Is Radiofrequency Ablation a Good Alternative to Surgery for Benign Thyroid Nodules? A Look at Benefits, Risks

Substernal goiters may not be accessible, added Dr. Orloff, and patients who don’t tolerate neck extension aren’t ideal. Additionally, if a patient has Hashimoto’s thyroiditis and already requires hormone replacement, they may have less incentive to keep their thyroid lobe or lobes, although this is not a contraindication.

With biopsied, indeterminate, or suspicious nodules, Dr. Steward prefers to resect or wait and see.

Potential complications from the procedure include injury to the recurrent laryngeal nerve (RLN) and, on rare occasions, the vagus nerve in the carotid sheath, the sympathetic chain posterior to the carotid artery, the brachial plexus in the supraclavicular fossa, and the phrenic nerve on the deep neck musculature (Head Neck. 2022;44:633-660).

Being able to explain the risks to patients and knowing when to refer them to surgery is vital. A 6-cm nodule likely requires two procedures, but a 4-cm nodule compressing the trachea significantly may need to go to surgery. —Kathleen E. Hands, MD

The most frequent complication after RFA is voice change. A systematic review and meta-analysis conducted by Chung et al. (Int J Hyperthermia. 2017;33:1-35) identified a 1.44% overall rate of transient or permanent voice change following RFA based on subjective voice assessment. The rate of voice change was higher (7.95%) in the subset of 176 patients undergoing RFA for recurrent thyroid cancer, primarily in the central compartment. Injection of cold irrigant in the region of suspected thermal injury when voice change develops has been proposed as a management strategy for mitigating RLN injury (Int J Hyperthermia. 2019;36:204-210), although prior studies have reported hypothermic nerve damage with exposure to cold solutions (Head Neck. 2022;44:633-660).

The next most recent complication of RFA is thyroid nodule rupture. Neck swelling typically appears two to four weeks following the procedure (Head Neck. 2022;44:633-660).

Best Practices and Training

In December 2021, an international interdisciplinary consortium of medical societies, including the American Head and Neck Society (AHNS) Endocrine Surgery Section, published a multiconsensus statement on best practices in the use of RFA (Head Neck. 2022;44:633-660). The statement’s recommendations for best practices included:

• Ultrasound (US)-guided ablation procedures may be used as a first-line alternative to surgery for patients with benign thyroid nodules contributing to compressive and/or cosmetic symptoms.
• Although less efficacious than surgery or radioactive iodine in normalizing thyroid function, thermal ablation procedures can be a safe therapeutic alternative in patients with an autonomously functional thyroid nodule and contraindications to first-line techniques.
• US-guided ablation procedures may be considered in patients with suitable primary papillary microcarcinoma who are unfit for surgery or who decline surgery or active surveillance.
• Prior to performing any US-guided thermal ablation procedure, advanced training in and facility with US of the thyroid and neck are essential.
• Proficiency with US-guided fine needle aspiration biopsies of thyroid nodules is recommended for performance of US-guided ablation procedures.
• The provider should receive specific instruction on the chosen ablation technique, with the opportunity to practice on a phantom model and to observe cases.
• Optimal practice involves one’s initial cases being supervised by a physician experienced in US-guided ablation procedures.
• Using the moving shot technique via the trans-isthmic approach and delivering energy only when the needle tip is visualized by US is paramount to effective ablation in the performance of RFA.

Proper training in RFA is essential for patient safety. Dr. Orloff said the landmark courses are in Korea, Brazil, and Italy, where her international colleagues have vast experience and expertise, having been the true pioneers in the thyroid RFA procedure. While COVID-19 put a damper on progress in RFA education and training, courses are beginning to be offered in the United States. She said didactic learning and case-based discussions are available through multiple online offerings, including the AHNS Endocrine Surgery Section, the World Congress on Thyroid Cancer, vendor- sponsored webinars, and institutional courses, but that hands-on learning is essential before undertaking the procedure.