Its appeal lies largely in avoiding loss of an entire thyroid lobe for the sake of treating a nodule, and there’s no surgical scar. —Lisa A. Orloff, MD
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March 2022
Patients with very large thyroid goiters need to weigh the pros and cons carefully, as they will be looking at more than one procedure over time to cause adequate shrinkage, said Catherine F. Sinclair, MD, a dual fellowship-trained neck and thyroid surgeon and laryngologist. Based in Melbourne, Australia, Dr. Sinclair completed fellowships in the United States and worked for nearly a decade at Mount Sinai in New York City as an associate professor and director of head and neck surgery at Mount Sinai West.
“Baseline nodule volumes greater than 20 cc have been shown to be more likely to require a second procedure,” she said. “Similarly, patients with significant retrosternal extension of a nodule will likely require multiple procedures, as a single procedure won’t significantly address the retrosternal component—a single procedure can be used to cause contraction of the upper part of such a nodule and thus pull the retrosternal component upward into the neck so that it can be ablated in a delayed fashion.”
Risks of the Procedure
Kathleen E. Hands, MD, an endocrinologist in San Antonio, Texas, who specializes in thyroid and parathyroid disorders, said she has had patients who present with 4- to 12-cm nodules. Dr. Hands said she has performed the procedure more than 50 times since November 2019, when she became the first female endocrinologist to perform it.
“Being able to explain the risks to patients and knowing when to refer them to surgery is vital,” she said. “A 6-cm nodule likely requires two procedures, but a 4-cm nodule compressing the trachea significantly may need to go to surgery. The entire neck needs to be assessed, including the airway and the great vessels. If the airway is so compromised that any swelling may cause loss of airway, they aren’t safe to do RFA as an outpatient,” Dr. Hands said.
Patients who have nodules with indeterminate biopsy results (Bethesda 3 or 4) are also not good candidates for ablation due to a heightened risk of malignancy in these nodules, said Dr. Sinclair. Similarly, thyroid cancers larger than 1.5 cm are poor candidates; surgery is a better option as long as the patient can tolerate surgery.
Other patients who may not be good candidates are those with needle phobias who may struggle with the procedure being performed under local anesthesia and may require sedation for adequate ablation. Patients with bleeding disorders need to be carefully assessed regarding their risk from the procedure. And Dr. Sinclair said that patients with Graves’ disease aren’t good candidates for ablation if their goal is to cure the hyperthyroidism in addition to shrinking any nodules. “Hyperthyroidism is caused by systemic antibodies that ablation alone will not combat,” she said.