Ablação por Radiofrequencia de nódulos tireoidianos

1. Dr. Leonardo G. Rangel
Thermal Ablation of
Thyroid Nodules
Head and Neck Surgeon
MD , PHD
UERJ

2. New Technique
❖ You have to answer 3 questions :
❖ What for ?
❖ How does it work ?
❖ When will I use it ?

3. Abraham Maslow
“If the only tool you have
is a Hammer, you tend too
see every problem as a Nail
Psychologist - 1908-1970

4. Background
Fig 1. Trends in incidence of overall thyroid cancer cases Fig 2. P
Surgery
Volume 148, Number 6
Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry
John D. Cramer, et al. Surgery, 2010

5. Background
ancer cases
U.S. Census
Fig 2. PTC incidence rates by tumor size (1983–2006).
Data are age-adjusted to the 2000 U.S. Census with
Cramer et al 1149
Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry
John D. Cramer, et al. Surgery, 2010

6. Background
ion for PTC
ercentage of
dectomy per-
to 82.6% in
a downward
roidectomies
d (20.5% in
P < .0001).
ative designa-
ed over time
5–2006; P <
disparities in
r collection
tion for PTC
hyroidectomy
in 1987–1988
0001) (Fig 3).
3,493 (38.5%) 223 (2.5%) 9,072 (100%)
3,903 (45.0%) 387 (4.5%) 8,671 (100%)
543 (51.6%) 127 (12.1%) 1,053 (100%)
Fig 3. Surgical therapy for papillary thyroid cancers
(1983–2006). Data are age-adjusted to 2000 U.S. Census
Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry
John D. Cramer, et al. Surgery, 2010

7. Let’s do the Math
❖ Total Incidence of Thyroid Cancer = 11,1 : 100.000
❖ Total of Thyroidectomies in 2006 : 93.000
❖ US population aprox. 300.000.000
❖ So….
❖ 33,300 new cases in 2005-2006
❖ only 35,8% of the cases where operated on Cancer
❖ if you take Microcarcinoma and Incidentalomas

8. Other Issues
❖ nontoxic goiter
❖ compressive symptoms 28% to 36%
❖ cosmetic symptoms 17% to 69%
❖ Hyperfunctioning nodules
❖ Cardiac effects
❖ Bone alterations
❖ RAI
Watt T, Groenvold Eur J Endocrinol 2006;154:501–510

9. Is there another way ?

10. Treatment of the Nodule
❖ Aspiration
❖ Chemical Ablation
❖ Ethanol Ablation
❖ Tetracycline
❖ Thermal Ablation
❖ Laser Ablation
❖ Radiofrequency Ablation
❖ Microwave Ablation

11. Treatment of the Nodule
❖ Thermal Ablation
❖ Radiofrequency Ablation

12. Eur Radiol (2008) 18: 1244–1250
DOI 10.1007/s00330-008-0880-6 HEAD AND NECK
Woo Kyoung Jeong
Jung Hwan Baek
Hyunchul Rhim
Yoon Suk Kim
Min Sook Kwak
Hyun Jo Jeong
Ducky Lee
Received: 30 June 2007
Revised: 19 December 2007
Accepted: 15 January 2008
Published online: 20 February 2008
# European Society of Radiology 2008
Radiofrequency ablation of benign thyroid
nodules: safety and imaging follow-up
in 236 patients
Abstract This study evaluated the
safety and volume reduction of ultra-
sonography (US)-guided radiofre-
quency ablation (RFA) for benign
thyroid nodules, and the factors af-
the complications during the follow-
up period (1–41 months). The corre-
lation between the VRR and several
factors (patient age, volume and
composition of the index nodule) was
evaluated. The volume of index
nodules was 0.11–95.61 ml (mean,
6.13±9.59 ml). After ablation, the
volume of index nodules decreased to
0.00–26.07 ml (mean, 1.12±2.92 ml)
and the VRR was 12.52–100% (mean,
84.11±14.93%) at the last follow-up.
A VRR greater than 50% was
observed in 91.06% of nodules, and
27.81% of index nodules disappeared.
The complications encountered were
pain, hematoma and transient voice
W. K. Jeong
Department of Radiology,
Asan Medical Center,
College of Medicine,
University of Ulsan,
Seoul, South Korea
H. Rhim
Department of Radiology,
Samsung Medical Center,
Sungkyunkwan University
School of Medicine,
Seoul, South Korea
D. Lee
Department of Internal Medicine,
Thyroid center,
Daerim St. Mary’s Hospital,
Seoul, South Korea
VRR However, they had normalized at the subsequent 1-month
follow-up.
Table 1 The changes in volume before RFA and at each follow-up
Initial 1 month later 3 months later 6 months later Last follow-up
No. of nodules 302 247 155 140 302
Volume (ml)a
0.11–95.61
(6.13±9.59)
0.00–40.30
(2.53±4.40)
0.00–24.17
(2.00±3.24)
0.00–30.11
(1.54±4.38)
0.00–26.07
(1.12±2.92)
Largest diameter (cm)a
0.6–10.00
(2.44±1.36)
0.00–7.00
(1.73±1.03)
0.00–5.20
(1.60±0.97)
0.00–6.00
(1.26±1.07)
0.00–5.70
(1.01±1.00)
Volume reduction rate (%) 58.20 74.41 84.79 84.11
a
Mean ±standard deviation in parentheses
1248
Retrospective / No Control Group
2008

