Thyroid Embolization for Graves' Disease
First American Patient Travels To China for Treatment
Nov 3, 2008
Thyroid arterial embolization is a procedure in which the arteries leading to the thyroid gland are blocked. This interferes with the thyroid gland’s ability to produce thyroid hormone. Embolization techniques are approved in the United States for parathyroid gland and hepatic surgeries. At this time, there are no American physicians certified to perform thyroid arterial embolization.
Who Qualifies?
Arterial embolization is used in Graves’ disease patients with severe hyperthyroidism who cannot tolerate or who prefer not to use conventional treatment methods (radioiodine ablation, thyroidectomy, or anti-thyroid drugs). Arterial embolization is also used in patients whose severe hyperthyroidism puts them at risk for surgery or ablation.
Early Studies
Dr. Xiao and his team have previously worked in conjunction with physicians in Alberta, Canada to treat severe hyperthyroidism with embolization. In a study of 22 patients with Graves’ disease, 6 of the patients who became euthyroid were in sufficient control to have thyroidectomy surgery three weeks later.
During the 27-month observation period of the remaining patients, all became euthyroid except for 2 patients who needed to remain on anti-thyroid drugs. Overall, patients experienced a reduction of from one-third to one-half their initial thyroid volume.
In a related study, Dr. Xiao and his team treated 41 Graves’ disease patients with arterial embolization and observed them for a period of 54 months. In this study, Dr. Xiao monitored thyroid antibody levels and levels of lymphocyte markers.
Outcome
Thyroid tissue studies from the patients who had embolization followed by surgery showed that embolization blocked both the superior and inferior thyroid arteries as well as most of their branches. Similar to what is seen after radioiodine ablation, evidence of chemical inflammation, necrosis, and fibrosis were observed in the embolized thyroid tissue. Although thyroid antibody production is greatly increased after radioiodine ablation, Dr. Xiao’s studies showed that levels of thyroid peroxidase (TPO), total TSH receptor (TRAb), thyroid stimulating immunoglobulin (TSI), and thyroglobulin antibodies fell in patients who had arterial embolization.
The Chinese researchers concluded that thyroid arterial embolization could effectively decrease the activity/titer and positive rate of total TSH receptor antibodies and the ratio of CD4+/ CD8+ to normal levels at 6 months following embolization. In addition, the ratio of CD3+CD8+ increased gradually to normal level at 1 year following embolization. In patients who showed evidence of recurrence, TSI and TRAb remained at a higher level, while the rate of CD3+CD8+ and the ratio of CD4+/CD8+ were not statistically significantly different from those before embolization. The results of tissue studies and clinical follow-up suggest that arterial embolization is an effective, minimally invasive treatment for patients with Graves’ disease.
The Patient Experience
The first American patient to have thyroid embolization in China, Ms. Stella, a retired nurse, had severe hyperthyroidism. Her doctors in the United States advised her that she would die within a year without treatment. However, she was unable to tolerate any of the available conventional treatments.
She first contacted the Alberta team who had been doing thyroid embolizations. She found that because their radiologist had retired, they had temporarily suspended the program. She then contacted Dr. Xiao in China and arranged to travel there and have him perform the procedure. She qualified for embolization because she had stable, although markedly elevated, thyroid hormone levels, and no evidence of any blood disorders or liver disease. Upon arrival in China, she had an electrocardiogram and ultrasounds of her liver and kidneys to ensure that she was a good candidate.
Because of her risk for thyroid storm, Ms. Stella could not have a general anesthetic. She remained awake for the procedure, which she watched through televised monitors. She reports that dye was injected to enable visualization of the arteries. A small incision was then made in the femoral artery and catheters were threaded through the superior arteries. After the procedure, Ms. Stella had minor symptoms of low-grade fever and sore throat, which were treated with antibiotics, prednisone and anti-inflammatory agents. Her thyroid hormone levels rose temporarily and were appropriately treated. As with radioiodine, levels of thyroid hormone can rise and stay elevated for several weeks after embolization.
The cost of the procedure, including diagnostic tests and hospital stay, came to approximately $7,000. Although Ms. Stella paid for the procedure, she is working with her insurance company to see what portion of the bill they will reimburse her for. Ms. Stella continues to do well although it's too soon to assess the final outcome of her procedure.
Future Prospects
Ms. Stella reports that Dr. Xiao is willing to come to the United States to train other physicians to perform this procedure. Ideally, he would like to come to a major medical college and work with a team there. In the meantime, other Graves’ disease patients willing to travel to China may want to see if they’re good candidates for arterial embolization. For more information, contact author.
Resources:
Haipeng Xiao, Wenquan Zhuang, Shenming Wang, Binjie Yu, Guorui Chen, Muheng Zhou and Norman C. W. Wong, Arterial Embolization: A Novel Approach to Thyroid Ablative Therapy for Graves’ Disease, The Journal of Clinical Endocrinology & Metabolism Vol. 87 (8): 3583-3589.
W Zhao, BL Gao, CZ Jin, GF Yi, H Yang, H Li, D Song, J Hu, ad Y Jiang, Long-term immunological study in Graves' disease treated with thyroid arterial embolization,
J Clin Immunol. 2008 Sep;28 (5):456-63. Epub 2008 Jul 17.
Private correspondence with V. Stella, Oct 23, 2008.
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