European Radiology

, Volume 29, Issue 3, pp 1469–1478 | Cite as

Role of second high-intensity focused ultrasound (HIFU) treatment for unsatisfactory benign thyroid nodules after first treatment

  • Brian Hung-Hin LangEmail author
  • Yu-Cho Woo
  • Keith Wan-Hang Chiu



We aimed to assess the efficacy and safety of second high-intensity focused ultrasound (HIFU) ablation treatment in benign thyroid nodules that had failed to shrink by > 50% 6 months after the first treatment.


Twenty-eight patients who did not achieve 50% volume reduction at 6 months after the first HIFU treatment underwent a second HIFU treatment. Nodule volume was measured on ultrasound at baseline, 3 months and 6 months. Extent of nodule shrinkage (by volume reduction ratio) (VRR) = [Baseline volume – volume at 6 months]/[Baseline volume] * 100. Treatment success was defined as VRR > 50%. Obstructive symptom score (by 0–10 visual analogue scale, VAS) was evaluated for 6 months after treatment.


No complications occurred after the second treatment. The mean 6-month VRR was 21.78 ± 16.87% with a median (range) of 16.16 (1.63–54.07)%. At 6 months, only two (7.1%) patients achieved treatment success, while nine (32.1%) patients had VRR < 10%. However, relative to baseline (3.96 ± 1.04), the mean VAS significantly improved at 3 and 6 months (2.96 ± 1.43, p<0.001 and 2.58 ± 1.39, p<0.001, respectively). There was a significant correlation between VRR and improvement in VAS score at 6 months (ρ=0.438, p=0.025). Greater nodule volume before the second treatment (OR=1.169, 95% CI=1.004–1.361, p=0.045) was a significant factor for greater VRR after the second treatment.


Although subjective obstructive symptoms continued to improve after the second treatment, the actual extent of nodule shrinkage was small. Larger-volume nodules tended to shrink more significantly than smaller-volume nodules in the second treatment.

Key Points

Second treatment resulted in small shrinkage in unsatisfactory nodules after first treatment.

• Obstructive symptoms tended to continue to improve after second treatment.

• Larger-size nodules tended to respond better in the second treatment.


Interventional ultrasonography High-intensity focused ultrasound ablation Treatment efficacy Ultrasound imaging Ablation techniques 



High-intensity focused ultrasound


Thyroid stimulating hormone




Vocal cord palsy


Volume reduction ratio



We would like to thank Mr. Hill Yu and Ms. Li Wing Kar for conducting all the symptom (or VAS score) assessments for the entire study period and Professor Stephen Cheng (Head of Department of Surgery, University of Hong Kong) for agreeing to be the guarantor of this paper.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Professor Stephen Cheng (Head of Department).

