Learn about a minimally invasive way to address an exceedingly common condition in this short presentation by interventional radiologist Alexander Lam, MD. He explains when benign nodules warrant treatment, which patients are candidates for RFA, how the technique works, and what the data show on safety and efficacy.
So, hi. Uh My name is Alex Lamb. I'm one of the interventional radiologists uh at U CS F. And today, I'll be discussing radiofrequency ablation of the thyroid, a mainly invasive intervention for benign thyroid nodules. Uh So I have no relevant disclosures. OK. Um So the objectives for this talk are to discuss the epidemiology of benign power nodules present the procedural steps and workflow. Uh briefly review the literature, support our R FA and provide some guidance on patient selection and adverse events after R FA. With that in mind. Here's ya. And, and let's get started with a brief background. As we know, benign thyroid nodules are present in up to 80% of the population with the vast majority of the nodules uh being typically benign. OK. Although benign thyroid nodules can be felt and seen when they become large. A bay is a new minimally invasive technique to treat benign thyroid nodules that are symptomatic. Um So, how is it done? Um Well, R fa utilizes the moving shot technique via TRANS ISMs approach. And here's a picture from the literature depicting what I mean. In this scenario, the patient is laying flat, uh typically with the head somewhat hyperextended and under ultrasound, the probe is advanced through the isthmus into the nodule. Once in the nodule, the R fa probe is activated um burning the nodule from the inside out the probe is continuously uh moving during the procedure, creating these linear micro bubbles. These ablation units if you will and this is shown on the ultrasound image to the right um where this these uh epigenetic structures are the bubbles. OK. Ultrasound is used during the entirety of the procedure to avoid damage to the nearby vessels and nerves including the recurrent laryngeal nerve marked by D in this image, uh the middle cervical ganglion which typically kind of seen posteriorly kind of around the area of C and the vega nerves seem more laterally de marketed by letter A uh moving on to indications and contraindications. Ok. Um So who would benefit from this procedure? The simplest answer is any patients with a symptomatic thyroid nodule who's not interested in surgery or or not a candidate for surgery? Ok. Uh Symptoms often include uh difficulty breathing, shortness of breath, difficulty swallowing pain or, or pressure. Um Solely cosmetic concerns are possible. However, patients typically present with symptoms in addition to cosmetic concerns, when nodules grow large enough to become noticeable with that being said that isn't always the case. Um toxic nodules also known as autonomously functioning nodules or A FTNS for short are also appropriate candidates. Um This particularly this uh particularly patients who would like to avoid radioactive iodine um surgery or medical management. Again. However, those treatments are more of the center to center treatment options. Ok. Diving a little deeper, the ideal nodule is one that is between 2 to 3 centimeters in diameter and less than 20 CCS in volume. Beyond that size R fa can be used. However, multiple treatment options or multiple treatments may be necessary to obtain a significant size reduction uh to result in clinical improvements. Um And surgery is typically recommended for multiple nodules or diffuse the enlarged no uh thyroid also known as a goiter. However, embolization or staged ablation approach can be considered for patients who are not surgical candidates. Oh, the nodule needs to be completely visualized under ultrasound if a significant portion of the nodule is retrosternal or sub clavicular or otherwise obscured by a bone R fa may not be the best option. Um At this point, only nodules shown to be benign or proven to be benign on two separate biopsies are considered appropriate candidates. Um As I mentioned, a FTNS less than 20 CCS in size are appropriate. Um R phase R phase is less effective for larger nodules greater than 20 CCS at restoring you thyroid. So it's typically not uh not a great option in this scenario. Um Here are a list of contraindications, ok. This technology has not been tested in pregnant patients or in those with pacemakers and it's currently not indicated in those uh in those patient populations. Uh relative contraindications include malignancy. Uh a predominant cystic nodule of where ethanol ablation may be better and cheaper. Uh in patients with pre-existing, contra, lateral vocal cord palsy injury of the recurrent laryngeal nerve during an ablation can result in significant disability. Um So we have to be cautious in, in treating those patients. Ok. As we discussed, um nodules with large substernal or subcom components, um uh may not be best candidates because the nodule can be obscured by the b similarly nodules with dense calcifications uh where we're unable to truly appreciate the size of the nodule. Um may not be good candidates as well moving on to the evaluation and work flow. So ultra ultrasound is the first step um in evaluating, evaluating these nodules. OK. We can appreciate their size, their volume, their vascularity, their composition and the surrounding lymph nodes. Um And all these characteristics go into determining whether R FA is is, is a good option. OK. We need, we need two biopsies to confirm that the nodule is, in fact benign. And ideally, this is done uh 4 to 6 weeks apart, give or take. Um With that being said a caveat is that one biopsy can be sufficient for nodules that have ultrasound features that are highly specific um for benign nodule and that's your cystic spongiform nodules. Ok. Um One biopsy is also sufficient for A FTNS. OK? Because those are um typically more often than not be nine. Um So here's a typical workflow for a patient who is found to have a symptomatic thyroid technology. Ok. Patients typically present to their primary care physician first, uh who may then involve