Thyroid Radiofrequency Ablation RFA: Italian Experience

Thyroid Radiofrequency Ablation RFA: Italian Experience

Thyroid Radiofrequency Ablation RFA: Italian Experience
Thyroid Radiofrequency Ablation RFA: Italian Experience
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Radiofrequency ablation for thyroid nodules: which indications? The first Italian opinion statement
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Dr.Valcavi’s located in Reggio Emilia at Centro-Palmer Institute.
I refer my patient’s for thyroid radiofrequency ablation to Dr.Valcavi.
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J Ultrasound. 2015 Dec; 18(4): 423–430.
1.Other nonsurgical therapies, such as high-intensity focused-ultrasound (HIFU), microwaves, cryotherapy, and electroporation, are presently under investigation.
2.With a percutaneous (no skin incision) transisthmic approach, the electrode is introduced within the nodule.

3. Remarkably, thyroid function is not affected by RF treatment, and this is an important advantage as compared with surgery or radioiodine therapy

4. Ultrasound and clinical outcomes appear to be faster and more pronounced in cystic and mixed nodules than in solid ones. However, in cystic lesions, a similar therapeutic success is obtained using PEI, which is an easier and less expensive technique [33, 34].

5. When after PEI symptoms persist, together with a residual solid portion in the treated nodule, one or more RF sessions can be useful to complete the ablation process [35, 36].

6 Hyperthyroidism caused by AFTN can be completely or at least partially cured by RF treatment.

7.Several studies [3942] investigated the usefulness of RF ablation to treat metastatic lymph nodes from recurrent thyroid cancer, in patients at high surgical risk, when radioiodine is not effective. Results showed a marked shrinkage of treated lesions, coupled with serum thyroglobulin reduction, suggesting that RF treatment, such as laser ablation or PEI, may be effective in selected cases.

8. In a recent large multicenter study [43], the overall complication rate for RF treatment was 3.3 %, and the major complication rate was 1.4 %. Pain, usually transient and mild, is the most frequent side effect during procedure. Voice change due to laryngeal dysfunction is reported, although very rare, and may be prevented paying special attention when the treatment is performed in nodular tissue close to laryngeal nerve. Hemorrhage, vagal symptoms, skin burns, and nodule rupture may also infrequently occur, as well as in other thermal ablation techniques. A learning curve is required to prevent complications or properly manage in case they occur.

Italian opinion statement

Indications for RF ablation in thyroid pathology

9. Nodules in patients presenting with local symptoms or cosmetic complaints when surgery is contraindicated or declined.

10. Autonomously functioning thyroid nodules (AFTN), hot/warm at scintiscan, either toxic or pretoxic, when surgery and radioiodine are contraindicated or declined.

11.Palliative therapy for recurrent thyroid cancers in the neck when surgery is contraindicated and radioiodine is ineffective.

12.The above-mentioned indications are intended for solid or dominantly solid thyroid nodules.

13.The following indications were accepted instead with partial disagreement:

14. Nonfunctioning, benign thyroid nodules (even with volume < 20 ml) coupled with early local discomfort that significantly grow over time.

15. RF may be useful to strongly reduce nodule size to prevent its future growth, together with progressive increase in symptoms and cosmetic concerns, and to avoid future thyroid surgery.

16. Besides, RF treatment could have easier, faster, more tolerable, and more effective results if pretreatment nodule volume is not too large. The agreement for this indication was not complete among experts because someone suggested that surgery is more advisable if thyroid nodules seem to be fast-growing. Although nodule growth speed is not considered to be a significant marker for malignancy, the panel concluded that special caution is needed in fast-growing nodules, for which FNA repeat is recommended to rule out the risk of malignancy, before RF treatment can be proposed.

17. Large (volume > 20 ml) AFTN, for whom combined treatment RF + radioiodine could induce faster and greater improvement in local symptoms, allows a reduction in radioiodine-administered activity, if compared with radioiodine alone.

18. The usefulness of a combined treatment, using thermal ablation and radioactive iodine, is not yet fully established in scientific literature such as in clinical practice. However, it has been recently proposed for large hyperfunctioning nodular goiters [38], producing a faster and more marked nodule shrinkage, coupled with a lower-radioiodine-administered activity, if compared with radioiodine therapy alone. These data, similar to those obtained from previous studies using PEI + radioiodine for the treatment of large toxic thyroid nodules [48], seem to be promising, suggesting that combined nonsurgical treatment could be effective and safe in selected cases. Nevertheless, the agreement for this indication was incomplete among experts, meeting disagreement especially from specialists in nuclear medicine.

The following discussed indications for RF ablation were not accepted:

19.Thyroid cysts and dominantly cystic thyroid nodules: PEI is first-line treatment.

20.Primary thyroid cancers or follicular neoplasms surgery is standard therapy.

21.Comment: microRNA studies are finding low risk primary thyroid cancers that RF can treat.

22. Ethanol ablation is also possible treatment for primary low risk thyroid cancer.

Conclusion and future perspectives

22. Radiofrequency ablation and other nonsurgical, minimally invasive, US-guided techniques may play an important role in the management of nodular thyroid disease today and in future clinical practice. This statement was made to clarify this role and to make it consistent in Italian centers for thyroid disease.

23.Focusing on radiofrequency thermal ablation after a comprehensive evaluation of pieces of scientific evidence and experts’ opinions and suggestions, the panel approved several indications for this technique in thyroid pathology, with complete or partial agreement among experts, trying to define the most appropriate treatment in different clinical conditions.

24.Looking at the future outlook, we can speculate about other possible fields of application of these techniques in benign and malignant diseases. For example, if cost-effectiveness evaluation will be favorable, slow-growing benign thyroid nodules might be treated with RF even at an early stage before they become responsible for local symptoms and cosmetic complaints, making RF treatment even more tolerable, easy, and effective.

25. Finally, some authors are highlighting worldwide that papillary thyroid microcarcinoma (PTMC) often represents a very low-risk lesion of indolent course, for which total thyroidectomy might be a very aggressive therapeutic choice.

Comments:

We do not have RFA in the US, but it is coming soon. Until then if you want to avoid surgery for benign thyroid nodules I can evaluate you and send you to Dr.Valcavi.

Call Matt at 310-393-8860 or thyroid.manager@protonmail.com for details.

DR.G.

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