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BackTable / VI / Article
Thyroid Ablation: Expanding Treatment Options with Radiofrequency
Gabrielle Gard • Updated Sep 20, 2022 • 251 hits
With the advent of thyroid radiofrequency ablation (RFA), surgery and radioactive iodine are no longer the only treatment options for patients with thyroid nodules, including functional nodules. However, this new technique comes with special considerations when it comes to patient candidacy and how to prepare patients for treatment. Dr. Huber discusses the role of thyroid ablation on the BackTable Podcast, and shares his approach to patient selection and workup. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Brief
• The main patients that qualify for thyroid radiofrequency ablation are those with over 2 cm benign symptomatic thyroid nodules, but patients with functional nodules and thyroid malignancies may benefit from RFA as well.
• The patient workup for thyroid ablation typically involves two benign FNAs (fine needle aspiration biopsies), an ultrasound, and lab work to check TSH, T3, and T4.
• One absolute contraindication of thyroid radiofrequency ablation is pregnancy. In addition, there are several other factors, such as large or multinodular goiters and nodule location, that may make thyroid ablation less effective for certain patients.
• To avoid damaging the recurrent laryngeal nerve in the danger triangle, Dr. Huber recommends the trans-isthmic approach.
• Insurance coverage is possible for thyroid ablation, and there is predicted growth of this technique into areas like cancer.
Image provided by Dr. Tim Huber
Table of Contents
(1) Indications for Thyroid Radiofrequency Ablation
(2) Thyroid RFA Patient Workup and Contraindications
(3) Practicalities of Thyroid Ablation: Insurance and Provider Training
Indications for Thyroid Radiofrequency Ablation
The key indicator for patients who may benefit from thyroid radiofrequency ablation are those with benign symptomatic thyroid nodules, which typically are over two centimeters. Dr. Huber also mentions that thyroid ablation can treat functional nodules, opening up another treatment beyond surgery or radioactive iodine, but providers should aim for 70 to 80% volume reduction for these patients. Ongoing research may actually widen the scope of thyroid radiofrequency ablation to include treating patients with thyroid malignancy in the future.
[Dr. Aparna Baheti]:
Do you treat patients who have cosmetic concerns about lumpy bumpy thyroids?
[Dr. Tim Huber]:
That's a good question. Typically, once they get to be over two centimeters in most people that are going to be somewhat visible, and they're going to be some sort of cosmetic defect. So far I haven't had any patients who have solely cosmetic concerns. It's always been cosmetic concerns plus symptoms, but you can do this for cosmetic concerns as well.
[Dr. Aparna Baheti]:
And then talk to me a little bit about your practice in treating patients who have functional nodules.
[Dr. Tim Huber]:
Yeah. So this is a definitely a tougher area to treat. So you can use this technique to treat functional nodules as well. The standard is obviously surgery or radioactive iodine treatments, but there are a lot of patients that don't want to have surgery, or they don't want to isolate for the period of time that you need to with radioactive iodine or they have small kids at home, or it's just not feasible. So RFA is a good option for people who don't want those other two options. It's a little bit trickier in that you have to get a more complete ablation of the nodule. You can't leave as much residual tissue behind to get them back to euthyroid state. So you really want to shoot for like a 70 to 80% volume reduction to get a good result for those patients. So a little more challenging, not something maybe to take on as your first case, but definitely something that can be treated.
[Dr. Aparna Baheti]:
Have you treated any patients who have a thyroid malignancy?
[Dr. Tim Huber]:
Yeah. So we have treated one patient so far with a recurrent PTC. He was a candidate who basically had had multiple prior neck dissections and some radioactive iodine treatments before, and was at a point where we were kind of considering repeat neck dissection versus starting systemic options for him to locally control the nodules. So he had basically two nodes, metastatic kind of near the carotid, and one near the trachea. And so we use this as a way to slow down that growth and prevent local invasion. It can also be used for a papillary microcarcinoma and that's a little bit of a newer area. There are a few trials are going to be starting up pretty soon, kind of Mayo and Sloan Kettering, and a few other centers kicking off pretty soon here, but that's an area of active, ongoing research.
[Dr. Aparna Baheti]:
I see. Okay, so obviously not standard of care for treatment of malignant nodules, but definitely something that might be in the future?
[Dr. Tim Huber]:
Yeah. The data out of Italy and Korea are really promising. So we think that this'll be a pretty successful in the US as it rolls out.
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Thyroid RFA Patient Workup and Contraindications
Before approving thyroid radiofrequency ablation for a patient, Dr. Huber recommends two benign FNAs (fine needle aspiration biopsies), an ultrasound, and lab work to check TSH. However, for patients with functional nodules, Dr. Huber suggests that one FNA is sufficient, but lab work should include TSH, T3, and T4.
