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The How-To of Thyroid Radiofrequency Ablation: Procedure Technique & Post-Procedure Management

Author Gabrielle Gard covers The How-To of Thyroid Radiofrequency Ablation: Procedure Technique & Post-Procedure Management on BackTable VI

Gabrielle Gard • Sep 21, 2022 • 39 hits

Thyroid radiofrequency ablation (RFA) is a minimally invasive technique that can reduce the size of thyroid nodules and restore thyroid function. Interventional radiologist Dr. Tim Huber provides an in-depth overview of his thyroid ablation technique on the BackTable Podcast, sharing pearls and pitfalls from his hands-on experience with the procedure. Read on to learn about the trans-isthmic approach, how to minimize complications, and what to look out for throughout post-procedure management. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Brief

• Dr. Huber uses the trans-isthmic approach to keep the nodule visible and to provide electrode stability.

• For patient safety, Dr. Huber checks for immediate voice changes during the procedure and keeps patients in the recovery room for an hour to watch for emergency complications.

• While it takes about 3 months for patients to reach a euthyroid state, Dr. Huber still does routine follow-ups and uses ultrasounds and TSH levels to check progress.

• Dr. Huber mentions that providers must inform the person who conducts the ultrasound that a thyroid ablation was performed to avoid misdiagnosis.

• For durable success, Dr. Huber suggests aiming for a 70-80% volume reduction at one year.

Thyroid nodule during thyroid radiofrequency ablation (RFA) procedure

Image provided by Dr. Tim Huber

Table of Contents

(1) Thyroid Radiofrequency Ablation via the Trans-isthmic Approach

(2) How to Maintain Patient Safety During Thyroid RFA

(3) Post-Procedure Follow-up and Measuring Success

Thyroid Radiofrequency Ablation via the Trans-isthmic Approach

In order to avoid hitting the “danger triangle” and damaging the recurrent laryngeal nerve, Dr. Huber uses the trans-isthmic approach for thyroid radiofrequency ablation. With the trans-isthmic approach, Dr. Huber recommends going from medial to lateral in a transverse plane and going deep to superficial with the electrode so the nodule is visible the entire time. Dr. Huber points out another benefit of this approach: stability of the probe in case the patient coughs or swallows. During the procedure, Dr. Huber watches for corresponding echogenic changes within the thyroid nodule to measure his progress in a similar fashion to a track ablation. From Dr. Huber’s experience with thyroid ablation, he has seen minimal impact on normal thyroid tissue with the trans-isthmic approach.

[Dr. Aparna Baheti]:
So just walk me through how you would do your standard run of the mill thyroid ablation.

[Dr. Tim Huber]:
Yeah. So we do these all in our outpatient IR suite here at OSHU. So we have a nice big room to put the patients in. They’re laid out on our angio table, which is definitely overkill for this procedure, but it's very nice for us. We get them positioned, and you want the neck pretty extended, so you can really get the nodule into a good position to visualize the whole nodule. And then I always scan the patient to make sure we're in a good spot. Then we prep everything out. We numb the neck, numbing the skin, numbing down to the thyroid capsule and that's with 1% lidocaine. And I find that really lidocaine is sufficient for most patients to get them a completely numb and more or less pain-free during the procedure. You don't need to do moderate sedation or anything more heavy. Then we go in with the electrode, trans-isthmic approach kind of medial to lateral in a transverse plane. And you really want to work basically ablating deep to superficial because as you start ablating the nodule, you're going to create this echogenic cloud of microbubbles around the tip of your electrode, and it's going to gas out everything posterior. So if you work deep to superficial, you'll be able to kind of see what you're doing the whole time. And basically you just fan your electrode up, ablating that whole segment of the nodule, and then work on another segment kind of go up down with your ultrasound unit and find another place to start ablating and keep it going until the whole thing is covered.

[Dr. Aparna Baheti]:
Okay. How big are these electrodes?

[Dr. Tim Huber]:
Good question. So most people are familiar with the really long electrodes that we use for kidney ablations or liver ablations. These are much shorter. They're specially designed to be a little bit more friendly for the head and neck and a little more user-friendly so they have a nice grippy handle that's a little bit shorter than the standard RFA electrode, and then the shaft is shorter as well. So it's more like a pencil size, a little bit longer than a pencil. So much more maneuverability allows for a lot more fine control.

[Dr. Aparna Baheti]:
Okay. So then in terms of equipment purchases, your capital equipment purchases, the RFA generator, and then a probe for each patient, right?

