Ultrasound-Guided Radiofrequency Ablation of Thyroid Nodules

Radiofrequency ablation of thyroid nodules has been around for about 15 years now.  It has been performed in several European countries for several years and is now available in the United States.  The term "radiofrequency ablation" refers to processed in which the tissue is destroyed by heat.  During thermal ablation, a probe is introduced into the nodule under the guidance of ultrasound.  The nodes are destroyed by selectively heating the probe tip.  Since there are no nerve fibers in the nodules, the procedure can be performed under local anesthesia.  It is relatively painless. Once the tissue is broken down, it shrinks between 60-90% the first year.

There are many advantages of this procedure:

• This is a minimally invasive procedure with little to no scarring.
• The procedure lasts 15 - 60 minutes.
• Since healthy tissue is not destroyed during this procedure, the use of thyroid medications is not expected afterwards.
• The procedure is highly effective.  The reduction in size for a nodule is typically between 60-90% after one year.
• This procedure has a very low complication rate.  Damage to the vocal cord nerve or parathyroid corpuscles are not expected.

As with any medical procedure, there are potential complications, although very rare, from having the RFA procedure which could include:

• change in voice
• hematoma 
• skin burn at the puncture site
• thyrotoxicosis
• hypothyroidism
• edema
• fever

Although very rare, an inpatient stay or follow-up treatment may become necessary if a complication presents during or after the procedure.

• Patients with benign thyroid nodules causing symptoms 
• Patients who cannot or choose not to undergo surgery. 
• Patients with rapidly growing thyroid nodules or cysts that are benign
• Nodules that produce excess thyroid hormone when radioactive iodine treatment is not preferred. 
• Visually disturbing thyroid nodules
• Any nodule considered for RFA must be confirmed by biopsy to be benign. 

• Someone who has undergone prior surgery, radiation, or sclerosing (scar forming) therapy to the thyroid or thyroid area of the neck as this causes altered anatomy increasing the risk of damage to  non-thyroid  tissue. 
• Individuals with implantable pacemakers or defibrillators.
• Individuals with extremely small thyroid nodules.
• Individuals who have sonographic features of their nodules that are suspicious for cancer unless additional studies have been performed to verify benign status of the nodule.
• Individuals who have had  previous damage to their vocal cord.
• Pregnant patients.
• Patients with severe heart disease.
• Patients taking chronic anticoagulants or blood thinners that can not briefly discontinue these medications for the procedure.

When thyroid tissue is exposed to temperatures in excess of 64 degrees celsius, it is permanently destroyed.  This is very similar to boiling an egg.  The special defense cells of the body break down the dead nodule tissue, which leads to the shrinking of the nodules.  Typically, we see 40-60% after 3 months and around 60-90% after 1 year.  Residual connective tissue is the only remnant of the former nodule.  Any surrounding healthy tissue remains untouched and will continue to produce hormones.  This means that daily intake of tablets is not necessary following the procedure.  

RFA requires local rather than general anesthesia and is relatively painless. RFA does not affect energy levels, and allows the patient to resume most normal activities within a day of the procedure. 

Fewer complications

Preservation of thyroid function

Because the procedure is minimally invasive and does not require general anesthesia there is no scarring and no associated general anesthesia risk. 

RFA also minimizes the risk of permanent damage to the vocal cord nerves or to the parathyroid glands. 

One of the most meaningful advantages of the procedure is that long term thyroid medication is not needed. The treatment preserves healthy thyroid tissue allowing the gland to continue functioning normally. No ongoing medication management is necessary. 

One treatment will sufficiently decrease the average size nodule. Repeated procedures may be necessary for very large nodules or nodules close to vocal cord nerves. 

Untreated areas of hormone producing nodules may interfere with the improvement in thyroid function. Complete ablation is then required, and more than one treatment may be necessary. 

