1): 346\u2013353.<\/li>\n\n\n\n
    2. Ha EJ, Baek JH, Kim KW, et al.: Comparative efficacy of radiofrequency and laser ablation for the treatment of benign thyroid nodules: systematic review including traditional pooling and bayesian network meta-analysis. The Journal of clinical endocrinology and metabolism 2015; 100(5): 1903\u20131911.<\/li>\n\n\n\n
    3. Lim HK, Lee JH, Ha EJ, et al.: Radiofrequency ablation of benign non-functioning thyroid nodules: 4-year follow-up results for 111 patients. European radiology 2013; 23(4): 1044\u20131049.<\/li>\n\n\n\n
    4. Baek JH, Ha EJ, Choi YJ, et al.: Radiofrequency versus Ethanol Ablation for Treating Predominantly Cystic Thyroid Nodules: A Randomized Clinical Trial. Korean journal of radiology 2015; 16(6): 1332\u20131340.<\/li>\n\n\n\n
    5. Sung JY, Baek JH, Kim KS, et al.: Single-session treatment of benign cystic thyroid nodules with ethanol versus radiofrequency ablation:
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      <\/p>\n\n\n\n

      InFo ONKOLOGIE & H\u00c4MATOLOGIE 2024; 12(3): 12\u201315<\/em><\/p>\n\n\n\n

        <\/ol>\n","protected":false},"excerpt":{"rendered":"

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