Dr.Guttler’s comments:

1. Despite the increasing evidence of safety and efficacy of EA and RFA for benign thyroid nodules, there is still a large variation in the application of the different available techniques among different countries [9], and not uniform knowledge among patients and referring physicians.

2. EA and RFA are considered as minimally-invasive because they do not require any general anesthesia, or surgical incision, or the removal of healthy thyroid tissue, thus allowing for a minimal impact on patients while providing an effective treatment of the disease.

3.Given that they are provided under the guidance of ultrasound, EA and RFA are also called “ultrasound-guided treatments”.

4.In case of EA, and RFA, a small probe (21–17G) is inserted through the skin into the thyroid nodule to be treated, whereby ethanol or thermal energy are delivered directly into the nodule, to determine cellular death.

5.EA or RFA are indicated when thyroid nodules become symptomatic and cause local discomfort or cosmetic concerns.

6. They can be taken into account also in nodules that tend to grow, provided that they are cytologically benign.

7.RFA can be used to treat autonomously functioning nodules, and -in this case- it is particularly effective for small (<10 ml) nodules.

8. Patient refuse surgery for micropapillary thyroid cancers can be treated with RFA.

9.EA is the preferred technique to use in case of cystic or predominantly cystic thyroid nodules, because it has fewer side effects and lower costs as compared to the other techniques.

10.RFA is indicated for the treatment of spongiform, predominantly solid, or solid nodules.

11.How is ethanol ablation (EA) of a thyroid cystic nodule performed? EA consists of the injection of ethanol into a cystic (or a predominantly cystic) nodule, once its liquid content has been aspirated.

12.EA is an outpatient procedure. The patient lies on the operating table with the neck extended, and under ultrasound guidance local anesthesia is performed. Then, the thyroid cyst is punctured under continuous ultrasound visualization, and the cystic fluid is aspirated to the maximum extent possible. Once the fluid component has been aspirated, ethanol is slowly injected into the cystic cavity. Usually, ethanol is injected in an amount corresponding to ~50% of the aspirated liquid volume. After EA, a small plaster is applied to the neck, and the patient remains under observation for about 30 min before returning to activity.

13.How is a thermal ablation RFA of a benign thyroid nodule performed? RFA consists of the ablation of a solid (or predominantly solid) nodule with the application of thermal energy to the nodule.

14.RFA procedures are performed in an outpatient setting, without the use of general anesthesia. Local anesthesia is generally used.

15. During the procedure, the patient should lay on the operating table with the neck extended. Under ultrasound guidance the operator injects a small amount of local anesthetic around the thyroid capsule and into the surrounding soft tissues of the neck.

16. With RFA a single device is inserted into the nodule, and moved several times to achieve ablation of the whole nodule (moving-shot technique)

17.According to the volume of the nodule and the technique used, the ablation can last from few minutes to up to 30 minutes approximately. 

18.During the procedure, the patient can speak to the operator, and the ablation can be stopped immediately in case of discomfort or pain.

19.In general, patients can return to their usual activities the day after the intervention.

20. The only special precautions that must be taken before the procedure concern patients with voice changes, previous neck surgery, patients on oral anticoagulants or antiplatelet drugs, and patients with pacemakers or implantable-cardioverter defibrillators (in case RFA is performed with monopolar electrodes).

21.Particularly, before the procedure, thyroid and vocal cord function, comorbidities, and contraindications to treatment should be evaluated; laryngoscopy is recommended in patients with hoarseness, previous neck surgery, or with nodules close to critical structures.

22.Although MITT carry a low risk of major bleeding, oral anticoagulants or antiplatelet drugs can lead to prolonged bleeding or bruising. Before the procedure, it is recommended withholding oral anticoagulants.

23.Patients with a high-intermediate thromboembolic risk require bridging warfarin with low molecular weight heparin, while patients with low thromboembolic risk do not.

24.New oral anticoagulants, which include dabigatran, rivaroxaban, apixaban, and edoxaban, should be hold for 24–36 h and can be safely resumed 24 h after the procedure.

25.RFA performed with monopolar electrodes may cause electromagnetic interferences, as the heat at the tip of the electrode is produced by an alternating electric field, which might interfere with cardiac pacemakers (PM) or implantable-cardioverter defibrillators (ICD) functions.

26. In patients with a cardiac activity that is Pacemaker-dependent, the operator should place a magnet over the device and peripheral pulse should be monitored during the procedure.

27.. The magnet placed over the cardiac region is considered to be safer than any PM reprogramming, as it allows an immediate restoration of the PM functions after the procedure.

28.What may a patient expect after the procedure? Patients may briefly experience mild pain in the days following the treatment; which usually extends as far as the jaw and can be relieved by oral painkillers.

29. Apply an ice pack on the neck with mild pressure, and to keep the patient under observation for a couple of hours.

30.A minority of patients (~10%) may experience neck pain with sensation of local heat sometimes radiating to the jaw, ipsilateral dental arch, mandibular angle, or shoulder.

31.Recommended avoiding strenuous physical exercise, as well as overextending the throat in the first few days after MITT in order to support the healing process.

