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Collected Research

Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules.

This consensus statement is organized around three key themes:
(1) safety of ablation techniques and their implementation,
(2) optimal skillset criteria for proceduralists performing ablative procedures, and
(3) defining expectations of success for this treatment option given its unique risks and benefits.

Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided.

General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement

Currently the evaluation of the thyroid nodules is covered by insurance companies. However, radiofrequency ablation of thyroid nodules is new and is not considered a recognized benefit. As the exciting success of thyroid RFA is recognized, the insurance companies are paying and reimbursing more frequently.

This therapy will save the patient and the entire healthcare system a considerable amount of money. As the healthcare community and patients continue to advocate for this non-surgical solution of benign thyroid nodules, the availability to utilize insurance healthcare benefits will increase.

You should demand an appeal to an insurance coverage denial.

Insurance Authorization Letter for Radiofrequency Ablation of the Thyroid Gland

Thyroid nodules are lumps in the thyroid gland. The majority are benign (not cancerous) and this must be determined using appropriate diagnostic tests. In this procedure, a small probe is inserted through the skin into a benign nodule in the neck and an electrical current is used to heat and destroy the nodule.

Radiofrequency ablation is a minimally invasive technique that aims to reduce symptoms and improve cosmetic appearance, while preserving thyroid function, and with fewer complications than surgery. Before treatment, the thyroid nodule is confirmed as benign, typically by the use of 2 fine-needle aspiration biopsies. Ultrasound-guided percutaneous radiofrequency ablation for thyroid nodules is usually done using local anaesthesia in an outpatient setting. The patient is placed in the supine position with moderate neck extension. A radiofrequency electrode is inserted into the nodule using ultrasound guidance to visualise the electrode during the procedure. Once in position, the radiofrequency electrode is activated to heat and destroy the tissue.

Interventional procedure overview of ultrasound-guided percutaneous radiofrequency ablation for benign thyroid nodules

Objective:
To determine the number of total thyroidectomies per surgeon per year associated with the lowest risk of complications.

Background:
The surgeon volume-outcome association has been established for thyroidectomy; however, a threshold number of cases defining a "high-volume" surgeon remains unclear.

Methods:
Adults undergoing total thyroidectomy were identified from the Health Care Utilization Project-National Inpatient Sample (1998-2009). Multivariate logistic regression with restricted cubic splines was utilized to examine the association between the number of annual total thyroidectomies per surgeon and risk of complications.

Is There a Minimum Number of Thyroidectomies a Surgeon Should Perform to Optimize Patient Outcomes?

Radiofrequency ablation (RFA) seems to achieve a significantly larger nodule volume reduction rate (VRR) than laser ablation (LA) in benign nonfunctioning thyroid nodules (BNTNs).

Objective:
To compare the efficacy and safety of both treatments at 12-month follow-up in patients with solid or predominantly solid BNTN.

Methods:
This was a single-center, 12-month, randomized, superiority, open-label, parallel-group trial conducted in an outpatient clinic. Sixty patients with a solitary BNTN or dominant nodule characterized by pressure symptoms/cosmetic problems were randomly assigned (1:1 ratio) to receive either a single session of RFA or LA. Twenty-9 patients per group completed the study. The main outcome measures were VRR and proportion of nodules with more than 50% reduction (technical success rate).

Laser Ablation Versus Radiofrequency Ablation for Thyroid Nodules: 12-Month Results of a Randomized Trial (LARA II Study)

Background: Ultrasound-guided thermal ablations have become one of the main options for treating benign thyroid nodules. To determine efficacy of thermal ablation of benign thyroid nodules, we performed a meta-analysis of studies with long-term follow-up of more than 3 years.

Methods: Databases were searched for studies published up to August 25, 2019, reporting patients with benign thyroid nodules treated with thermal ablation and with follow-up data of more than 3 years. Data extraction and quality assessment were performed according to PRISMA guidelines. The analysis yielded serial volume reduction rates (VRRs) of ablated nodules for up to 3 years or more, and adverse effect of ablation during follow-up. Radiofrequency ablation (RFA) and laser ablation (LA) were compared in a subgroup analysis.

Results: The pooled VRRs for ablated nodules showed rapid volume reduction before 12 months, a plateau from 12 to 36 months, and more volume reduction appearing after 36 months, demonstrating long-term maintenance of treatment efficacy. Thermal ablation had an acceptable complication rate of 3.8%. Moreover, patients undergoing nodule ablation showed no unexpected delayed complications during the follow-up period. In the subgroup analysis, RFA was shown to be superior to LA in terms of the pooled VRR and the number of patients who underwent delayed surgery.

Long-Term Results of Thermal Ablation of Benign Thyroid Nodules: A Systematic Review and Meta-Analysis

Background: Nearly 20 years after the first feasibility study, minimally invasive ultrasound (US)-guided therapeutic techniques are now considered as a safe and effective alternative to surgery for symptomatic benign thyroid nodules. Radiofrequency ablation (RFA) is one of the most widely used treatment in specialized thyroid centers but, due to the relatively recent introduction into clinical practice, there are limited long-term follow-up studies. Aim of our work was to review the outcomes of RFA on solid nonfunctioning and on autonomous thyroid nodules (AFTN) on a long-time period for assessing the results in term of efficacy, complications, and costs and to compare them to the current indications of RFA.

