Thyroid Radiofrequency Ablation (RFA)

Thyroid RFA is considered successful when the nodule shrinks by >50%. On average, thyroid RFA shrinks solid thyroid nodules by 80%, with a range of 65-94%, so the results are usually really good! Sometimes, the nodules disappear completely. Almost all patients have great symptomatic improvement, with complete or almost complete resolution of their compressive symptoms and/or cosmetic concerns. Significantly more than half the patients (around 90%) will do well with a single RFA session. A minority of patients with very large nodules may require more than one RFA session, to achieve the best outcomes and prevent future re-growth.

For hyperfunctioning thyroid nodules, the volume reduction is similar, and hyperthyroidism eventually resolves in 50-80% of the patients.

It is important to note that thyroid RFA does not lead to these results immediately. There is significant tumor reduction within a month after the treatment, but the nodules continue to gradually shrink for up to a year after the RFA procedure.

If by chance the nodule grows back and there is a volume reoccurrence and becomes symptomatic again, then Thyroid RFA can always be performed again. Having this procedure does not actually preclude having surgery down the line. One can always go back to the traditional approach of surgery if you needed to.

• This is a minimally invasive procedure with little to no scarring.
• The procedure lasts 15 – 60 minutes. You only need to take time off work for the day of the procedure. No need for a hospital stay.
• Since healthy tissue is not destroyed during this procedure, the use of thyroid medications is not expected afterwards.
• The procedure is highly effective. The reduction in size for a nodule is typically between 60-90% after one year.
• Almost no time needed for recovery. Most patients resume normal activities the next day.
• Much lower complication rates – topical anesthetic only (no general anesthesia)

Thyroid RFA is indicated for benign thyroid nodules that:

• Are causing compressive symptoms (difficulty swallowing, voice change, difficulty breathing, foreign body sensation in the neck, etc.).
• Are toxic (overfunctioning), causing hyperthyroidism.
• Cause cosmetic concerns due to their size.
• Form large multinodular goiters.
• A doctor has recommended surgery for their treatment, and the patient is not a surgical candidate, or would prefer to avoid surgery.

Sometimes RFA is not possible, or it is not recommended. The following are some scenarios that surgery is preferred over Thyroid RFA:

• There is known thyroid cancer, or there is high suspicion for thyroid cancer.
• The thyroid nodule extends to areas that cannot be accessed for treatment with RFA, such as behind the trachea or inside the chest.
• There is a large substernal goiter (large amount of thyroid tissue getting in the chest).
• There are heavy calcifications in the nodule, which are expected to prevent us from advancing the needle.
• There is concomitant Graves’ disease and surgery has been recommended as the best treatment of this disease for the patient.

In order to be a candidate for Thyroid RFA, the patient must:

• Not have thyroid cancer or suspicion of thyroid cancer.
• Have had 2 FNA biopsies of the target thyroid nodule that are benign on cytopathology, for inactive (cold) thyroid nodules.
• Have had 1 FNA biopsy of the target thyroid nodule that is benign on cytopathology, for overactive (toxic/hot) thyroid nodules.
• Be able to get off anticoagulation for the time of the procedure (for patients on blood thinners)

• Someone who has undergone prior surgery, radiation, or sclerosing (scar forming) therapy to the thyroid or thyroid area of the neck as this causes altered anatomy increasing the risk of damage to non-thyroid tissue.
• Individuals with implantable pacemakers or defibrillators.
• Individuals with extremely small thyroid nodules.
• Individuals who have sonographic features of their nodules that are suspicious for cancer unless additional studies have been performed to verify benign status of the nodule.
• Individuals who have had previous damage to their vocal cord.
• Pregnant patients.
• Patients with severe heart disease.
• Patients taking chronic anticoagulants or blood thinners that cannot briefly discontinue these medications for the procedure.