13. The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
2
All Nodules Volume
2013

14. 3cm x 3cm x 2cm = 9,4 cm3 = 9,4 ml
3cm x 3cm x 3cm =14,2cm3=14,2ml

15. The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
2
Hot Nodules Volume
2013

16. 2. Nodule volume change. (A) Pooled nodule volume change. (B) Hot nodule subgroup volume change. (C) Cold nodule subgroup
change. CI 5 confidence interval; IV 5 inverted variance; SD 5 standard deviation.
The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
2
Cold Nodules Volume
2013

17. The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
INTRODUCTION
Thyroid nodules are very common in the adult pop-
ulation with a prevalence of 20% to 76%.1
Although the
majority of nodules are benign, many require interven-
tion due to compressive symptoms, cosmetic concerns, or
the presence of hyperfunctioning thyroid tissue. Large
nodules may arise from nodular goiter, causing dyspha-
gia, dyspnea, and dysphonia due to local mass effect on
important anatomical structures in the head and neck
involved in swallowing, phonation, and breathing. In
extreme cases, nodular goiter may even lead to airway
obstruction requiring emergent surgical intervention.
Goiter may also cause significant cosmetic concerns.2
Prevalence of compressive and cosmetic symptoms in
patients with nontoxic goiter has been reported from
28% to 36% and 17% to 69%, respectively.3
Hyperfunctioning nodules are relatively rare among
benign nodules4
; however, a subset may cause subclini-
cal or overt hyperthyroidism.5
Although the majority of
patients are adequately controlled with currently avail-
able medical interventions, a small number may have
progression of hyperthyroidism. However, even subclini-
cal hyperthyroidism may adversely affect the cardiovas-
cular and skeletal systems,6
leading patients and
physicians to employ definitive treatment with radioac-
tive iodine and/or surgery.
Neither of these strategies, however, is without
risks. Radioactive iodine (RAI) therapy specifically, when
used to treat any cause of hyperthyroidism, may cause
transient thyrotoxicosis, and although this risk can be
ameliorated by pretreatment antithyroid medications,
such a pretreatment regimen may also be associated
with reduced RAI treatment success.7
Additionally, the
majority of patients undergoing RAI and virtually all
patients undergoing total thyroidectomy will have resid-
ual hypothyroidism following treatment.
From the Department of Otolaryngology–Head and Neck Surgery,
Medical University of South Carolina, Charleston, South Carolina,
U.S.A.
Editor’s Note: This Manuscript was accepted for publication
August 26, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Colin Fuller, MD, Clinical Research Fel-
low, Department of Otolaryngology–Head and Neck Surgery, Medical
University of South Carolina, 135 Rutledge Ave. MSC 550, Charleston,
SC 29425-5500. E-mail: fullercw@musc.edu
DOI: 10.1002/lary.24406
Symptoms
2013

18. comparing RFA, PEI, and PLA for the various benign
hyroid nodules that may require intervention. Addition-
ally, the articles that satisfied our inclusion criteria had
some overlap in authorship, with seven of the nine stud-
es deriving from one of two author groups. Therefore,
he data available for meta-analysis may not be as rigor-
ous and generalizable as data from a higher number of
ndependent centers. Operator experience has been sug-
gested as a factor affecting treatment efficacy,18
and thus
he generalizability of the results may be reduced by the
relatively high level of RFA experience in these two
author groups compared to the average practicing endo-
crinologist, surgeon, or radiologist. Furthermore, occult
bias not detected by the authors of this meta-analysis
might be magnified by its repeated presence in the data.
However, the lack of variety in authorship may
evidence that the technique is relatively underutilized
many regions where its introduction or expansion wou
lead to better patient care. Although the authors do n
presently submit survey data to this effect, it is o
belief that there is sufficient evidence to suppo
expanded use of radiofrequency techniques to treat go
ter and AFTNs in the United States.
At least 60,000 thyroidectomies, hemithyroidect
mies, and partial thyroidectomies are performed in th
United States each year, based on a study of 2009 data
Based on the same data, nontoxic nodular goiter is th
indication in 36% of cases, making it the most commo
indication for this procedure. The subset of these proc
dures for which consideration of RFA might pro
Fig. 4. Change in requirement of methimazole. CI 5 confidence interval; M-H 5 Mantel-Haenszel odds ratio. [Color figure can be viewed
he online issue, which is available at wileyonlinelibrary.com.]
Laryngoscope 124: January 2014 Fuller et al.: RFA for Thyroid Nodul
35
The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
INTRODUCTION
Thyroid nodules are very common in the adult pop-
ulation with a prevalence of 20% to 76%.1
Although the
majority of nodules are benign, many require interven-
tion due to compressive symptoms, cosmetic concerns, or
the presence of hyperfunctioning thyroid tissue. Large
nodules may arise from nodular goiter, causing dyspha-
gia, dyspnea, and dysphonia due to local mass effect on
important anatomical structures in the head and neck
involved in swallowing, phonation, and breathing. In
Goiter may also cause significant cosmetic concerns.2
Prevalence of compressive and cosmetic symptoms in
patients with nontoxic goiter has been reported from
28% to 36% and 17% to 69%, respectively.3
Hyperfunctioning nodules are relatively rare among
benign nodules4
; however, a subset may cause subclini-
cal or overt hyperthyroidism.5
Although the majority of
patients are adequately controlled with currently avail-
able medical interventions, a small number may have
progression of hyperthyroidism. However, even subclini-
Use of Methimazole
2013