32.What happens to the nodule? With EA, due to the aspiration of the fluid component, the nodule is immediately reduced in size after the treatment, with an immediate improvement of patients’ symptoms.

33. It achieves a volume reduction of 60 to 80% at 6 months from treatment.

33.The nodule might appear even slightly enlarged due to the edema occurring after the RFA treatment, and patients might not experience an immediate benefit.

34.The nodule continues to decrease in size, with a parallel symptom improvement, up to its maximum volume reduction, which is usually achieved between 6 and 24 months after the treatment.

35.The technique efficacy of RFA is generally achieved in as much as 90% of cases.

36.Which side effects and complications might occur? The overall likelihood of modest or severe complications is low, and -when occurring- complications are in the vast majority of cases of minor entity. The most common complications and side effects are bruising and mild pain in the neck. The risk of scarring is minimal. In exceptional cases, there may be temporary hoarseness or nodule rupture and infections.

37.Side effects (7–30%) include: pain, bruising, fever, nodule swelling, cough, and vasovagal reactions.

37.Immediate complications include: hoarsenes/voice changes, and skin burns.

38.Delayed complications include: bruising, nodule pseudocystic transformation (also known as nodule rupture) with or without fasciitis, and thyroid dysfunction.

39.Hoarseness/voice changes occur in 0.8–2.4% of patients. They can be due to the thermal injury to the laryngeal nerve or to its compression caused by perinodular edema and generally they resolve spontaneously with the administration of corticosteroids.

40.Cold solution of 5% dextrose may be injected close to the nerve route as a rescue maneuver.

41. The risk of skin burn is extremely low [27, 30, 33]. In order to avoid it, it can be useful to inject cold fluid in the subcutaneous layers in order to create a cushion that will raise the skin and increase the distance from the nodule.

42.Bruising occurs in 0.8–2.5% of patients, and generally it appears within a couple of hours-days after the procedure, disappearing in a few days-weeks.

43.. Pseudocystic transformations/nodule rupture occur in 0.3–4.9% of patients. They manifest as a painful sudden swelling a few days after the procedure.

44. In case of fever and persistence of symptoms, patients should be treated with antibiotics and analgesics.

45.Can the nodule regrow after the procedure? After MITT, the treated nodule usually shrinks and changes US features, but a small “remnant” nodule remains. Over time, some nodules might regrow. Regrowth is often asymptomatic and does not necessarily require further treatments.

46.Based on the literature, regrowth (which should be defined as a > 50% increase as compared to the smallest recorded volume) occured in as much as one third of patients in a retrospective 5-year analysis.

47.Regrowth is often asymptomatic and does not require further treatments. In case of rapid nodule regrowth, clinicians might consider US-guided FNAC.

48.Thyroid nodules can be treated more than once with RFA.In particular, it has been suggested that one session is enough for small nodules, while 2 or 3 sessions may be required for medium or large size nodules.

49.However, the decision of performing more than one EA or RFA session should be based on patient’s complaints (symptoms and cosmetic concerns) rather than the amount of nodule volume reduction, and it should be limited to patients with unresolved clinical problems.

50.Will the procedure impact on future thyroid surgery? The surgical removal of thyroid nodules appears to be minimally impacted by EA or RFA.

51.What are the pros and cons of EA and RFA in comparison to surgery? They are outpatient procedures with good efficacy, minimal recovery time, and few adverse events.

52..They do not require levothyroxine replacement therapy.

53.Standard thyroid surgery is invasive, requires general anesthesia, and has some drawbacks. The duration of a procedure is 2 to 3 h, it requires a hospital stay of 1 or 2 days and the recovery time is usually 1 to 2 weeks. Surgery leads to complete removal of the thyroid nodule, which allows for final pathology, and usually there is no need to repeat the procedure. On the other hand, it leaves a neck scar, it often requires the introduction of levothyroxine replacement therapy, and it carries a higher risk of permanent voice damage, bleeding complications and postoperative pain and -in the case of thyroidectomy- also of hypoparathyroidism.

54. RFA does not leave scars, does not require replacement therapy, and the risk of permanent voice damage is very low.

55. What are the pros and cons of RFA in comparison to radioactive iodine for the treatment of AFTN?

56.RFA can be used for the treatment of small AFTN. Its advantages include a rapid reduction of nodule volume  and no need of hormonal replacement therapy. Also, it can be applied in pregnant and breastfeeding women.

57. As a rule of thumb, RFA should be used as a treatment for AFTN only in selected cases, preferably in small AFTN when RAI is contraindicated (pregnant and breastfeeding women) or refused by patient, or in women with an immediate desire to conceive.

58. Call me for an evaluation if you have a benign thyroid nodule.

310-393-8860 or email to thyroid.manager@thyroid.com.

Ask for Alicia

Dr.G.

Minimally-invasive treatments for benign thyroid nodules: re

Clients

commendations for information to patients and referring physicians by the Italian Minimally-Invasive Treatments of the Thyroid group

• Giovanni Mauri,et al

• Endocrine March 2022.