Thyroid Tumor Ablation with Radiofrequency RFA 101
Comments on this review article looking at it 4 years ahead in 2017.
1.The first results were obtained with a 17-gauge internally cooled electrode, followed by 14-gauge devices equipped with expandable prongs (23, 24). Treatments were mostly performed under conscious sedation and on large-size lesions. due to the large bore of the employed needles. 2017 treatment is done with just local injection of the thyroid capsule.
2.Dedicated 18-gauge, straight-type, internally cooled electrodes have recently been developed for thyroid lesions.
3. After local anesthesia, with a transisthmic approach, the electrode is inserted from the isthmus into the targeted nodule.
4. With a “moving shot technique,” multiple conceptual areas of the nodule are ablated unit-by-unit by moving the electrode tip.
5. Initially, the electrode tip is positioned in the deepest area of the nodule and then moved backward in the central area and in superficial directions.
6.Ablation is started with 30–50 W of radiofrequency power and is followed by 10-W increments if an echogenic zone does not appear at the electrode tip.
7. RFA was reported as effective in AFTNs with the moving shot technique as well. Nodule volume, local problems, and thyroid hyperfunction showed a significant improvement in a few noncontrolled series of patients.
8.It is noteworthy that the incomplete ablation of the margin of the hyperfunctioning nodule is followed by the partial regrowth of the AFTN.
9. Hence, a complete ablation of the nodule margins is required to prevent the regrowth of the toxic nodule, thus preventing the relapse of hyperthyroidism at long-term follow-up
10.Cysts or dominantly cystic benign thyroid nodules RFA has been proposed for the treatment of dominantly cystic nodules in a few small studies.However, these similar outcomes were obtained with fewer treatments and at a much lower cost in the PEI series than in the RFA group.
11. Symptomatic cystic (fluid portion > 90%) nodules, PEI should be the first-line treatment because of its similar safety and efficacy compared to RFA, the fewer number of treatment sessions, and its cost effectiveness.
12 Complications in 1459 patients, the overall complication rate was 3.3%, and the major complication rate was 1.4%
13. Pain is the most common complaint during the RFA procedure, but in most cases the pain decreases rapidly when the radiofrequency generator is turned off.
14.Only a few patients complain of protracted or intractable pain.
15. Voice changes due to injury of the recurrent laryngeal or vagus nerves are the major risk. This complication may be prevented by undertreating the conceptual ablation areas adjacent to the nerves.
16.Perithyroidal hemorrhage may be prevented by examining the perithyroidal vessels before inserting the electrode and with the use of small-bore electrodes.
17. Hematomas can be controlled by neck compression and usually disappear within 2 weeks.
18.Skin burn at the electrode puncture site is possible, especially in large thyroid nodules.
19.Nodule rupture presents with sudden neck bulging and pain during the follow-up period.
20.This complication is due to the acute volume expansion of a nodule due to hemorrhage and should be managed conservatively with antibiotics and/or analgesics.
21. The cost of a radiofrequency generator is approximately $30,000, and the cost of an electrode is about $1200 per session in 2017.
22.Treatment may be performed on outpatients by an operator and a sonographer with a time expenditure of about 30 minutes.
23. Recent recommendations for thyroid RFA by the Korean Society of Thyroid Radiology suggested indications as follows: 1) patients with nodule-related symptoms; 2) patients with cosmetic problems; and 3) patients with AFTNs causing thyrotoxicosis.
24. RFA is currently not recommended for follicular neoplasms or primary thyroid cancers.2017 it can be used for recurrent cancer lymph nodes and even primary micro-papillary cancers instead or surgery or active surveillance.
25.Caution should be taken in pregnant women, ( bipolar electrode makes doing pregnant or pacemaker patients safe in 2017) patients with serious heart problems, and patients with contralateral vocal cord palsy.
2018 it is expected the FDA will approve Thyroid tumor ablation for thyroid nodules.
Until then you can still avoid surgery by having a candidate evaluation by me at my center and the 2 day visit to Italy or Korea for the treatment.
Details at: 310-393-8860 or [email protected]
Richard Guttler MD,FACE,ECNU