RFA in thyroid disorders-journal club presentation

1. JOURNAL CLUB -23/11/22
Dr MANO ZAC MATHEWS
Mch Resident
Department of Endocrine Surgery

2. From the *Division of Endocrine and Oncologic Surgery, Department of
Surgery, Division of Endocrine and Oncologic Surgery, Tulane University
School of Medicine, New Orleans, LA;

3. • Vol 276,number 4
• October 2022
• Impact factor :13.79

4. INTRODUCTION
• Thyroid nodules detected by Usg in upto 68% of healthy patients
• 15% - progressive enlargement with compression/cosmetic symtoms
• Now RFA : first-line alternative to surgery for patients with benign
thyroid nodules with compressive and/or cosmetic symptoms.
• (The international multidisciplinary consensus statement of multiple scientific societies)

5. • Percutaneous thermal procedure under LA
• First introduced by Korea in 2006
• RFA approved by the US FDA recently
• First,large, multi-institutional, prospective study examining
thyroid nodule treatment response to RFA ,reported in US
• Tulane University School of Medicine, New Orleans, LA
• The Johns Hopkins University School of Medicine, Baltimore

6. Study design
• Prospective multi-institutional study
• Treatment of thyroid nodules with RFA with subsequent regular
follow-up at 1, 3, 6, 12 months, and then yearly
• Treatment was performed by 5 thyroid surgeons

7. Primary outcome
• Volume reduction rate (VRR) >50%
• Sonographic features associated with RFA success
• Procedure associated complications

8. Recruited cohort
• All consecutive patients with benign nodules treated with RFA
between July 2019 and January 2022
• Comprehensive neck ultrasound assessment was performed for
each thyroid nodule
• Measurements taken in three dimensions and evaluated for
composition, echogenicity, margins, echogenic foci, vascularity,
and elastography.
• The majority of nodules underwent fine-needle aspiration
(FNA) biopsy twice to confirm benignity.

9. Inclusion criteria
1. Benign thyroid nodule on 2 FNA biopsies prior to ablation or
benign sonographic appearance with 1 benign cytologic result
2. No history of ethanol injection or Radioactive iodine ablation
3. Follow-up for at least 3 months.

10. Definitions
• Elasticity : predominantly stiff(>80% stiff)
predominantly soft(<20% stiff)
mixed(21-79%)
• Composition: Solid(<10% cystic)
Cystic(>90%cystic)
Mixed
• Vascularity:
grade 0 (no flow)
grade 1 (peripheral flow)
grade 2(internal flow <50%)
grade 3 (internal flow > 50%)

11. • Volume reduction rate (VRR) -the percentage reduction in
nodule volume.
• VRR = [(V0-V1)/V0]×100
• V0 - baseline nodule volume
• V1 - postablation nodule volume at a specific follow-up interval.

13. RFA-procedure details
• Supine position with mild neck extension
• Grounding pad is firmly attached to each thigh
• Neck painted and draped, LA administered
• Trans-isthmic approach: medial to lateral
• Moving shot technique
• 18- or 19-Guage RFMedical (Seoul, Korea) electrode was used, with an
active tip of either 5, 7, 10, or 15 mm
• Nodules with a large cystic component were aspirated prior to RFA
• Multiple small conceptual ablation units are ablated unit-by-unit by moving
the electrode

14. Moving shot technique
unit-by-unit ablation of thyroid nodules accomplished by moving the electrode

15. • RF power :30-120W
• Ablation initiated with an energy of 15 Watts (W): 5-10 sec
• Incremental power delivered at 10 W until adequate impedance,
(confirmed by tissue bubbling) was achieved.
• Active tip was left in the initial position until impedances increased
over 200 ohms
• Voice quality was monitored during the procedure by intermittent
self-assessment
• Postprocedure flexible laryngoscopy was performed to assess the
recurrent laryngeal nerve function.

17. VRR (volume reduction rate)

19. 4 AFTNs

23. Literature Review

24. • 94 patients: 66 non toxic and 28 toxic
• All TNs significantly decreased in size after RTA
• The mean percent decrease in TN volume 12 months after RTA 78.6 ± 2.0%
• At 2 years: 79.4 ± 2.5%
• Hyperthyroidism resolved in most patients ( methimazole therapy completely
patients )

25. • Mean percentage decrease of BTN volume was 66.8 ± 13.6%
(p < 0.001)at 6 months
• At 6-month, symptom score had improved significantly (p <
0.001)
• Cosmetic score improved significantly between baseline and 6
months

26. • 8 articles published between 2008 and 2018 were included
• The overall number of AFTN treated by RFA was 205.
• The pooled rate of patients with TSH normalization was 57%
• Scintigraphically proven optimal response was 60%
• The pooled VRR at 1 year was 79%
• Baseline nodules volume was associated with the rate of TSH normalization.
• ‘Moderate efficacy’

27. • Retrospective study done in Korea
• From June 2002 to September 2009
• 1459 patients underwent RF ablation of 1543 thyroid nodules
• observed 48 complications (3.3%), 20 major and 28 minor

28. Major complications
• Voice changes (n =15)
• Brachial plexus injury (n= 1)
• Tumor rupture (n= 3)
• Permanent hypothyroidism
(n=1)
Minor complications
• Hematoma (n = 15)
• Skin burn (n = 4)
• Vomiting (n = 9)

29. ATA 2015 guidelines
• 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% and 95% and
complete disappearance of the metastatic foci in 40%–60% of the cases
• RECOMMENDATION 93
• (A) Both stereotactic radiation and thermal ablation (RFA and cryoablation)
show a high efficacy in treating individual distant metastases with
relatively few side effects and may be considered as valid alternatives to
surgery.

30. • comparison of the Thyroid RFA Guidelines of International Societies

34. International consensus statement-2021

38. Pros of this study
• Large prospective cohort study
• Multi-institutional
• Study performed by Thyroid surgeons
• Assessment of elastography features in conjunction with RFA VRR

39. Cons of this study
• Short follow up period :1 year
• Efficacy of RFA on symptom improvement (pre and post RFA)was not
assessed in a questionnaire based objective scoring format
• Demographic profile : mean age of cohort-61 years

40. References
1. Cesareo R, Pasqualini V, Simeoni C, et al. Prospective study of effectiveness of ultrasound-
guided radiofrequency ablation versus control group in patients affected by benign thyroid
nodules. J Clin Endocrinol Metab. 2015;100:460–466
2. Baek JH, Lee JH, Sung JY, et al. Complications encountered in the treatment of benign thyroid
nodules with US-guided radiofrequency ablation: a multicenter study. Radiology.
2012;262:335–342.
3. Zhang M, Luo Y, Zhang Y, et al. Efficacy and safety of ultrasoundguided radiofrequency ablation
for treating low-risk papillary thyroid microcarcinoma: a prospective study. Thyroid.
2016;26:1581–1587.
4. Spiezia S, Garberoglio R, Milone F, et al. Thyroid nodules and related symptoms are stably
controlled two years after radiofrequency thermal ablation. Thyroid. 2009;19:219–225.

41. 5) Orloff LA, Noel JE, Stack BC Jr, et al. Radiofrequency ablation and related ultrasound-guided ablation
technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary
consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia
Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine
and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean
Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association.
Head & Neck. 2022;44(3):633-660. doi:10.1002/hed.26960
6) Bryan R. Haugen et al.2015 American Thyroid Association Management Guidelines for Adult Patients
with Thyroid Nodules and Differentiated Thyroid Cancer; THYROID,Volume 26, Number 1, 2016

42. Thank you