[Dr. Tim Huber]:
That's negotiable as it always is with these kinds of ablation systems. So the newer model that most practices are going with now is essentially rolling the cost of the generator into the volume purchase with your electrodes, and see that's the most common thing that I've heard about across the country. So you can choose to buy the generator upfront and kind of reduce your probe costs that way, or kind of roll that in on a per probe cost. Pay a little bit more per electrode, but then if you're not using them, you can basically give everything back and not have purchased that piece of equipment.

[Dr. Aparna Baheti]:
Oh, that's great. Gives people a chance to try it before they buy it, right?

[Dr. Tim Huber]:
Absolutely.

[Dr. Aparna Baheti]:
One other thing you've mentioned to me before about the trans-isthmic approach with these probes is just that going trans-isthmic allows the probe to really have a place to stay. And it prevents it from moving around a bunch in the thyroid. Have you found that that's another benefit of going trans-isthmic as opposed to lateral to medial?

[Dr. Tim Huber]:
Yeah. So a lot of patients and even providers kind of worry that the thyroid, being so superficial in the neck and not having much tissue to kind of anchor it, what's going to happen when the patient breathes or coughs or swallows? How are we going to secure the probe as you're doing this ablation? And the trans-isthmic approach really gives you more tissue at that oblique angle to kind of hold everything in place. And I found that really, security of the probe is not an issue, it works just fine. And even when patients are talking or swallowing or breathing, that electrode is not going anywhere.

[Dr. Aparna Baheti]:
What's your end point for treating a certain area? Like, do you do 30 seconds at each site or something like that?

[Dr. Tim Huber]:
What I found from doing a little bit of back table experimenting is that the echogenic appearance/echogenic changes that you'll see on ultrasound correspond really well to the ablation zone. So as you're doing your ablation, you really want to see those echogenic changes within the thyroid nodule. And you'll kind of know from that what's been ablated. And so it's this sort of moving shot technique or pullback technique. So you go in, you ablate, and slowly kind of pull back along a track, almost like a track ablation, if you're familiar with that. And as you're doing that, you'll see changes in the nodule and you want to see basically those same changes throughout the entire nodule.

[Dr. Aparna Baheti]:
Okay. How long does the whole procedure take?

[Dr. Tim Huber]:
It varies a lot on the size of the nodule for a two to three centimeter nodule, you're looking at probably 15 to 20/25 minutes. For a bigger nodule, that's say six centimeters, you're looking at probably 45 minutes, maybe an hour.

[Dr. Aparna Baheti]:
I see. Yeah, you get faster the more you do it, right?

[Dr. Tim Huber]:
Yeah. Yeah, definitely. There's a learning curve with this, that the first couple you do are going to be much slower. And I find that with myself too. The first few that I did definitely took a lot longer, trying to be very meticulous and get the whole thing ablated very carefully. As you go on, you can kind of use a little bit higher wattage, move a little bit faster to the nodule and a little faster with your times.

[Dr. Aparna Baheti]:
So, is it a big deal if you ablate some normal thyroid tissue too?

[Dr. Tim Huber]:
In general, no. There's usually not a huge impact to the thyroid function with this procedure. It's very difficult to really ablate too much into the normal thyroid tissue. There's usually enough peritumoral vascularity that'll kind of buffer a little bit of the heat and the ablation zone kind of outside the nodule. So I've really found very minimal impact on the normal thyroid tissue in my follow-ups.

Listen to the Full Podcast

Thyroid Nodule Ablation with Dr. Tim Huber on the BackTable VI Podcast)
Ep 182 Thyroid Nodule Ablation with Dr. Tim Huber
00:00 / 01:04

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How to Maintain Patient Safety During Thyroid RFA

Patient safety is of utmost importance during the thyroid radiofrequency ablation, and Dr. Huber has a few ways to ensure this. One method he uses is a sort of squeezy toy that patients can squeeze if they feel pain or need attention during the thyroid ablation. Dr. Huber also recommends periodically pausing ablation and checking to see if there are voice changes. One rescue technique that can be effective is to inject chilled D5 or saline into the danger triangle and chill the laryngeal nerve, but these have to be on hand and ready to use during the procedure. In general, Dr. Huber has not found skin burns to be an issue, but he recommends keeping the electrode off while puncturing the skin and when entering.

In Dr. Huber’s experience, most patients tolerate this procedure well, and ibuprofen is sufficient for post-procedure pain management. That said, if any of the following are observed, the patient should be sent to the ER: significant swelling or bruising or a rapidly evolving hematoma.

[Dr. Aparna Baheti]:
What kind of feedback do you elicit from your patients during the procedure to let you know that you could be in trouble?

