The management of nodular thyroid disease has changed dramatically within the past decade. 1
Improvements in imaging technology as well as sophisticated cytologic testing can now differentiate low risk lesions from high-risk lesions without thyroid removal for pathologic confirmation.
The confidence in this testing now allows us to treat and destroy symptomatic benign thyroid disease using highly technologic minimally invasive treatments. 2
Thyroid nodular disease is common and is present in all ages. Over half of the population over 50 years old will have at least one thyroid nodule. Most of these nodules will be asymptomatic and are discovered with imaging tests ordered for unrelated issues.
The patients with larger nodules, however, are identified early due to visible and palpable neck deformity.
Symptoms for patients with large thyroid nodules often include
choking,
swallowing difficulty,
foreign body sensation, and
hoarseness.
Many patients simply notice a large lump in their neck either unilaterally or central.
The evaluation of these patients begins with a designated neck ultrasound to include the thyroid gland and inspection of the central and lateral lymph node zones. The Thyroid Imaging Reporting and Data (TI-RAD) score in neck ultrasound helps to distinguish indeterminant thyroid lesions which could be at risk for malignancy. This score helps to guide which lesions should be considered for ultrasound guided fine needle aspiration biopsy. 3
Once the nodules’ cytology is confirmed, specific treatment options can be discussed.
Indeterminant nodules and malignant disease is managed with surgical resection according to the American Thyroid Association Guidelines. Patient undergoing surgery by high volume thyroid surgeons have been demonstrated to have the lowest morbidity and shortest hospital stays.4,5
Symptomatic benign thyroid nodules can now be managed with percutaneous thermal ablation techniques. The three technologies effective for this include
laser fiber ablation,
radiofrequency ablation (RFA), and
high frequency ultrasound ablation.
Currently only laser fiber ablation and radiofrequency ablation (RFA) are available in the United States.
With radiofrequency, the tissue immediately adjacent to the probe vibrates at such high frequency that heat is created, thus altering the cellular membrane proteins. The warmed tissue is unable to recover and is devitalized. Cooled RFA probes advanced under ultrasound guidance are used to safely destroy the entire thyroid nodule without injuring adjacent tissue.
With laser ablation, a laser fiber is introduced into the middle of a nodule and the energy is applied for circumferential heating of the tissue, intentionally leaving a rim of untreated tissue. The adjacent normal tissue is preserved, and thyroid function is unaltered. This has the benefit of avoiding the potential complications of surgery, avoiding hypothyroidism, avoiding the surgical recovery, and avoiding a surgical incision. For many patients this non-surgical option is a highly desirable.
The management of toxic or autonomous nodules (AN) is rapidly being transformed by this new technique. Destruction of a well-defined AN rapidly creates a euthyroid patient within days. The nodule also shrinks in size within weeks of treatment.
No longer is it necessary to stay on marginally effective antithyroid medications experiencing frequent breakthrough hyperthyroid symptoms. Symptoms of palpitations, heat intolerance, and anxiety quickly resolve.
Additionally, treatment with radioactive iodine can also be avoided given its associated risk of hypothyroidism, bone marrow suppression, and long-term potential for hyperparathyroidism.
The short-term management of these treated RFA patients involve scheduled surveillance ultrasound examinations of the treated area to document tissue destruction and volume reduction. In these visits normal thyroid function is confirmed and structural changes in the thyroid gland are documented. These scheduled visits are at 1, 3, 6 and 12 months after treatment.
Huge thyroid nodules are also effectively treated with this regimen. Nodule volume reduction leads to symptom resolution.
Large nodules well above 50 ml in size will shrink by over 50% in three months and generally over 80% in 6 months. These patients notice dramatic improvement in their ability to breath, swallow, and sleep in ways they never imagined.
This is all achievable with a procedure performed under a local anesthetic block.
Conditions which disqualify patients include cancer, pregnancy, pacemaker, indeterminant lesions, and inability to undergo a local anesthetic block. Prior thyroid surgery with nerve injury is also a relative contraindication.
Statistics on outcomes for these procedures have documented complication rates which are one tenth of surgery complication rate.
Thermal Ablation of thyroid nodules is a paradigm shift in the management of structural thyroid conditions, not associated with neoplastic disease.
The cost savings to the healthcare system will be realized by
1. avoiding hospital expenses,
2. avoiding lifelong medications for hypothyroidism, and
3. avoiding costs for complications incurred with surgery.
With a capable provider, nodule ablation is now performed as an office-based procedure with amazing efficacy. Patient demand and satisfaction has been extremely high.
Bibliography
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2. Nishino, M., & Nikiforova, M. (2018). Update on Molecular Testing for Cytologically Indeterminate Thyroid Nodules. Archives of pathology & laboratory medicine, 142(4), 446–457. https://doi.org/10.5858/arpa.2017-0174-RA
3. Patel, K. N., Yip, L., Lubitz, C. C., Grubbs, E. G., Miller, B. S., Shen, W., Angelos, P., Chen, H., Doherty, G. M., Fahey, T. J., 3rd, Kebebew, E., Livolsi, V. A., Perrier, N. D., Sipos, J. A., Sosa, J. A., Steward, D., Tufano, R. P., McHenry, C. R., & Carty, S. E. (2020). The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Annals of surgery, 271(3), e21–e93. https://doi.org/10.1097/SLA.0000000000003580
4. Zhang J, Liu BJ, Xu HX, Xu JM, Zhang YF, Liu C, Wu J, Sun LP, Guo LH, Liu LN, Xu XH, Qu S. Prospective validation of an ultrasound-based thyroid imaging reporting and data system (TI-RADS) on 3980 thyroid nodules. Int J Clin Exp Med. 2015 Apr 15;8(4):5911-7. PMID: 26131184; PMCID: PMC4484032. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484032/
5. Adam, M. A., Thomas, S., Youngwirth, L., Hyslop, T., Reed, S. D., Scheri, R. P., Roman, S. A., & Sosa, J. A. (2017). Is There a Minimum Number of Thyroidectomies a Surgeon Should Perform to Optimize Patient Outcomes?. Annals of surgery, 265(2), 402–407. https://doi.org/10.1097/SLA.0000000000001688