19. The Laryngoscope
VC 2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Systematic Review
Radiofrequency Ablation for Treatment of Benign Thyroid Nodules:
Systematic Review
Colin W. Fuller, MD, MS; Shaun A. Nguyen, MD, MA; Shivangi Lohia, MD; M. Boyd Gillespie, MD, MSc
Objective: To summarize the literature published to date on the use of radiofrequency ablation (RFA) in the treatment
of benign thyroid nodules, to evaluate the effectiveness of this treatment, and to attempt an evaluation of factors that may
influence treatment outcome.
Study Design: Systematic review with meta-analysis.
Methods: Systematic literature search was performed by two separate authors in four commonly used literature data-
bases. Trials included in meta-analysis included only those presenting prospective data. Meta-analysis compared pretreatment
values to post-treatment outcomes.
Results: Of 46 full-text articles identified, nine articles satisfied inclusion criteria. Two of these articles were randomized
controlled trials comparing RFA to placebo or to some other treatment. One article was a randomized controlled trial compar-
ing one RFA treatment to two treatments. The remaining six articles were noncontrolled, prospective observational studies.
All analyzed outcomes showed statistically significant improvements from baseline to final follow-up, including reduction in
nodule size, improvement of symptom and cosmetic scores, and withdrawal from methimazole. Improvement in nodule size
remained significant in both “hot” and “cold” nodule subgroups. Twelve adverse events were identified across all studies out
of 306 total treatments. Two of these events qualified as significant adverse events. None of these events resulted in hospital-
ization or death.
Conclusions: Radiofrequency ablation is a safe and effective treatment for symptomatic thyroid nodules that are con-
firmed benign. However, the paucity of level 1 evidence comparing RFA to surgical or to other nonsurgical treatment modal-
ities is concerning.
Key Words: Radiofrequency catheter ablation; thyroid nodule; systematic review; meta-analysis.
Level of Evidence: NA
Laryngoscope, 124:346–353, 2014
INTRODUCTION
Thyroid nodules are very common in the adult pop-
ulation with a prevalence of 20% to 76%.1
Although the
majority of nodules are benign, many require interven-
tion due to compressive symptoms, cosmetic concerns, or
the presence of hyperfunctioning thyroid tissue. Large
nodules may arise from nodular goiter, causing dyspha-
gia, dyspnea, and dysphonia due to local mass effect on
important anatomical structures in the head and neck
involved in swallowing, phonation, and breathing. In
Goiter may also cause significant cosmetic concerns.2
Prevalence of compressive and cosmetic symptoms in
patients with nontoxic goiter has been reported from
28% to 36% and 17% to 69%, respectively.3
Hyperfunctioning nodules are relatively rare among
benign nodules4
; however, a subset may cause subclini-
cal or overt hyperthyroidism.5
Although the majority of
patients are adequately controlled with currently avail-
able medical interventions, a small number may have
progression of hyperthyroidism. However, even subclini-
Adverse Effects
Serious :2/277 (no death)
Non-Serious:10/277
No RCT
Few Control groups