[Dr. Tim Huber]:
So we give all of our patients, it's basically a little squeezy, almost like a dog toy, that they can squeeze during the procedure if anything's painful or are hurting and they want to get our attention. So it just gets us to pay attention real quick and turn off the generator and check in with them. But during the procedure, I will intermittently pause and kind of check in and see how they're doing in terms of pain, comfort, and just check their voice and make sure there aren't any voice changes.

[Dr. Aparna Baheti]:
I see, you can sometimes see immediate voice changes with this ablation?

[Dr. Tim Huber]:
So you can see immediate voice changes if you do start to ablate in the danger triangle, typically you'll know that you were kind of in a sketchy area and that happens and you'll check in with your patient. It's pretty uncommon for you to be totally surprised by a voice change. There are some rescue techniques of trying to inject some chilled D5 or saline into the danger triangle of that had been described to try to sort of rescue the recurrent laryngeal nerve and chill it. They can be effective, but you have to have that kind of ready to go on hand, so it's not real feasible for most people.

[Dr. Aparna Baheti]:
So we kind of talked about what you don't want to hit and what you do want to hit. And then, in terms of skin burns, has that been an issue with these probes at all?

[Dr. Tim Huber]:
I haven't found it to be an issue. The shaft of the probe is cooled with chilled saline that prevents char and also helps prevent skin burns. You want to keep the electrode off as you're puncturing the skin, and they have a diamond cut tip, so they go into this skin really easily, no incision needed, but electrode off as you enter. And if you do that really there's minimal chance of skin burning.

[Dr. Aparna Baheti]:
So in the US, the only system available is the RF monopolar system, correct?

[Dr. Tim Huber]:
Correct. And they're about three companies offering different systems, but they're all monopolar right now in the US. They have bipolar in Korea, but we don't have that here yet.

[Dr. Aparna Baheti]:
Classic Korea, always ahead of us for thyroids. So, let's talk a little bit about post-op care. What do you do once you get the patient off the table?

[Dr. Tim Huber]:
Yeah. So we always check the voice. It's the first thing we do. I've talked to the patient, see how they're doing. Then they go to our recovery area for about an hour post procedure. We're checking in to make sure their voice hasn't changed, they're swallowing okay, breathing okay, able to eat, and their pain is well controlled. And in general, most patients do okay. A little sore, but nothing too severe. We give them ice packs for the neck, give them some ibuprofen and recommend that pretty much for pain control after the procedure for the first couple of days. I warn them that for about three to five days after the procedure, they'll have some soreness in the neck and kind of like a bad strep throat, usually nothing worse than that. If they're having a lot of swelling, bruising, or kind of a rapidly evolving hematoma, they should call us and go to the ER and get checked out pretty quickly. But we have not had a case of that sort of delayed hematoma here.

[Dr. Aparna Baheti]:
Do most of the complications you see kind of rear their head within an hour?

[Dr. Tim Huber]:
In general, most things are going to be pretty immediate. The things that are going to happen later are going to be a little more easily manageable over the phone if you will. Some patients will have more pronounced swelling and even kind of post embolization or post ablation syndrome of kind of like malaise and feeling kind of run down. Some steroid taper can really help with those symptoms if you get to that situation. I've discussed that with one patient, but she didn't want to do that and ended up resolving the next day and feeling better.

Post-Procedure Follow-up and Measuring Success

During the follow-ups, Dr. Huber regularly checks ultrasounds for the nodule size and for volume shrinkage, and he also will check TSH to ensure it has stabilized and normalized. Because the appearance of the nodule post-ablation may trigger a TI-RADS 5 or cancer warning, Dr. Huber mentions that it is critical to inform the person who reads the ultrasound of the thyroid ablation procedure and that it may last up to a year. During the follow-ups, providers can also measure the success of the thyroid radiofrequency ablation, and there are 3 metrics commonly used: volume reduction ratio, symptomatic score, and cosmetic score. From his practice, Dr. Huber has seen that in order for the thyroid ablation to be a true and durable success, the volume reduction should be around 70-80% at one year. Typically Dr. Huber will retreat a patient only if the patient begins to have symptoms again that are bothersome.

[Dr. Aparna Baheti]:
I want to knock on wood here, but it sounds like it doesn't have a ton of complications associated with it. That's great. So then tell me about your clinical follow-up.

[Dr. Tim Huber]:
Yeah, so we're probably a little more aggressive then maybe totally necessary, but we basically see patients back at one month and then every three months for the first year. And at those follow-ups we're checking ultrasound each time to check the nodule size and check for the shrinkage in the volume. We're also checking TSH at the one month visit. And then for non-functional benign nodules, we just check it once, if it's normal, and we kind of hold off until the one-year mark and we check it again there. For the functional nodules, I'll keep checking TSH until it's basically stabilized and normalized, hopefully at a new euthyroid state.