However, thyroid RFA is not for every patient. Dr. Huber mentions that pregnancy is an absolute contraindication. Additionally, patients with larger nodules (4 centimeters and over), multinodular goiters, subclavicular/substernal nodules, and intermediate grade pathology on FNA are tougher to treat with thyroid ablation and patients with these patterns of nodules may require surgery or additional thyroid RFA sessions. For every patient, Dr. Huber points out the necessity to not hit the danger triangle and damage the recurrent laryngeal nerve, and he uses the trans-isthmic approach to prevent this.
[Dr. Aparna Baheti]:
What's your workup for a patient who comes to you for a thyroid ablation?
[Dr. Tim Huber]:
Great question. So we start off obviously with an ultrasound of the thyroid and of the neck to assess just the nodule composition, the vascularity, the size, and also to look for any enlarged lymph nodes in the neck that might be kind of a tip off that there could be something more than just a simple, benign nodule. Everybody needs to have, we recommend two benign FNAs, before we do RFA and that's in line with the KSIR and an ETA guidelines. There are some cases where the guidelines recommend a single biopsy being sufficient if it's a very classically benign appearing nodule, but in most cases, just to be conservative, we're recommending two prior to treatment. We do a single FNA prior to RFA for functional nodules though. That's the one kind of care area we can just do a single for functioning nodules.
[Dr. Aparna Baheti]:
Okay. So they get their FNA, and they get their thyroid ultrasound. Do you do any lab work before you do a thyroid ablation?
[Dr. Tim Huber]:
Yep. So we check TSH, in everybody, sometimes we'll add in T3 and T4. It just depends on if they're functional or non-functional. For the non-functional folks, typically just a TSH is sufficient. There's a little bit of debate back and forth throughout thyroglobulin. Is that necessary? Or about TPO antibodies, things like that. And generally, most people aren't doing any of those additional lab tests, so typically TSH is sufficient for most people.
[Dr. Aparna Baheti]:
Is there anything that you would see on your patient workup that would give you pause for doing the procedure? What I'm getting at: thyroid location or giant patient with a BMI over a hundred, or anything that has given you pause in the series that you've done so far?
[Dr. Tim Huber]:
Yeah. So patient selection, like most things in IR, is really important. I would say that the size of the nodule was one of the biggest things is going to make your life easier or hard. And so, two/three centimeter nodules are pretty easy to treat. Four and five centimeters get more challenging. 6, 7, 8 centimeter nodules are a lot tougher, and generally over seven or eight, I think surgery's probably your way to go. That being said, people are treating much larger nodules in the US, we're seeing a larger volume of disease being referred in, so definitely bigger nodules or multinodular goiter. And that's been treated with RFA, but it's a bit more challenging, usually requires more treatment sessions to get a good result. So bigger nodules are tougher. Nodules that go below the sternum, kind of subclavicular or substernal nodules, can be tough if you can't see the whole nodule, you can’t ablate safely that lower margin. So that can be a little bit challenging. Again, you can kind of stage your procedure and hopefully get that lower portion at a future procedure, but again, multiple procedures. And then any kind of intermediate grade pathology on the FNA. So Bethesda three or four categories are a little bit more indeterminate right now. We're doing some studies to figure out if those nodules are safe to treat. But right now the thinking is to probably stick with Bethesda two, the definitely benign nodules.
[Dr. Aparna Baheti]:
Anything in the patient history that would modify your approach? For example, pregnancy or if they have pacemakers?
[Dr. Tim Huber]:
Yeah. So there are two contraindications. Well, one's absolute, and one's sort of relative contraindication to the RFA system. So pregnancy is an absolute contraindication. No one's tested it in pregnant patients, but no one's going to, and so we recommend not treating pregnant patients with the system. Pacemakers, you have to do some adjustments to where you place the electrode grounding pads, so typically we have grounding pads on the outside of the thighs. For people with pacemakers, you can do a modified placement and put them up on the shoulders, on the back. And so the rep can sort of walk through the protocol there, and there are a few different protocols that are online that they've done before that have been successful. You have to decrease the wattage and that can be a little bit more of a hassle, but it can be done.
[Dr. Aparna Baheti]:
And then how about a location of the thyroid nodule? You've already kind of spoken about the ones that go below the sternum, but how about the just deep, deep nodules? Are you allowed to ablate those?
[Dr. Tim Huber]:
So really you shouldn't be ablating, anything that you can't see. So as long as you can see the nodule, or at least the portion nodule that you're ablating, that's fine. But if there's a portion of nodule that is just too deep for your ultrasound unit to kind of register clearly or to see the tip of your electrode well, then I would stay away from that, but that's really the only sort of limit.