Methods: A systematic review was performed using EMBASE and Medline library data between 2008 and 2021. Seventeen studies evaluated RFA for the treatment of benign solid (nonfunctioning or autonomous) thyroid nodules, with an at least 18 months of follow-up. Data extraction and quality assessment were performed by two endocrinologist according to PRISMA guidelines. Anthropometric data, safety and efficacy parameters were collected.

Results: The majority of the studies was retrospective study and reported 933 nodules, mostly solid. Baseline volume ranged between 6.1 ± 9.6 and 36.3 ± 59.8 ml. Local analgesia was used and the time duration of the treatment was between 5 ± 2 and 22.1 ± 10.9 min. The volume reduction rate at 12 months ranged from 67% to 75% for the nodule treated with a single procedure and reached to 93.6 ± 9.7% for nodules treated with repeat ablations. The regrowth rate at 12 months ranged from 0% to 34%.

Long-Term Results of Ultrasound-Guided Radiofrequency Ablation of Benign Thyroid Nodules: State of the Art and Future Perspectives-A Systematic Review

Background: Monopolar radiofrequency ablation is currently deemed an exotic treatment option for benign thyroid nodules in many central European countries. The aim of this study was to evaluate prospectively the safety and efficacy of this method in a large patient cohort following its introduction in Austria.

Methods: Peri- and post-interventional complications were analyzed for 277 patients. Efficacy was determined for 300 and 154 nodules at 3 and 12 months post treatment, respectively. All treatments were performed with an internally cooled 18G radiofrequency electrode using a free-hand, “moving-shot” technique following subcutaneous and local perithyroidal anesthesia.

Results: Mean patient age (SD) was 52 ± 12.9 years (75% female), and overall mean baseline nodule volume (SD) was 13.8 ± 15.9 mL. Nodules were visible in 62.8% of patients, 40% had a symptom score ≥4 on a 10-point visual analogue scale, and 14.4% had hyperthyroidism. Mean overall nodule volume reduction rates (VRR) at 3 and 12 months were 68 ± 16% and 82 ± 13%, respectively (p < 0.001). At 12 months, 81% of nodules exhibited a VRR of ≥70%, with 10%, 6%, and 2% of nodules showing VRRs of 60–70%, 50–60%, and ≤50%, respectively. Subgroup analysis according to baseline nodule size (≤10 mL to >30 mL) or baseline nodule composition (solid, mixed, cystic) revealed significantly higher VRRs for smaller and cystic nodules. Moreover, nodule shrinkage was accompanied by significantly improved symptom and cosmetic scores after 3 and 12 months (p < 0.001). Of 32 hyperthyroid patients, 27 (84%) were euthyroid, four had subclinical hyperthyroidism, and one had subclinical hypothyroidism at last follow-up. Post-procedural complications were absent in 83% of patients, minimal in 12.9%, moderate and reversible in 3.2% (1.8% voice change, 0.7% hyperthyroidism, 0.3% wound infection treated with antibiotics, 0.3% epifascial hematoma), and irreversible in 0.7% (one case with hypothyroidism and one with a wound infection treated by surgery).

In summary, the results of the present study are consistent with the existing literature and confirm the safety of RFA in general and the efficacy of a single treatment course of monopolar RFA in a large central European cohort. The results also provide some potentially significant data for future discussions regarding possible selection criteria for patients with thyroid nodules that could be treated with RFA.

Monopolar Radiofrequency Ablation of Thyroid Nodules: A Prospective Austrian Single-Center Study

On December 9, 2024 the Centers for Medicare & Medicaid Services (CMS) released the CY 2025 MPFS Final Rule. In this rule, CMS finalized the valuation and established the official CPT code for percutaneous radiofrequency ablation of the thyroid.

60660: Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency

60661: Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency.

New CPT Codes

Benign thyroid nodules are exceedingly common in the adult population. Only a small percentage of nodules are toxic or autonomously functioning thyroid nodules (AFTNs). The options clinicians have for treating the symptoms of hyperthyroidism include anti-thyroidal medications, radioactive iodine, or surgery. Depending on the patient population treated, these options may not be suitable or have inherent risks that are undesirable to the patient. On the other hand, untreated hyperthyroidism can lead to osteoporosis, atrial fibrillation, emotional lability, and neurological consequences. Thus, we present a review of two novel safe and effective approaches for treating AFTN; one surgical (transoral endoscopic thyroid surgery) and one non-surgical (radiofrequency ablation), as a means for expanding our treatment armamentarium.