Thyroid RFA is a very safe procedure, with a very low complication rate, much lower compared to surgery. A study of approximately 1500 patients showed an overall complication rate of 3.3%. The major complication rate was 1.4%

The following are the potential serious complications of thyroid RFA and their frequency, based on the most recent literature review of thousands of patients:

• Temporary voice change: 0.94%
• Permanent voice change: less than 0.17%
• Nodule rupture: 0.17% (usually treated conservatively, surgery is rarely indicated)
• Hematoma: rare, usually disappears within 1-2 weeks
• Hypothyroidism: exceedingly rare
• Other nerve damage: exceedingly rare
• Infection/abscess formation: exceedingly rare
• Life-threatening complications: none reported so far

• The procedure itself takes between 15 to 60 minutes depending on the number or volume of nodules.
• The patient will be able to breathe and talk the entire time and will be able to converse with the doctor during the procedure.
• Two grounding pads will be attached to the thighs (recommend wearing shorts).
• The patient will lay flat on their back with their head and shoulders on a pillow. Knees can be bent or a small pillow can be placed under the lower back for comfort.
• Similar to thyroid FNA biopsies, the doctor will use a very thin needle to place a local anesthetic under the skin in the area surrounding the thyroid gland.
• The procedure is so gentle that most people have little to no discomfort. The thyroid gland itself is not sensitive to pain, and the skin and surrounding area of the thyroid gland (including the thyroid capsule) are anesthetized for the procedure. Only 2-3 % of patients experience discomfort. This is usually a temporary burning sensation similar to that experienced during dental procedures. Pain tends to happen only during the procedure when there is energy delivery, with subsequent complete resolution of the pain. In the event of severe discomfort, the procedure will be interrupted and anesthetic will be injected again until there is no pain.
• Other minor side effects of the procedure are very uncommon, and include nausea, vomiting, mild skin burn, parasympathetic/vasovagal reaction (such as temporary slow heart rate or feeling of faint), fever.

Follow up visits at our office along with thyroid ultrasound is recommended at 6-8 weeks, 6 months, and 12 months after Thyroid RFA. Thyroid function will also be assessed to make sure hypothyroidism does not occur.

No. Thyroid RFA received approval by the FDA and is performed at many prestigious academic institutions across the country such as John’s Hopkins, Columbia, and Stanford. Thyroid RFA for thyroid nodules has been performed in Korea for over a decade and throughout Europe and their outcomes are excellent. The published data shows impressive nodule shrinkage rates of more than 80 percent with RFA that is maintained over years of follow-up.

Currently the evaluation of the thyroid nodules is covered by insurance companies, however the radiofrequency ablation of thyroid nodules is not considered a recognized benefit. We will assist with a case review and application will be made for a pre-approval from your insurance company. In case of denial, a peer-to-peer review or reconsideration will be followed. Unfortunately, some insurance companies do not cover thyroid RFA. In that situation, it would be an out-of-pocket expense for the patient.

We will work with your insurance company to determine coverage, benefits, and out-of-pocket cost. With Thyroid RFA at AE, we eliminate the costs associated with either having RFA performed at a hospital, surgical center, and/or anesthesia which often had facility fees. Thyroid surgery often has a significant out of pocket expense due to high-deductible insurances. For more information on out of pocket expenses, please call our office.

Payment for Thyroid RFA must be completed prior to the procedure. Payment options include:

1. Pay with Cash/Credit card
2. Use your Healthcare HSA
3. Finance using CareCredit – an independent healthcare credit company that helps make care affordable by offering convenient, flexible payment options with no interested if paid over 12-24 months.

Summary:
In the final analysis Thyroid RFA is an attractive alternative for patients who experience problems caused by benign thyroid nodules. It is a safe and FDA approved procedure with less pain, less down time, and no scarring. With its long-lasting effects RFA is a breakthrough in treating symptoms related to thyroid nodules.

For more information, visit RFA For Life: https://www.rfaforlife.com/

Patient Videos :

John’s Hopkins – https://clinicalconnection.hopkinsmedicine.org/videos/radiofrequency-ablation-rfa-for-benign-thyroid-nodules
Columbia – https://www.youtube.com/watch?v=437cDux1rlA

Procedure Video: https://youtu.be/MPko4-Z-Umc

1. Basic concepts: https://youtu.be/-Dufp6vTEHw
2. RFA set-up specifics: https://youtu.be/zp3YqAulLdY
3. Technical tips and pearls: https://youtu.be/7HDizhj4y4g
4. Ethanol ablation: https://youtu.be/CBF7jm0WGfY
5. Patient selection, counseling and consent: https://youtu.be/ehPkpGhxJt4
6. Data collection and outcomes reporting: https://youtu.be/SpW_H0gq890