[Dr. Aparna Baheti]:
Okay. Could you touch a little bit on the danger triangle? I remember Dr. Park always talking about that way when he talked about thyroid ablations.
[Dr. Tim Huber]:
Yeah. So there's a term, they throw around in the thyroid literature that you'll see if you start reading the papers, and they it called the danger triangle. And basically it's where the recurrent laryngeal nerve lives. And basically it's a triangle that's bordered by the thyroid gland and the trachea. And so we know that's anatomically where the recurrent laryngeal nerve is going to be, and that's basically the big concern during most thyroid surgeries that you ding the recurrent laryngeal nerve and paralyzed vocal cord. So when we do the technique that we recommend it's this trans-isthmic approach that we talk about, and that's kind of going from a medial to a lateral approach with your electrode. It makes it really, really hard, I find, to direct the tip of my electrode back into that danger triangle. So when Dr. Beck was developing this in Korea, he sort of thought of that and kind of developed it in this way to prevent damage to the recurrent laryngeal nerve.
Practicalities of Thyroid Ablation: Insurance and Provider Training
While other practices offer a cash only self-pay model, Dr. Huber’s practice has successfully filed with insurance to cover thyroid radiofrequency ablation. That said, Dr. Huber mentions that it takes a lot of upfront work on his end and sometimes multiple rounds of appeals, but it greatly widens accessibility of thyroid RFA. This accessibility will become increasingly necessary as the demand for thyroid RFA procedures increases, especially with new areas of growth for thyroid RFA, like cancer. Much of current literature comes from Korea and Italy, but Dr. Huber proposes that more US literature on thyroid radiofrequency ablation is on the rise as well as hands-on courses taught in the US.
[Dr. Aparna Baheti]:
I'd like to talk a little bit more about how, for example, how a private practice radiologist could make this a part of their practice? So starting off with the big thing that drives us is reimbursements. So do any insurance companies in the US cover it right now?
[Dr. Tim Huber]:
So it's a great question. Everyone wants to know that. The answer is it's complicated. They don't cover it easily by and large. A few of them have come around and are working with us a little more carefully, a little more closely. And we're having some success there. So the way we do it here is that I submit everything to insurance before the procedure and have worked through the appeals process on the front end. And in general, I'm able to get approval for the procedures usually with one or two rounds of appeals. Usually it's denied as investigational, but after submitting documentation references, they'll usually accept that it's legitimate. Other practices have taken more of a cash only self-pay model. And I see that's probably the majority of places are doing that around the country. It just limits how many patients can have access to the procedure. And I kind of wanted to keep it as open to as many people as we could here. So that's why I opted for the insurance, which has been successful, but a lot of work on my end to be honest.
[Dr. Aparna Baheti]:
Oh, I bet. Nobody likes to talk to those insurance companies about anything. can you give me kind of like a market, if you feel comfortable, can you give me a range of kind of what people are charging for self-pay out in the community?
[Dr. Tim Huber]:
Yeah, so I can kind of give you a rough kind of low/high, I've heard low end being around 3 and high-end being 10 or 12.
[Dr. Aparna Baheti]:
Okay.
[Dr. Tim Huber]:
So definitely a huge range depending on the market.
…
[Dr. Aparna Baheti]:
And then can you give me a little bit of information about future directions of thyroid ablation? If I wanted to start doing this next month in my OBL, what kind of resources should I look in?
[Dr. Tim Huber]:
So a two part question, I'll start with the future directions part first. Cancer is definitely the next area of growth for this technology, but there are a few other areas as well, like parathyroid adenomas or parotid tumors are also showing some early promise and being able to treat with RFA. And how did you get started with this? A lot of resources out there. There's a ton of papers from Italy and Korea describing the technique, describing their outcomes with benign disease and even some malignancy. If you want more US-based literature, there's a growing amount of literature from US-based populations, which is great. So expect more and more papers to come out in the next couple of years on outcomes in the US. You can look in this last August's seminars in IR for how-to paper for me and Dr. Park. And there'll be an upcoming TVIR edition dedicated to thyroid ablation, coming out hopefully next year.
[Dr. Aparna Baheti]:
Are there any courses around the country that a provider can go to learn this?
[Dr. Tim Huber]:
Yeah. So there are actually a lot of hands-on courses being offered around the country, more on the east coast. We were getting one set up here at OSHU, kind of in the middle of COVID, but with the recent round of restrictions, we haven't been able to go live just yet, but we're hoping to start offering some hands-on training here as well.
Podcast Contributors
Dr. Tim Huber
Dr. Timothy Huber is an interventional radiologist with Jefferson Radiology in Hartford, Connecticut.
Dr. Aparna Baheti
Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2022, January 28). Ep. 182 – Thyroid Nodule Ablation [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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