20. ❖ Indications
❖ Benign nodules
❖ with clinical Symptoms
❖ Esthetic problem
❖ Autonomous nodule
❖ Malignant nodules
❖ Recurrent malignancy (in the bed or neck)
Korean Journal of Radiology
Review Article ^
http://dx.doi.org/10.3348/kjr.2012.13.2.117 .
pISSN 1229-6929 • elSSN 2005-8330
Korean J Radiol 2012;13(2):117-125 J
Radiofrequency Ablation of Benign Thyroid Nodules and
Recurrent Thyroid Cancers: Consensus Statement and
Recommendations
Dong Gyu Na, MD^ Jeong Hyun Lee, MD So Lyung Jung, MD^ Ji-hoon Kim, MU Jin Yong Sung, MD^
Jung Hee Shin, MD^ Eun-Kyung Kim, MD^ Joon Hyung Lee, MD^ Dong Wook Kim, MD^
Jeong Seon Park, MD'°, Kyu Sun Kim, MD', Seon Mi Baek, MD", Younghen Lee, MD", Semin Chong, MD",
Jung Suk Sim, MD", Jung Yin Huh, MD^ Jae-Ik Bae, MD", Kyung Tae Kim, MD'',
Song Yee Han, MD'', Min Young Bae, MD", Yoon Suk Kim, MD'°, Jung Hwan Baek, MD';
for Korean Society of Thyroid Radiology (KSThR), Korean Society of Radiology
'Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736,
Korea; ^Department of Radiology, Human Medical Imaging & Intervention Center, Seoul 137-902, Korea; 'Department of Radiology, Seoul St.
Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea; "Department of Radiology, Seoul National University
College of Medicine, Seoul 110-744, Korea, 'Department of Radiology and Thyroid Center, Daerim St. Mary's Hospital, Seoul 150-070, Korea;
'Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710,
Korea; 'Department of Radiology, Yonsei Univsersity College of Medicine, Seoul 120-752, Korea; 'Department of Radiology, Dong-A University
Medical Center, Busan 602-713, Korea; 'Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan 633-165, Korea;
'"Department of Radiology, Hanyang University College of Medicine, Hanyang University Hospital, Seoul 133-792, Korea, "Department of
Radiology, Haeundae Healings Hospital, Busan 613-101, Korea; '^Department of Radiology, Ansan Hospital, Korea University Medical College,
Ansan 425-707, Korea; "Department of Radiology and Thyroid Center, Chung-Ang University Hospital, Chung-Ang University College of Medicine,
Seoul 156-755, Korea; '"Department of Radiology, Mothers' Clinic, Seongnam 463-821, Korea; '^Department of Radiology, CHA University College
of Medicine, Gangnam CHA Hospital, Seoul 135-081, Korea; "Department of Radiology, Ajou University School of Medicine, Suwon 443-721,
Korea; "Department of Radiology, UNMEC Clinic, Daegu 704-910, Korea; "Department of Radiology, Dr. Han's Breast Clinic, Seoul 135-892, Korea;
"Department of Radiology, Myung Jindan Health Care Center, Seoul 157-927, Korea; ^"Department of Radiology, Thyroid Clinic, Philip Medical
Center, Seoul 150-042, Korea
Thermal ablation using radiofrequency is a new, minimally invasive modality employed as an alternative to surgery in
patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of
Thyroid Radiology has developed recommendations for the optimal use of radiofrequency ablation for thyroid nodules. These
recommendations are based on a comprehensive analysis of the current literature, the results of muLticenter studies, and
expert consensus.
Index terms: Thyroid, radiofrequency; Thyroid, ethanol; Thyroid, US; Thyroid, nodules; Thyroid, recurrent cancers; Thyroid,
intervention
2012