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective

• Observational

• Single institution


  1. 1.
    Gharib H, Papini E, Garber JR et al (2016) P. AACE/ACE/AME Task Force on Thyroid Nodules. 2016 American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the diagnosis and management of thyroid nodules - 2016 Update. Endocr Pract 22(5):622–639Google Scholar
  2. 2.
    Haugen BR, Alexander EK, Bible KC et al (2016) 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 26:1–133CrossRefGoogle Scholar
  3. 3.
    Durante C, Costante G, Lucisano G et al (2015) The natural history of benign thyroid nodules. JAMA 313(9):926–935CrossRefGoogle Scholar
  4. 4.
    Korkusuz Y, Gröner D, Raczynski N et al (2018) Thermal ablation of thyroid nodules: are radiofrequency ablation, microwave ablation and high intensity focused ultrasound equally safe and effective methods? Eur Radiol 28(3):929–935Google Scholar
  5. 5.
    Pacella CM, Mauri G, Cesareo R et al (2017) A comparison of laser with radiofrequency ablation for the treatment of benign thyroid nodules: a propensity score matching analysis. Int J Hyperthermia 33(8):911–919Google Scholar
  6. 6.
    Dietrich CF, Müller T, Bojunga J et al (2018) Statement and Recommendations on Interventional Ultrasound as a Thyroid Diagnostic and Treatment Procedure. Ultrasound Med Biol 44(1):14–36CrossRefGoogle Scholar
  7. 7.
    Mauri G, Sconfienza LM (2016) Percutaneous ablation holds the potential to substitute for surgery as first choice treatment for symptomatic benign thyroid nodules. Int J Hyperthermia 33(3):301–302CrossRefGoogle Scholar
  8. 8.
    Korkusuz H, Fehre N, Sennert M, Happel C, Grünwald F (2015) Volume reduction of benign thyroid nodules 3 months after a single treatment with high-intensity focused ultrasound (HIFU). J Ther Ultrasound 3:4. CrossRefGoogle Scholar
  9. 9.
    Kovatcheva RD, Vlahov JD, Stoinov JI, Zaletel K (2015) Benign Solid Thyroid Nodules: US-guided High-Intensity Focused Ultrasound Ablation-Initial Clinical Outcomes. Radiology 276(2):597–605CrossRefGoogle Scholar
  10. 10.
    Lang BH, Woo YC, Wong CKH (2017) High-Intensity Focused Ultrasound for Treatment of Symptomatic Benign Thyroid Nodules: A Prospective Study. Radiology 284(3):897–906Google Scholar
  11. 11.
    Trimboli P, Bini F, Marinozzi F, Baek JH, Giovanella L (2018) High-intensity focused ultrasound (HIFU) therapy for benign thyroid nodules without anesthesia or sedation. Endocrine.
  12. 12.
    Bini F, Trimboli P, Marinozzi F, Giovanella L (2018) Treatment of benign thyroid nodules by high intensity focused ultrasound (HIFU) at different acoustic powers: a study on in-silico phantom. Endocrine 59(3):506–509CrossRefGoogle Scholar
  13. 13.
    Lang BH, Woo YC, Chiu KW (2017) Single-Session High-Intensity Focused Ultrasound Treatment in Large-Sized Benign Thyroid Nodules. Thyroid 27(5):714–7214CrossRefGoogle Scholar
  14. 14.
    Lang BHH, Woo YC, Chiu KW (2018) Significance of hyperechoic marks observed during high-intensity focused ultrasound (HIFU) ablation of benign thyroid nodules. Eur Radiol 28(6):2675–2681CrossRefGoogle Scholar
  15. 15.
    Lim HK, Lee JH, Ha EJ, Sung JY, Kim JK, Baek JH (2013) Radiofrequency ablation of benign non-functioning thyroid nodules: 4-year follow-up results for 111 patients. Eur Radiol 23(4):1044–1049CrossRefGoogle Scholar
  16. 16.
    Huh JY, Baek JH, Choi H, Kim JK, Lee JH (2012) Symptomatic benign thyroid nodules: efficacy of additional radiofrequency ablation treatment session--prospective randomized study. Radiology 263(3):909–916CrossRefGoogle Scholar
  17. 17.
    Cibas ES, Ali SZ, NCI Thyroid FNA State of the Science Conference (2009) The Bethesda System For Reporting Thyroid Cytopathology. Am J Clin Pathol 132(5):658–665Google Scholar
  18. 18.
    Zimmermann M, Saad A, Hess S, Torresani T, Chaouki N (2000) Thyroid ultrasound compared with World Health Organization 1960 and 1994 palpation criteria for determination of goiter prevalence in regions of mild and severe iodine deficiency. Eur J Endocrinol 143(6):727–731CrossRefGoogle Scholar
  19. 19.
    Wong KP, Lang BH, Ng SH, Cheung CY, Chan CT, Lo CY (2013) A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy. Surgery 154(6):1158–1164CrossRefGoogle Scholar
  20. 20.
    Giovanella L, Piccardo A, Pezzoli C et al (2018) Comparison of high intensity focused ultrasound and radioiodine for treating toxic thyroid nodules. Clin Endocrinol (Oxf).
  21. 21.
    Piana S, Riganti F, Froio E, Andrioli M, Pacella CM, Valcavi R (2012) Pathological findings of thyroid nodules after percutaneous laser ablation: a series of 22 cases with cyto-histological correlation. Endocr Pathol 23(2):94–100CrossRefGoogle Scholar
  22. 22.
    Negro R, Salem TM, Greco G (2016) Laser ablation is more effective for spongiform than solid thyroid nodules. A 4-year retrospective follow-up study. Int J Hyperthermia 32(7):822–828CrossRefGoogle Scholar
  23. 23.
    Papini E, Rago T, Gambelunghe G et al (2014) Long-term efficacy of ultrasound-guided laser ablation for benign solid thyroid nodules. Results of a three-year multicenter prospective randomized trial. J Clin Endocrinol Metab 99(10):3653–3659CrossRefGoogle Scholar
  24. 24.
    Spiezia S, Garberoglio R, Milone F et al (2009) Thyroid nodules and related symptoms are stably controlled two years after radiofrequency thermal ablation. Thyroid 19(3):219–225CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of SurgeryThe University of Hong KongHong KongChina
  2. 2.Department of SurgeryQueen Mary HospitalHong KongChina
  3. 3.Department of MedicineThe University of Hong KongHong KongChina
  4. 4.Department of RadiologyThe University of Hong KongHong KongChina

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