The procedure is so gentle that most people have little to no discomfort. The thyroid gland itself is not sensitive to pain, and the skin and surrounding area of the thyroid gland are anesthetized for the procedure. Only 2-3 % of patients experience discomfort. This is usually a temporary burning sensation similar to that experienced during dental procedures. In the event of severe discomfort the procedure will be interrupted and anesthetic will be injected again until there is no pain. 

The patient will be able to breathe and talk the entire time and will be able to converse with the doctor during the procedure. 

Two grounding pads will be attached to the thighs. 

The patient will be covered with sterile cloths and antiseptic will be applied to the neck. The patient’s head will rest on a small cushion. 

The doctor will use a very thin needle to place a local anesthetic under the skin in the area surrounding the thyroid gland. 

The patient will be monitored for about an hour rafter the procedure and discharged with any necessary prescriptions. Certain activities will need to be limited for three days. These include:

• Lifting objects over 10 lbs.
• Strenuous physical activities
• Activities that involve holding ones breath such as playing a wind instrument or inflating objects. 
• Singing, shouting or over stressing the voice. 

The procedure is typically performed in our office in an exam room.  Using ultrasound guidance, the doctor inserts a probe into the thyroid nodule. The probe generates radio frequency energy which destroys the nodule. The body then breaks down the treated tissue. 

The procedure itself takes between 15 to 60 minutes depending on the number or volume of nodules.  After the treatment, a chilled bag is placed on the treated area with light pressure.  We will monitor you for at least 30 minutes following the procedure to be sure there are no complications.  Prescription pain medication is generally not required. Please have a driver available to take you home after the procedure.  Driving yourself home is not recommended.  

We recommend that our patients set aside approximately 3 hours on the day of the treatment.  

Studies done in Asia and Europe have typically shown at least a 50 percent reduction in nodule size over 6-12 months from undergoing the procedure. 

At this time, most insurance companies do not cover the cost of the RFA procedure.  This would be an out-of-pocket expense for the patient.  Please contact our office to schedule a consultation with Dr. Michael and learn more about the costs associated with this procedure.

Typically, we treat nodular cysts with percutaneous ethanol instead of RFA.  Feel free to contact our office to schedule a consultation with Dr. Michael to learn more about this procedure.

For at least three days following your procedure, you should avoid:

• Lifting of heavy objects over 10 lbs
• Strenuous physical activity and exercise
• Any activities that involve holding your breath
• Overstressing your voice (singing, shouting)
• Taking a full body bath on the evening of the procedure.  Showering with the treatment area covered with waterproof plaster is ok, however.

RFA is highly effective. Depending on the type, nodules shrink 60-90 percent after one year. Clinical trials have shown that non- functioning benign nodules shrank by 51-85 % within six months.  In most patients nodule related symptoms significantly improved or disappeared. In a long term follow up study, nodules consistently decreased by 93 %. 

Clinical trials have shown that hormone producing benign nodules shrank 53-71 % at 6 months. Blood hormone levels completely normalized in 82 % of patients who no longer required medication. This normalization led to the conclusion that RFA is an effective alternative treatment to surgery and radioactive iodine therapy. 

A study of approximately 1500 patients showed an overall complication rate of 3.3%. The major complication rate was 1.4%

While uncommon, complications can be:

• Temporary hoarseness
• Slight bleeding, generally disappearing within a few days.
• Wound infections
• In rare cases, vomiting, cough, or seared skin at the puncture site. 
• Patients with hormone producing nodules may rarely develop hypothyroidism. Although rare, a complication could require an inpatient hospital stay or follow up treatment. 

Ablation takes place in an outpatient setting and the patient will need to follow some pre-procedural instruction from the health care facility. The patient’s current medication list will be reviewed and appropriate instruction provided. No makeup or metal jewelry can be worn on the day of the procedure. 

In the final analysis RFA is an attractive alternative for patients who experience problems caused by benign thyroid nodules. It is a safe and FDA approved procedure less pain, less down time and no scarring. With its long lasting effects RFA is a breakthrough in treating symptoms related to thyroid nodules.