21. Korean Journal of Radiology
Review Article ^
http://dx.doi.org/10.3348/kjr.2012.13.2.117 .
pISSN 1229-6929 • elSSN 2005-8330
Korean J Radiol 2012;13(2):117-125 J
Radiofrequency Ablation of Benign Thyroid Nodules and
Recurrent Thyroid Cancers: Consensus Statement and
Recommendations
Dong Gyu Na, MD^ Jeong Hyun Lee, MD So Lyung Jung, MD^ Ji-hoon Kim, MU Jin Yong Sung, MD^
Jung Hee Shin, MD^ Eun-Kyung Kim, MD^ Joon Hyung Lee, MD^ Dong Wook Kim, MD^
Jeong Seon Park, MD'°, Kyu Sun Kim, MD', Seon Mi Baek, MD", Younghen Lee, MD", Semin Chong, MD",
Jung Suk Sim, MD", Jung Yin Huh, MD^ Jae-Ik Bae, MD", Kyung Tae Kim, MD'',
Song Yee Han, MD'', Min Young Bae, MD", Yoon Suk Kim, MD'°, Jung Hwan Baek, MD';
for Korean Society of Thyroid Radiology (KSThR), Korean Society of Radiology
'Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736,
Korea; ^Department of Radiology, Human Medical Imaging & Intervention Center, Seoul 137-902, Korea; 'Department of Radiology, Seoul St.
Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea; "Department of Radiology, Seoul National University
College of Medicine, Seoul 110-744, Korea, 'Department of Radiology and Thyroid Center, Daerim St. Mary's Hospital, Seoul 150-070, Korea;
'Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710,
Korea; 'Department of Radiology, Yonsei Univsersity College of Medicine, Seoul 120-752, Korea; 'Department of Radiology, Dong-A University
Medical Center, Busan 602-713, Korea; 'Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan 633-165, Korea;
'"Department of Radiology, Hanyang University College of Medicine, Hanyang University Hospital, Seoul 133-792, Korea, "Department of
Radiology, Haeundae Healings Hospital, Busan 613-101, Korea; '^Department of Radiology, Ansan Hospital, Korea University Medical College,
Ansan 425-707, Korea; "Department of Radiology and Thyroid Center, Chung-Ang University Hospital, Chung-Ang University College of Medicine,
Seoul 156-755, Korea; '"Department of Radiology, Mothers' Clinic, Seongnam 463-821, Korea; '^Department of Radiology, CHA University College
of Medicine, Gangnam CHA Hospital, Seoul 135-081, Korea; "Department of Radiology, Ajou University School of Medicine, Suwon 443-721,
Korea; "Department of Radiology, UNMEC Clinic, Daegu 704-910, Korea; "Department of Radiology, Dr. Han's Breast Clinic, Seoul 135-892, Korea;
"Department of Radiology, Myung Jindan Health Care Center, Seoul 157-927, Korea; ^"Department of Radiology, Thyroid Clinic, Philip Medical
Center, Seoul 150-042, Korea
Thermal ablation using radiofrequency is a new, minimally invasive modality employed as an alternative to surgery in
patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of
Thyroid Radiology has developed recommendations for the optimal use of radiofrequency ablation for thyroid nodules. These
recommendations are based on a comprehensive analysis of the current literature, the results of muLticenter studies, and
expert consensus.
Index terms: Thyroid, radiofrequency; Thyroid, ethanol; Thyroid, US; Thyroid, nodules; Thyroid, recurrent cancers; Thyroid,
intervention
Benign Nodule Recurrent Cancer
Benign cytology ( twice ) diagnosis of recurrence
US features (nodule and Neck) US features (surrounding structures)
Nodule Volume Tumor Volume
Symptom Score Lab tests (TG,anti-TG)
Cosmetic Score CT (selected Cases)
Laboratory Tests
CT, MRI (selected cases)
mCT Technetium (hot nodule)
2012
Case Workup

22. VASCULAR AND INTERVENTIONAL RADIOLOGY
Vascular and interventional radiology radiofrequency ablation
of benign thyroid nodules and recurrent thyroid cancers:
literature review
Irene Chiara De Bernardi • Chiara Floridi • Alessandra Muollo •
Roberta Giacchero • Gian Lorenzo Dionigi • Alfonso Reginelli • Gianluca Gatta •
Vito Cantisani • Roberto Grassi • Luca Brunese • Gianpaolo Carrafiello
Received: 27 April 2014 / Accepted: 30 April 2014 / Published online: 14 June 2014
Ó Italian Society of Medical Radiology 2014
Abstract Thermal radiofrequency ablation is a relatively
new, minimally invasive modality employed as an alter-
native to surgery in patients with benign thyroid nodules
and recurrent thyroid cancers. Different recommendations
are necessary for the optimal use of radiofrequency abla-
tion for thyroid nodules. These recommendations are based
on a comprehensive analysis of the current literature, the
results of multicenter studies, and expert consensus.
Keywords Thyroid Á US Á CEUS Á Radiofrequency Á
Ablation Á Thyroid nodules Á Thyroid recurrent cancers Á
Intervention radiology
Introduction
Thyroid nodules are very common in the adult population
with a prevalence of 20–76 % [1]. The incidence of thyroid
nodules has increased with the recently increased use of
thyroid ultrasonography (US) [1]. Although most thyroid
nodules are benign and do not require treatment, some
benign nodules may require treatment for associated
symptoms and/or because of cosmetic problems [2, 3]. As
curative surgery has several drawbacks and the efficacy of
thyroid hormone-suppressive therapy has not yet been
determined, nonsurgical, minimally invasive treatment
modalities, such as ethanol ablation (EA), percutaneous
laser ablation, and radiofrequency (RF) ablation, have been
used to treat thyroid nodules [2–7].
Thermal ablation using radiofrequency is a new, mini-
mally invasive modality that may be an alternative to
surgery in selected patients with benign thyroid nodules
and recurrent thyroid cancers [8].
This paper provides information regarding the basic
principles, indications, devices, and techniques that have
been especially designed to optimize thyroid RF ablation,
as well as the clinical results and complications.
Principles of radiofrequency ablation (RFA)
I. C. De Bernardi (&) Á C. Floridi Á A. Muollo Á
G. L. Dionigi Á G. Carrafiello
University of Insubria, Varese, Italy
e-mail: irenedebernardi@gmail.com
R. Giacchero
Radiol med (2014) 119:512–520
DOI 10.1007/s11547-014-0411-2
❖ Indications
❖ Benign nodules (3 Groups)
❖ “Symptomatic patients"
❖ “Cosmetic Problems"
❖ "Thyrotoxicosis
❖ Malignant nodules (exceptional cases)
❖ Recurrent malignancy (in the bed or neck)
2014