Radiofrequency ablation (RFA) is a novel minimally invasive approach that is a potential alternative to surgery for treating symptomatic benign nodules (43) as well as AFTN (44). This approach eliminates the need for a general anesthetic, an incision, radioactive iodine, or prolonged ATD treatment, making it an attractive non-surgical option. With the use of local anesthesia, the RFA probe is introduced into the midline of the anterior neck at the level of the isthmus, and the nodule is approached using the moving shot technique under ultrasound guidance (45). This causes tissue necrosis and fibrosis by introducing a high frequency alternating current, which raises tissue temperatures to 60 to 100 C (46). Over time, there is progressive shrinkage of the ablated nodule. In benign nodules, the volume of the nodule is thought to decrease between 50 and 80% for most patients, although this is operator and tumor dependent (47, 48).

RFA has been offered to patients internationally since 2000 and has been used to treat primary and metastatic tumors of the liver, lung, bone, and kidney and to ablate aberrant conduction pathways in the heart (49–53). More recently, RFA has been applied to the head and neck, particularly for thyroid nodules. While the early results have been promising internationally, there is little North American data (47, 48, 54–61). The current international recommendations for treating benign thyroid nodules include patients who are symptomatic or those who have a disfiguring goiter or a nodule that exceeds 2 cm, or if an AFTN is present (43, 44, 57). Prior to RFA treatment of AFTN, confirmation that the nodule is benign on at least one US-guided FNA or core biopsy is recommended, unless there are concerning features on ultrasound in which case two biopsies should be obtained (43, 44). Nodules that are benign on FNA but that have suspicious US features (EU-TIRADS 5), the latest European Thyroid Association Guidelines strongly recommend (moderate quality evidence) against thyroid ablation to avoid potential delay in treatment of a malignant lesion (62).

Novel Approaches for Treating Autonomously Functioning Thyroid Nodules

Objective: To assess the effectiveness, tolerability, and complications of radiofrequency ablation (RFA) in patients with benign large thyroid nodules (TNs).

Patients and methods: This is a retrospective review of 14 patients with predominantly solid TNs treated with RFA at Mayo Clinic in Rochester, Minnesota, from December 1, 2013, through October 30, 2016. All the patients declined surgery or were poor surgical candidates. The TNs were benign on fine-needle aspiration, enlarging or causing compressive symptoms, and 3 cm or larger in largest diameter. We evaluated TN volume, compressive symptoms, cosmetic concerns, and thyroid function.

Results: Median TN volume reduction induced by RFA was 44.6% (interquartile range [IQR], 42.1%-59.3%), from 24.2 mL (IQR, 17.7-42.5 mL) to 14.4 mL (IQR, 7.1-19.2 mL) (P<.001). Median follow-up was 8.6 months (IQR, 3.9-13.9 months). Maximum results were achieved by 6 months. Radiofrequency ablation did not affect thyroid function. In 1 patient with subclinical hyperthyroidism due to toxic adenoma, thyroid function normalized 4 months after ablation of the toxic nodule. Compressive symptoms resolved in 8 of 12 patients (67%) and improved in the other 4 (33%). Cosmetic concerns improved in all 8 patients. The procedure had no sustained complications.

Outcomes of Radiofrequency Ablation Therapy for Large Benign Thyroid Nodules: A Mayo Clinic Case Serie

Purpose: To confirm the efficacy of ultrasound (US) guided radiofrequency ablation (RFA) in the treatment of benign thyroid nodules, we evaluated as primary outcome the technical efficacy and clinical success in a single center dataset. The secondary outcome was to find a correlation between nodules’ pre-treatment features and volume reduction rate (VRR) ≥75% at 12 months after RFA and during follow-up period.

Methods: This retrospective study included 119 consecutive patients (99 females, 20 males, 51.5 ± 14.4 years) with benign thyroid nodules treated in our hospital between October 2014 and December 2018 with a mean follow-up of 26.8 months (range 3–48). Clinical and US features before and after RFA were evaluated by a US examination at 1, 3, 6, 12 months and annually thereafter up to 48 months.

Results: The median pre-treatment volume was 22.4 ml; after RFA we observed a statistically significant volume reduction from the first month (11.7 ml) to the last follow-up (p < 0.001 for all follow-up times). The median VRR was 47.1, 55.3, 61.2, 67.6, 72.8, 71.3, and 62.9% at 1, 3, 6, 12, 24, 36, and 48 months of follow-up respectively, showing a progressive significant improvement up to 24 months (VRRs 1 vs 3 months, 3 vs 6 months and 6 vs 12 months p < 0.001, 12 vs 24 months p = 0.05) while no differences at 24 vs 36 and 36 vs 48 months were observed. Symptoms improved significantly (complete resolution 64.35%, partial resolution 35.65%), and neck circumference was reduced as compared to pre-treatment (p < 0.001). Lower pre-treatment neck circumference (37.5 vs 36.0 cm, p = 0.01) was a positive predictor of VRR ≥75% at 12 months. Macrocystic echostructure (HR 2.48, p 0.046) and pre-treatment volume >22.4 ml (HR 0.54, p 0.036) were found to be independent positive and negative predictors of VRR ≥75% respectively. One-month post RFA VRR ≥50% represented the best positive predictor of technical success.

Predictor Analysis in Radiofrequency Ablation of Benign Thyroid Nodules: A Single Center Experience

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