The use of radiofrequency ablation may soon be preferred to thyroidectomy for the treatment of certain thyroid nodules. The minimally invasive procedure known as RFA is slowly becoming more common in the United States, and preliminary results from two clinical trials on the procedure will be presented at the upcoming American Association of Endocrine Surgeons (AAES) annual meeting, taking place in April in Dallas.
Thermal ablation has been used for more than a decade in Europe and Asia and the FDA approved RFA treatment for soft tissue tumors in 2018. In the past 6 years, other types of thermal ablation, including microwave, laser, and hypothermic, also have come into use around the world.
“In terms of physicians and patients, awareness of these procedures has increased tremendously in the last few years and, in most cases, is an already accepted alternative treatment for benign thyroid nodules, though we are still trying to explore some other thyroid nodules that may also benefit from these procedures,” said Jennifer H. Kuo, MD, director of the Interventional Endocrinology Program and Endocrine Surgery Research Program at New York-Presbyterian/Columbia University Irving Medical Center. Dr. Kuo is the lead on the aforementioned trials, examining clinical outcomes and quality of life and efficacy and safety in treating indeterminate nodules.
Gary Clayman, MD, DMD, surgeon-in-chief and founder of the Clayman Thyroid Center at the Hospital for Endocrine Surgery, Tampa, FL, agreed that RFA is effective – under the right conditions. First, a biopsy should confirm that nodules are benign, and second, considering the location is important so the trachea, carotid artery, nerve to the voice box, and other areas of the neck are not damaged during the procedure.
“For thyroid nodules that are clearly benign and are producing too much hormone, it is a really great approach. In doing so, you can retain normal thyroid tissue, ablate the tissue that is producing too much hormone, and leave patients as whole as possible,” he explained.
See also, How to Proceed with Small Thyroid Tumors
Thyroidectomy Versus Radiofrequency Ablation Treatment
About one-half of all people have a thyroid nodule by age 60, according to the American Thyroid Association, and more than 90% of those nodules are benign. The most common treatment of all thyroid nodules has been a thyroidectomy, a low-risk procedure, according to Dr. Kuo. However, there can be complications following the procedure, such as hematoma, decreased parathyroid hormone activity, or nerve injury, and 25% to 30% of these patients will need to take a thyroid hormone supplement for the rest of their lives.
Thyroid cancer is found in only 5% of all thyroid nodules and two-thirds of nodules have benign disease on final pathology. RFA was introduced in the early 2000s as a minimally invasive alternative to thyroidectomy because it shrinks the nodules as the body reabsorbs the ablated tissue, shared Dr. Kuo. The procedure is often used in pain management, such as for painful nerves in the shoulder and hip joints as well.
See also, How to Locate and Assess Thyroid Nodules
RFA Use Slowly Overcoming Barriers
While many large institutions in the US have begun using RFA to treat thyroid nodules, it has taken several years for the practice to be accepted as more trained surgeons gained experience with the procedure, Dr. Clayman said.
“RFA is not going to disappear. It is going to continue to be used and it needs to be used in a thoughtful fashion. Knowing what you are treating is the most important thing… That level of comfort should be there before anyone entertains radiofrequency ablation,” he said. “One of the problems was that early on, adopters [rushed to] push its potential and in doing so there were failures and a level of concern over its use and potential overutilization.”
Another factor slowing its adoption was that RFA procedures for thyroid nodules were in a “no-man’s land” because third-party payers were not approving reimbursements, Dr. Clayman added.
Dr. Kuo agreed, saying, “Access to these procedures remains an issue, largely because we still lack a CPT code and insurance coverage remains unreliable. However, the CPT code application was submitted last February and is going through the process for approval. We anticipate this should come through over the next year or two, and that should enable more patients to access these procedures.”
Ongoing RFA Research
Still, interest in using RFA to treat benign thyroid nodules is growing. Demonstrations of the procedure were presented during the North American Society for Interventional Thyroidology annual meeting in February 2024 and several clinical trials are being used to examine its effectiveness. Dr. Kuo is involved in some of those trials at Columbia University Irving Medical Center and said the data from those trials could be published in the next year.
“The field remains active and fast-evolving,” Dr. Kuo said. “New technology is constantly being introduced, so it is an exciting time to be involved.”
Disclosures: Dr. Kuo and Dr. Clayman reported no conflicts.