23. VASCULAR AND INTERVENTIONAL RADIOLOGY
Vascular and interventional radiology radiofrequency ablation
of benign thyroid nodules and recurrent thyroid cancers:
literature review
Irene Chiara De Bernardi • Chiara Floridi • Alessandra Muollo •
Roberta Giacchero • Gian Lorenzo Dionigi • Alfonso Reginelli • Gianluca Gatta •
Vito Cantisani • Roberto Grassi • Luca Brunese • Gianpaolo Carrafiello
Received: 27 April 2014 / Accepted: 30 April 2014 / Published online: 14 June 2014
Ó Italian Society of Medical Radiology 2014
Abstract Thermal radiofrequency ablation is a relatively
new, minimally invasive modality employed as an alter-
native to surgery in patients with benign thyroid nodules
and recurrent thyroid cancers. Different recommendations
are necessary for the optimal use of radiofrequency abla-
tion for thyroid nodules. These recommendations are based
on a comprehensive analysis of the current literature, the
results of multicenter studies, and expert consensus.
Keywords Thyroid Á US Á CEUS Á Radiofrequency Á
Ablation Á Thyroid nodules Á Thyroid recurrent cancers Á
Intervention radiology
Introduction
Thyroid nodules are very common in the adult population
with a prevalence of 20–76 % [1]. The incidence of thyroid
nodules has increased with the recently increased use of
thyroid ultrasonography (US) [1]. Although most thyroid
nodules are benign and do not require treatment, some
benign nodules may require treatment for associated
symptoms and/or because of cosmetic problems [2, 3]. As
curative surgery has several drawbacks and the efficacy of
thyroid hormone-suppressive therapy has not yet been
determined, nonsurgical, minimally invasive treatment
modalities, such as ethanol ablation (EA), percutaneous
laser ablation, and radiofrequency (RF) ablation, have been
used to treat thyroid nodules [2–7].
Thermal ablation using radiofrequency is a new, mini-
mally invasive modality that may be an alternative to
surgery in selected patients with benign thyroid nodules
and recurrent thyroid cancers [8].
This paper provides information regarding the basic
principles, indications, devices, and techniques that have
been especially designed to optimize thyroid RF ablation,
as well as the clinical results and complications.
Principles of radiofrequency ablation (RFA)
I. C. De Bernardi (&) Á C. Floridi Á A. Muollo Á
G. L. Dionigi Á G. Carrafiello
University of Insubria, Varese, Italy
e-mail: irenedebernardi@gmail.com
R. Giacchero
Radiol med (2014) 119:512–520
DOI 10.1007/s11547-014-0411-2
❖ No New Data
❖ Just recommendations
❖ procedures
❖ patient selection
❖ No Society Recommendation
2014
IF 2,49

24. ❖ The new guidance discusses the use of ethanol and
radiofrequency for ablation of overactive nodules,
options that have been used primarily outside the
United States. The guidance notes that these approaches
“can be considered in select patients where RAI, surgery
or long-term ATD are inappropriate, contraindicated, or
refused, and expertise in these procedures is available
❖ Hyperthyroidism
❖ Autonomous nodule
2015

25. The use of radiofrequency ablation (RFA) with local anesthesia in the
treatment of recurrent thyroid cancer has been associated with a mean
volume reduction that ranges between approximately 55-95% (881;882),
and complete disappearance of the metastatic foci in 40-60% of the
cases (845;882;883). As with alcohol ablation, multiple treatment
sessions are often required. Complications include discomfort, pain,
skin burn and changes in the voice (884). Similar to alcohol ablation
techniques, it appears that RFA may be most useful in high risk surgical
patients or in patient refusing additional surgery rather than as a
standard alternative to surgical resection of metastatic disease
(883-885). More recently, preliminary findings using ultrasound guided
laser ablation for treatment of cervical lymph node metastases have
been reported (886).
❖ Nodule Guideline - Cancer
❖ [C21] Radiofrequency or Laser Ablation
2015

26. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
Inclusion Critirea Exclusion Critirea
older than 18 years of age
nodules w/ US features suggestive of
malignancy
resence of a solid thyroid nodule (solid portion >70%
(volume between 10 and 20 mL)
treatments for the thyroid nodule in
the six months prior to enrollment in
this study
presence of pressure symptoms or cosmetic problems
confirmation of benign findings in at least two separate US-
guided core needle or fine-needle aspiration (FNA)
normal serum levels of thyroid hormones, thyrotropin
(TSH), and calcitonin

27. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
n=80
n=40
observation
n=40
RFA
n=20 n=20 n=20 n=20

28. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
Study end points
The primary end points of the current study were (a) the
quantitative volume reduction ratio of BTN between control
(40 patients) and RFA (40 patients) at six months after the
procedure, and (b) the comparison of the volume reduction
ratio of the patients (20 vs. 20) of two centers after RFA. The
Korean center (the ‘‘more experienced group’’ in this field)
had an experience of about 3000 cases of thyroid RFA; the
Italian center (the ‘‘less experienced group’’ in this field) had a
significant experience in interventional US-guided therapies
(both PEI and RFA by other devices), and had previously
treated 50 cases of BTN with the moving-shot technique, after
an initial instruction given by a Korean radiologist (J.H.B.).
in the treated nodules in comparison with an expected max-
imum volume reduction of 5% in the control group, enrol-
ment of 40 patients for each group could guarantee statistical
power of more than 80%.
Thirteen percent was chosen as the clinically relevant
difference between the experienced and less experienced
group, according to previous data of US measurement–
remeasurement variability (the results of previous studies
were 5.1–6.6%, and relevant difference in the primary end-
point was set as 13%, which is double 6.6%) (28,29).
Results
BaselinecharacteristicsofpatientsingroupAandgroupBare
shown in Table 1.BTN volume,function,and US characteristics
Table 2. Treatment Parameters of RFA
Korea (n = 20) Italy (n = 20) p-Value
Mean ablation time (s) 435.8 – 142.4 819.5 – 225.9 0.0001
Mean RF power (Watt) 75.3 – 10.4 49.7 – 4.7 0.0001
Total energy (Joule) 33,068.0 – 13,800.5 40,364.7 – 10,801.1 0.72
Energy/mL (J/mL) 2436.3 – 916.2 2521.7 – 803.6 0.84
Values are reported as mean – SD. Significant values are shown in bold.
RFA, radiofrequency ablation.
faster w/ higher power
longer w/ less power
Same Energy

29. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
inte
ma
No
A
in
bas
p<
3.3
6 m
W
Table 3. Comparison of Clinical Characteristics
Between RFA and Control Groups at Six Months
Outcome
RFA
(n = 40)
Controls
(n = 40) p-Value
% Volume reduction [IQR] 71 [21] - 3 [23] 0.0001
Symptom score 0.4 – 0.7 3.3 – 1.7 0.0001
Cosmetic score 1.7 – 0.8 3.5 – 0.7 0.0001
TSH (lIU/mL) 0.9 – 0.8 1.0 – 0.9 0.190
fT4 (pg/mL) 10.8 – 2.9 11.9 – 2.0 0.05
Thyroglobulin (ng/mL) 31.5 – 38 13.6 – 22 0.02
Values are mean – SD; volume reduction values are reported as
RADIOFREQUENCY ABLATION FOR NONFUNCTIONING BEN

30. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
inte
ma
No
A
in
bas
p<
3.3
6 m
W
Table 3. Comparison of Clinical Characteristics
Between RFA and Control Groups at Six Months
Outcome
RFA
(n = 40)
Controls
(n = 40) p-Value
% Volume reduction [IQR] 71 [21] - 3 [23] 0.0001
Symptom score 0.4 – 0.7 3.3 – 1.7 0.0001
Cosmetic score 1.7 – 0.8 3.5 – 0.7 0.0001
TSH (lIU/mL) 0.9 – 0.8 1.0 – 0.9 0.190
fT4 (pg/mL) 10.8 – 2.9 11.9 – 2.0 0.05
Thyroglobulin (ng/mL) 31.5 – 38 13.6 – 22 0.02
Values are mean – SD; volume reduction values are reported as
RADIOFREQUENCY ABLATION FOR NONFUNCTIONING BEN

