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Collected Research

Thyroid nodules are a fairly common finding in general population and, even if most of them are benign, a treatment can be however necessary. In the last years, non surgical minimally invasive techniques have been developed to treat this pathology, starting from percutaneous ethanol injection (PEI), to laser ablation (LA), radiofrequency ablation (RFA) and, most recently, microwave ablation (MWA).

Most recently, microwave ablation (MWA) has been proposed to treat thyroid nodules, taking experience from its use in other organs like liver, kidney and lung in particular (9). MWA has the following advantages respect to RFA: reduction in treatment time, larger ablation zone, less heat sink effect (10). Aim of this review article was to evaluate all the studies concerning thyroid MWA, with a particular focus on safety and efficacy of the procedure and on results compared to RFA.

Microwave ablation (MWA) for thyroid nodules: a new string to the bow for percutaneous treatments?

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Microwave ablation (MWA) has become increasingly popular as a minimally invasive treatment for benign and malignant tumors of the liver, lung and kidney. Recently, two studies have attempted to apply the technique to debulk benign thyroid nodules and gained positive results. MWA of benign nodules demonstrated significant volume reductions, while solving nodule-related clinical problems. This article reviews the basic physics, therapeutic indications, patient preparation, devices, procedures, clinical results
and complications of thyroid MWA.

Microwave ablation of benign thyroid nodules

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Microwave ablation (MWA) has emerged as a minimally invasive technique, transforming the therapeutic landscape for benign thyroid nodules (BTN), papillary thyroid microcarcinoma (PTMC), and cervical lymph node metastasis (CLNM). This study aims to present the first experience in Ecuador using MWA. We included adults undergoing MWA for BTN, PTMC, and CLNM between September 2022 and April 2023. Descriptive statistics and the Wilcoxon signed-rank test were used to compare some pre- and post-intervention outcomes.

Microwave ablation of thyroid nodules and metastatic thyroid cervical lymph nodes: the first case series from Ecuador

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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

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Hyperthyroidism can be treated with antithyroid drugs (ATD), radioactive iodine (RAI), or surgery. We aimed to evaluate the long-term outcomes of these treatments through a systematic review and network meta-analysis (NMA).

Mortality Risks Associated with Antithyroid Drugs, Radioactive Iodine, and Surgery for Hyperthyroidism: A Systematic Review and Network Meta-Analysis

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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

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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

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Graves’ disease (GD) is a common thyroid disorder with a population prevalence of 1%–1.5%, occurring in approximately 3% of women and 0.5% of men in their lifetime. It is the most frequent cause of hyperthyroidism. Treatment options for GD currently comprise antithyroid drugs (ATD), radioactive iodine (RAI), and surgery. Although each treatment has its own benefits and shortcomings, ATD treatment represents the predominant first-line treatment in Europe, Asia, and to some extent, the USA.

Apart from the benefits of low cost and ease of administration, a continued ATD treatment of 12–18 months could enhance disease remission when compared to no intervention.6 Unlike ATD, RAI treatment utilizes ionizing radiation to cause cellular damage and deaths of thyroid follicular cells and decreases thyroid function and size of thyroid gland. Within 3–12 months after RAI treatment, the thyroid function among 50%–90% of patients is normalized. Surgery in the form of thyroidectomy is the least commonly-selected first-line treatment in GD patients. Previous surveys conducted in the USA and Europe reported that only around 2% of patients underwent surgery as a first-line therapy. Despite its benefits of rapid control of hyperthyroidism, lack of radiation exposure, and less chance of worsening coexisting Graves’ ophthalmopathy, surgery requires hospitalization and bears permanent hypothyroidism, anesthetic, and surgical risks.

Outcome of Graves’ disease patients following antithyroid drugs, radioactive iodine, or thyroidectomy as the first-line treatment

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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

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This early 20th‑century surgical report by Thomas Peel Dunhill outlines his experience performing partial thyroidectomy under local anesthesia, with particular emphasis on its application in patients with exophthalmic goiter (now recognized as Graves’ disease). Dunhill describes the operative rationale, technical considerations, and advantages of local anesthesia in reducing perioperative risk during a period when mortality from thyroid surgery remained significant. The paper highlights his preference for staged or unilateral subtotal resection—an approach that would later become known as the “Dunhill procedure”—and emphasizes the importance of minimizing surgical stress in hyperthyroid patients. This publication represents one of the foundational contributions to safer operative management of Graves’ disease prior to the development of antithyroid medications and radioactive iodine therapy.

PARTIAL THYROIDECTOMY UNDER LOCAL ANESTHESIA, WITH SPECIAL REFERENCE TO EXOPHTHALMIC GOITRE

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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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Ultrasound (US) features of solidity, hypoechogenicity or marked hypoechogenicity, microlobulated or irregular margins, microcalcifications, and taller-than-wide shape are suspicious characteristics for thyroid nodules. An US based Thyroid Imaging Reporting and Data System (TI-RADS) is classified based on the number of aforesaid features. TI-RADS category 3 included nodules without any suspicious features, and categories 4a, 4b, 4c, and 5 included nodules with one, two, three or four, or five suspicious US features. The purpose of the study was to prospectively validate the effectiveness of the TI-RADS.

Methods:
From October 2011 to June 2013, we prospectively categorized 3980 thyroid nodules (3752 benign and 228 malignant lesions) in 2921 patients using TI-RADS classification. TI-RADS categories 2 and 3 were considered as benign whereas TI-RADS categories 4 and 5 as malignant. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were calculated. Results: Of the 3980 nodules, 2953 nodules were TI-RADS category 2 (0% malignancy), 466 nodules TI-RADS category 3 (1.3% malignancy), 186 nodules TI-RADS category 4a (4.8% malignancy), 165 nodules TI-RADS category 4b (30.3% malignancy), 188 nodules TI-RADS category 4c (75.5% malignancy), and 22 nodules TI-RADS category 5 (95.5% malignancy). The sensitivity, specificity, PPV, NPV and accuracy were 97%, 90%, 40%, 99%, and 91%, respectively.

Prospective validation of an ultrasound-based thyroid imaging reporting and data system (TI-RADS) on 3980 thyroid nodules

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