Skin Burn from Radiofrequency Ablation of a Thyroid Nodule

Skin Burn from Radiofrequency Ablation of a Thyroid Nodule

Skin Burn from Radiofrequency Ablation of a Thyroid Nodule

Full-Thickness Skin Burn Caused by Radiofrequency
Ablation of a Benign Thyroid Nodule
Stella Bernardi,1 Valentina Lanzilotti,1 Giovanni Papa,2
Nicola Panizzo,2 Chiara Dobrinja,3 Bruno Fabris,1 and Fulvio Stacul4
Dear Editor:
Today, radiofrequency ablation (RFA) represents an effective
therapeutic option for symptomatic benign thyroid nodules.
The advantages of this outpatient treatment modality
include reduced morbidity, no risk of cosmetic damage, and
decreased costs (1). In Trieste, we started using RFA for
symptomatic thyroid nodule ablation in 2012, and so far, 107
patients have been treated with this approach, with overall
satisfactory results and a low complication rate (3%), which is
consistent with the literature (1–3). All the procedures were
performed by the same operator, who is a well-trained radiologist,
experienced in ultrasound (US), fine-needle aspiration
biopsy, and RFA procedures. Nevertheless, in one of these
patients (0.9%), the procedure unexpectedly caused (3,4) a
third-degree skin burn. Here, we report our experience.
A healthy 34-year-old woman with a slim body habitus
presented with a thyroid nodule located in the left inferior pole
of the gland, which was partly plunging (Supplementary
On presentation, she complained of local
cosmetic concerns, seeking advice on the best treatment modality
of her nodule. The nodule measured 42 mm· 40 mm·
23 mm and was cytologically benign.
Given that she refused surgery and met all the eligibility
criteria for thyroid RFA (5), we suggested that she undergo this
procedure. The patient was informed and prepared as already
described (1,2). Before the procedure, she underwent local
anesthesia at the puncture site with 10 mL of 2% lidocaine, as
well as conscious sedation with 2 mg of midazolam.
To ablate the nodule, a monopolar electrode featuring a
shaft length of 10 cm and an exposed tip length of 10 mm (RF
AMICA_PROBE model RFH18100V1, HS Hospital Service
SpA, Italy) was inserted into the thyroid nodule under US
guidance. In particular, due to the position of the nodule
the electrode was inserted directly into the nodule from above
(direct approach), instead of
reaching it through the thyroid isthmus (transisthmic approach).
We began by ablating the central areas of the nodule
with an initial RF power of 30 W,
which was then increased to 40 W. Then, in order to treat the
other parts of the nodule, the electrode was moved and pulled
slightly backward. Probably at that moment, the active needle
tip must have come in close proximity to the skin with the
power delivery possibly not switched off yet, so that a skin
burn developed. The lesion was noticed by the operator immediately
after it developed, and as soon as it was noticed the
procedure was stopped, leaving most of the nodule untreated.
Otherwise, the patient did not
perceive anything and she did not complain of pain during the
skin injury because of the conscious sedation and local anesthesia.
No other complications were encountered.
Initially, the lesion appeared as a full-thickness burn that
surrounded the electrode puncture site, with a maximum diameter
of 1.5 cm and a charred white necrotic core.
The patient was seen by a plastic surgeon who recommended
treatment with topical gentamicin sulfate and hyaluronic acid
for the first week, in order to reduce the risk of bacterial colonization
of the wound and to help tissue regeneration and
wound healing. The following week, the patient started applying
an activated charcoal cloth with silver. Then, after surgical
debridement of the wound the skin burn was treated
with a collagen wound dressing for another two weeks. Overall,
although this skin burn took more than one month to heal, its
final appearance looked almost like the normal skin.
To our knowledge, this is the first report of a full-thickness
skin burn caused by RFA of a benign thyroid nodule. The RFA induced
skin burns that have been reported so far were usually
of first degree, and patients recovered within seven days (3–4).
Here, we describe this clinical experience to raise awareness
that RFA can also lead—although rarely—to full-thickness
burns that take at least three weeks to heal and usually develop
a scar, which may be severe. Patients should be informed of
this extremely infrequent but regrettable possibility as well as
its remedies, especially if they are undergoing RFA because of
cosmetic concerns (and they want to avoid surgical scars).

In order to prevent such a complication, it is important to
keep the active needle tip within the nodule. To do so, it is
recommended to use the transisthmic approach whenever
possible. It can also be useful to inject cold fluid in the subcutaneous
layers under the puncture site in order to create a wheal
that will raise the skin and increase the distance from the nodule
(we generally do that when injecting the lidocaine). It is also
suggested (3) to apply an ice bag on the skin next to the puncture
site during the ablation. In any case, it is important to keep in
mind that conscious sedation may delay the detection of
complications, and it is important to pay attention when treating
superficial nodules in lean patients, where the active needle tip
is more likely to come into contact with the skin. In cases when
a skin burn develops, specific care will facilitate the wound
healing process in order to achieve a satisfactory esthetic result.

Comment:
The isthmus approach is the ideal method and is used by most expert interventional thyroidologists.
The burn in this case occurred by a direct entry to the nodule.
Richard Guttler MD,FACE,ECNU
If you think have nodule that is a possible candidate for RFA call Matthew at 310-393-8860 for details.

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