a surgeon, interventional radiologist and or endocrinologist. At this time. A multidisciplinary discussion may occur among all the relevant providers as needed and an evaluation for thyroid R fa is warranted and a referral is sent to us fir ok. From there, the IR staff ensures that ultrasound labs and at least one biopsy is documented uh prior to the clinic visits, the patient is then scheduled for evaluation in IR clinic in clinic. Uh We assess the patient's concerns whether it's cosmetic hoarseness, aphasia pain. What have you? Uh We uh we asked we discuss any prior interventions that the patient may have had. Uh we review their imaging, their labs um and their patho pathology results. We also perform a physical exam uh which can be done over zoom. But also we, we're seeing patients in person more often these days, we can evaluate the size of their nodule, the overall appearance, of course, the presence or absence of any pre-existing neurologic involvement. Ok. After that, we discuss the risks, the benefits and the alternatives to R fa. If the patient would like to proceed, we can place the order for the procedure and then if necessary, we can coordinate any kind of pretreatments for patients who are at higher risk for any kind of postablation thyrotoxicosis. And this is typically done um with our endocrinology colleagues. Um this is an outpatient procedure. It takes about an hour in length. Uh and patients can return to work in about 2 to 3 days at most. Ok. It's all done with moderate sedation with uh IV Fenty and versed. Um It's important to note that patients are still awake during the entirety of the procedure, but mildly sedate, important that they're able to communicate with us in the event that uh there's any pain um during experience during the ablation, if so, we can stop the ablation and perform any rescue maneuvers as needed. Um, her thyroid of anesthesia um with lidocaine is, is, is always provided and we use hydro dissection with essentially um 5% dextrose of water to separate the nodule from the adjacent sensitive structures such as skin, um nerves and vessels. Ok. Um The 5% dextrose and water is also used as our um uh rescue fluid as well in the event that um pain was experienced, um suggesting any kind of nerve injury. So after the procedure, the patients returns to our uh recovery room for 1 to 2 hours uh of monitoring. And so we evaluate, we monitor their vital signs, evaluate for any pain, any discomfort or any medications as needed. Uh Of course, um make sure the patient recovers appropriately from sedation. I call all my patients. Um usually within a week after the ablation just to check in, see how things are going. Uh And then I also see the patient in a formal clinic visits in one month. Um I ordered an ultrasound evaluation at three months and then I also see the patient again with an ultrasound evaluation at six and 12 months. Um So going on to efficacy and complications. Ok. So what we hope to achieve is a volume reduction between 60 to 80% at 6 to 12 months. In some studies, um a volume reduction of greatly 80% was seen at two years. Ok. Um Studies have also shown that um that there's a significant improvement in multiple quality of life surveys and that includes the SF 36 survey as well as the thyro 39 questionnaire. OK. Uh In addition, there is no significant impact on outcomes or safety of future thyroidectomy after R A. So that means that we don't burn any bridges in the event that um the patient would like to pursue thyroidectomy. Um, down the line compared to surgery. Dr Fa has been shown to have a few notable benefits including greater patient satisfaction, improved post-operative quality of life, fewer complications, uh shorter hospital stay, a lower incidence of uh hypothyroidism and lower cost. And there is however, a a slower volume reduction which makes sense, right? Because when after a thyroidectomy, the thyroid tissue is no longer present. However, after an ablation takes around 3 to 6 months for the uh nodule to decrease in size to shrink. Um Overall, this, this procedure is very well tolerated and very safe. OK. Um, there's an overall comp uh risk of complication, uh up to about 5% in the literature. OK. That includes transient nerve injury, uh resulting in hoarseness, nausea, rupture, transient, hypothyroidism or hyperthyroidism, hematoma or pain. Ok. Um, there's also an instance of nodule regrowth of about 5% at a meantime, interval about 22 months. It's not really complication, but it's important to know that the nodules may um increase over time. Uh If this were to happen, if this were to happen, a repeat of operation uh has been found to be safe. Uh So in summary, uh R fa is a novel, minimally invasive intervention for symptomatic benign thyroid nodules. It's safe and effective with a few significant benefits compared to surgical thyroidectomy. Ok. Uh And brief I over a quick case, a 52 year old female with a benign left thyroid nodule. She has symptoms of dystasia and hoarseness. Uh The patient was not interested in any surgery. She did not want the scar. She had a very uh busy life. She didn't wanna be um incapacitated for, for, for a week or so. She wanted an R FA. Uh So here are just images from the procedure. You can see the trans dismissed approach. There's our probe, um kind of uh being guided into the nodule. Um Here's the beginning of our ablation and you can see the um eogene bubbles uh within the thyroid nodule as we pull back the, the uh the probe. OK. And here's our in conclusion, showing the micro bubbles dispersed throughout the nodule uh in this patient in this case, but a decrease in volume around 40% and vascularity at one month, as you can see here, OK. Um Size continued to decrease over the course of multiple months, eventually reaching about 76%. Uh but hoarseness and dystasia was essentially resolved at one month. Um And that was a great a and so here are some information, you know, if you're interested or have a patient who's interested, feel free to call the number to our uh to use for interventional radiology. Again, I'm um Alex Lam and thank you for your attention.
