Preservation of normal thyroid function is paramount even if a patient has large and symptomatic thyroid nodules. Large thyroid nodules cause symptoms from compression of adjacent tissue. A non- surgical alternative to thyroidectomy and radio- iodine ablation is now available for effective treatment of large benign nodules. With RFA, tissue volume reduction and symptom relief are accomplished through pinhole incisions with long term protection of normal thyroid function. Symptomatic patients and patients with visible enlargement are candidates for this alternative therapy to surgery.
Multinodular goiter
60% size reduction
Patients who have large nodules (over 2 cm) which have been identified by CT scan or ultrasound and who have symptoms of compression. One or many individual ultrasound guided FNA biopsies of the nodules are necessary. These biopsies must demonstrate benign pathology.
Larger nodules become more symptomatic as they push against the esophagus and trachea. This may cause difficulty with breathing and swallowing. Additionally, nodules producing excessive thyroid hormone cause many other symptoms and health problems.
Thyroid nodules proven to be benign with several biopsies which are over 2 cm and not below the clavicle. All nodules studied with ultrasound should have a benign appearance, and all prominent nodules present should be individually biopsied. Nodules should not be larger than 80 ml
Hypothyroid patients are not ideal candidates for RFA thyroid. Prior thyroid surgery patients already have a neck incision. Those with indeterminate biopsies (AUS or FLUS) without genetic testing will require further testing. Thyroid cancer patients and those with follicular lesions are not currently candidates for RFA thyroid at the Thyroid Nodule Treatment Center
Unless the nodule is an autonomous functioning nodule (rarely malignant), two individual biopsies are required to conclude that a lesion is not cancer. With Thyroid RFA the nodule is not removed and sent to the pathologist for analysis. After RFA therapy, surveillance ultrasound might identify irregularities within the nodule which could be interpreted as suspicious. This interpretation may prompt further biopsies. Tissue cytology may look more atypical after RFA treatment . For that reason the assurance of benign thyroid tissue is critical prior to therapy.
Pregnancy, active coronary disease, prior neck irradiation, prior thyroid or lymph node malignancy, and anti-coagulation therapy. Thyroid nodules extending deep to the clavicle are only partially treated with this approach.
Some patients have hyperthyroidism related to a nodule with autonomous function (AFTN). Autonomously functioning thyroid nodules can create symptoms of fatigue and rapid heart rate. The determination of AFTN is optimally made with an I131 Iodine Uptake Scan to show increased iodine uptake in the nodule compared to the remainder of the gland. This alternative therapy destroys these nodules with RFA, avoiding both surgery and hypothyroidism. Restoration of normal thyroid function is accomplished in most patients. No daily thyroid medications are required after Thyroid RFA of AFTNs!
Hyperthyroidism caused by Grave’s disease is not managed with this therapy.
On the day of the treatment we do not advise returning to work. The day after your therapy you will be examined to inspect the treated area with ultrasound. You may return to work following that brief visit.
In patients who have one sided disease less than 50 ml of thyroid nodule volume, one treatment is very successful. For safety reasons, patients who have two sided disease will require two separate treatment sessions. Patients who have disease greater than 50 ml may elect to undergo surgery or can be treated in two sessions about 12-18 month apart.
A wide-field cervical nerve plexus block is performed with a local anesthetic. This field block is performed using local anesthesia and US guidance. This effectively numbs the anterior neck and capsule of the thyroid where the nerves are present. Because the internal aspect of the thyroid gland has no sensation, the treatment can be performed with little pain.
Optimal therapy includes communication with the patients during the procedure. General anesthesia is less desirable because the patient cannot speak. Under local anesthesia, we are still able to converse with the patient to assess the quality of the voice. Although rarely necessary, interventions to protect the recurrent laryngeal nerve can be initiated should the patient’s voice becomes weak or hoarse.
Usually oral Tylenol and/or Ibuprofen are adequate after ablation. Taking a mild anti-anxiety, anti-spasm medication tablet such as Valium prior to the procedure can improve the level of comfort during the procedure as well.
The effectiveness if therapy is measured by nodule volume reduction and preservation of normal thyroid function. The international data for nodule reduction has been overwhelmingly favorable for nodule reduction during the immediate months after therapy. We aim for a 60% reduction in volume at 3 months and a 90% volume reduction in one year. The success of the ablation is determined by the amount of energy delivered in each nodule as well as the precision of the application. Expertise in ultrasound guided therapies is a required to perform these challenging procedures.
Therapy decisions after a thyroid biopsy may be complex. The evaluation of tissue on slides may not always determine if the tissue is benign. Surgical removal of the nodule for complete analysis is appropriate therapy. For patients interested in a nonsurgical approach, the indeterminate nodule can be further studied with genetic classification testing. This is an added expense and may determine if a nodule is benign. The appropriateness of RFA therapy can be considered. Some nodules may still require surgery in order to assess for malignancy. If a scar-less approach is preferred, than Dr. Harding can discuss an endoscopic technique to remove the thyroid gland which leaves no visible scars. Currently he is the only surgeon in Arizona who is trained and experienced with this endoscopic trans-oral approach.
Radiofrequency ablation (RFA) is a targeted therapy which uses electric energy and heat to destroy the abnormal tissue. RAI is Radioactive Iodine therapy which involves ingesting the radioactive tablet containing the radioactive iodine. This is taken up by all thyroid tissue including the enlarged and hyperfunctioning nodule. The radioactive energy destroys the genetic elements in all thyroid cells and eventually destroys the tissue. Hypothyroidism is a common problem after RAI, but not RFA.