31. Efficacy and Safety of Radiofrequency Ablation Versus
Observation for Nonfunctioning Benign Thyroid Nodules:
A Randomized Controlled International Collaborative Trial
Maurilio Deandrea,1
Jin Yong Sung,2
Paolo Limone,1
Alberto Mormile,1
Francesca Garino,1
Federico Ragazzoni,1
Kyu Sun Kim,2
Ducky Lee,3
and Jung Hwan Baek4
Background: Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the
management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are
lacking.
Objective: The aims of this study were to assess the volume reduction of BTN after a single RFA performed
using the moving-shot technique and to compare the volume reduction obtained in patients treated in two
centers with different experience of the moving-shot technique.
Method: This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin,
Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunc-
tioning BTN (volume 10–20 mL) were enrolled. Twenty patients in each country were treated by RFA using a
18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as
controls (group B).
Results: At six months, BTN volume significantly decreased in group A (15.1 – 3.1 mL vs. 4.2 – 2.7 mL;
p < 0.0001), whereas it remained unchanged in group B (14.4 – 3.3 mL vs. 15.2 – 3.5 mL). The baseline volume
was larger in the Italian series (16.4 – 2.5 mL vs. 13.9 – 3.3 mL, p = 0.009). However, at six months, there was
no significant difference between the Korean group and the Italian group (3.7 – 2.9 mL vs. 5.5 – 2.2 mL). Both
cosmetic and compressive symptoms significantly improved (3.6 – 0.5 vs. 1.7 – 0.4 and 3.6 – 1.9 vs. 0.4 – 0.7,
respectively; p < 0.001). No side effects occurred.
Conclusions: RFA was effective in reducing the volume of BTN. The outcome was similar in centers with
different experience in the moving-shot technique.
Introduction
Thyroid nodules are very common in the general
population, with a prevalence of about 50% in subjects
older than 60 years of age undergoing neck ultrasound (US)
examination (1). In the majority of cases, thyroid nodules are
benign, but they can be responsible for compression of local
structures, which can result in discomfort and a decreased
quality of life. Large compressive benign thyroid nodules
(BTN) may also result in life-threatening conditions, due to the
possible onset of acute respiratory crisis. Surgery and radio-
iodine therapy are the main therapeutic approaches for com-
pressive or toxic nodules (1–3). However, surgery is charged by
the possibility of immediate complications such as wound in-
in 0.2–2.7% of cases, and by laryngeal recurrent nerve palsy and
hypoparathyroidism, which can either be transient (in 2–28% of
cases) or permanent (in 0.2–3% of cases) (4–7). Moreover, in
the case of surgery for recurrent goiter, the frequency of such
complications increases further (up to 37% for transient and
7.8%, for permanent damage) (4–7). In addition, a number of
patients with BTN with an indication for surgery refuse this
approach. In some of these cases, radioiodine therapy may be
ineffective, especially in large nonfunctioning nodules (8,9).
Minimally invasive therapeutic options have been pro-
posed to treat BTN when surgery or radioiodine is refused,
contraindicated, or ineffective (10). Percutaneous radio-
frequency ablation (RFA) is a minimally invasive procedure
that has been used to treat both malignant and benign tumor
THYROID
Volume 25, Number 8, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2015.0133
2015
inte
ma
No
A
in
bas
p<
3.3
6 m
W
Table 3. Comparison of Clinical Characteristics
Between RFA and Control Groups at Six Months
Outcome
RFA
(n = 40)
Controls
(n = 40) p-Value
% Volume reduction [IQR] 71 [21] - 3 [23] 0.0001
Symptom score 0.4 – 0.7 3.3 – 1.7 0.0001
Cosmetic score 1.7 – 0.8 3.5 – 0.7 0.0001
TSH (lIU/mL) 0.9 – 0.8 1.0 – 0.9 0.190
fT4 (pg/mL) 10.8 – 2.9 11.9 – 2.0 0.05
Thyroglobulin (ng/mL) 31.5 – 38 13.6 – 22 0.02
Values are mean – SD; volume reduction values are reported as
RADIOFREQUENCY ABLATION FOR NONFUNCTIONING BEN

32. Technique

33. Advanced Ultrasound Skills
Oblique approach
Vertical approach

34. Radiofrequency Ablation
200-1200 KHz
friction heat

35. Radiofrequency Ablation
Fixed electrode technique
- ablate completely all the cancers
- effective in larger organs, liver, lungs

36. Moving-Shot Technique

37. Moving-Shot Technique

38. Tree Dimension Treatment

39. Trans-Isthmic Access
Clearly visible anatomical
Prevent back leakage of hot liquid
Stability on swallowing,gag, or cough

42. Trans-isthmic approach: 5 As
Appearance

43. Trans-isthmic approach: 5 As
Alignment
Appearance
Target location

44. Trans-isthmic approach: 5 As
Alignment
Advance
Appearance
Target location

45. Trans-isthmic approach: 5 As
Alignment
Advance
All the length
Appearance
Target location

46. Seeing All the Length

47. Trans-isthmic approach: 5 As
Alignment
Advance
All the length
Appearance
Target location
Ablation

48. Steps for Successful RFA
❖ Surgical Anatomy Familiarity
❖ Ultrasound Principles
❖ Ultrasound FNA experience
❖ Radiofrequency Training

49. Case 1
77 y/o women, isoechoic nodule, with hipoechoic halo, peripheral vascularization.
2.39 cm x 2,0cm x 1,39cm ( 3,47ml)
bethesda II
Very Symptomatic

50. Case 1
77 y/o women, isoechoic nodule, with hipoechoic halo, peripheral vascularization.
2.39 cm x 2,0cm x 1,39cm ( 27,8 ml)
bethesda II
Very Symptomatic
1 month

51. Case 1
2,39 cm x 2,0cm x 1,39cm ( 27,8ml): 1,36cm x 1,36cm x 1,22cm (9,45ml)
% Volume Reduction = 66 %
Became Asymptomatic
3 month

52. Case 1
2,39 cm x 2,0cm x 1,39cm ( 27,8ml):
1,36cm x 1,36cm x 1,22cm (9,45ml)
1,17cmx1,17cmx1,41cm (8,08ml)
6 month
•pré-op 27,8cm3 - 1º Mês 25 cm3 - 3º Mês 9,45 cm3
1,17 x 1,17 cm 1,41
- 70%

53. acknowledgement
Dr. Jung Suk Sim
Dr. Cho

54. Thank You !