[Dr. Aparna Baheti]:
How long does it usually take for the hyper functioning nodules to get them to euthyroid state?

[Dr. Tim Huber]:
So I've done about three patients so far, and in my practice I've found that it takes about three months, and they're back to euthyroid state. It can take a little bit longer for their symptoms to totally normalize, but in general, I find that it's fairly quick.

[Dr. Aparna Baheti]:
Yeah, I was thinking a year. That's great, and then I know you have the luxury of being able to do the follow-up ultrasounds yourself. But in a lot of practices, the diagnostic folks are going to be reading the follow-up ultrasounds. And I imagine these things look pretty scary, post ablation, like many things post ablation. Can you just talk a little bit about what they look like on the follow-up and how to get them not to say it's like a TI-RADS 5 lesion.

[Dr. Tim Huber]:
Yeah. So that's one of the big things you have to worry about. And that's one of the reasons why I do a lot of the follow-ups in my own clinic. I do get the three month and the one year ultrasounds done in our radiology department here just for some objectivity to make sure I'm not totally making up numbers. But you do want to make sure that whoever's doing the ultrasounds knows what you're doing and what the appearance should be after this procedure. If you lose a patient to follow up and they go off to some other city and get scanned, it's very easy for someone to say, “Hey, this is hypoechoic. This looks scary. There's maybe areas of calcification. This looks like a TI-RADS 5. This is cancer. It needs to come out now.” And if they biopsy it after ablation, it's going to come back with all kinds of weird pathology and necrosis and strange things that are going to look really scary. So it'll get read out as something bad and they're going to get surgery most likely. So you want to make sure they're getting ultrasounds by people who know what's going on and that they're able to basically give you a decent read. So whether that's just informing your local department of, “Hey, I did this ablation, it's going to look a little funky, just FYI,” or doing it yourself. I think either one's acceptable.

[Dr. Aparna Baheti]:
How long does it look all crazy for?

[Dr. Tim Huber]:
So that's a good question. It can look a little bit funky even up to a year. Usually the margin cleans up by about three to six months, and it's looking a little bit more like a normal ablation zone, but it'll look hypoechoic and obviously shrinking down up to a year plus.


[Dr. Aparna Baheti]:
So Tim, how do you gauge outcomes from this procedure?

[Dr. Tim Huber]:
Yeah. So the papers that have been published on this typically report the volume reduction ratio, so how much the nodule has shrunk by. They also look at the symptomatic score and the cosmetic score. So the symptom score is super subjective. It's basically like a zero to 10 scale of how bothersome the symptoms are for the patient. It's not the most scientific thing in the world, but at least it gives you some sense of how bothered the patient was by symptoms pre-procedure and then kind of where they are afterwards. In general, we're finding that the symptoms improve very quickly, usually by the three-month mark. By the 3-6 month mark, people have a pretty significant reduction in their symptoms. And then the cosmetic grade is basically a one to four scale. Four is a visible neck bulge, three is visible if they swallow, two is palpable, and one is not visible. So those are three different metrics that we're using, just because they've been used in other papers to kind of mirror that.

[Dr. Aparna Baheti]:
How much volume reduction is considered successful?

[Dr. Tim Huber]:
Yes, a lot of the papers talk about 50% as being kind of technical success. But I find that if you want to really reduce the size of the nodule and have it be durable, at least for five plus years, you really want to shoot for something higher than that. More like 70 to 80% at a year. That's kind of what we do here.

[Dr. Aparna Baheti]:
What pushes you to re-treat a patient?

[Dr. Tim Huber]:
So incomplete symptom resolution. If they're getting to sort of the six or nine month mark, and they're still saying, “Yeah, I was at an eight and I'm down to a five, but I'm still kind of feeling this sensation of something in my throat or occasional dysphasia,” and there's still some residual tissue there that's not totally ablated, I'll go back and try to re-ablate and touch that up. Typically patients will have a pretty significant improvement even with a modest reduction in size, like 50%. And there could be some tissue that's viable, but if their symptoms improve, I usually just leave it alone. Kind of let the patient symptoms drive it mostly.

[Dr. Aparna Baheti]:
Have you treated any patients with multinodular goiter?

[Dr. Tim Huber]:
So we have, it's a definitely a little more controversial, especially in the Korean and the Italian literature. They're definitely more challenging patients. And they often have bilateral nodules, which can present some challenges. I don't treat both sides at the same time, just still with that theoretical risk of damaging the laryngeal nerve on both sides and causing bilateral vocal cord paralysis. I just stick to one side at a time, and I'll kind of target the dominant nodule and any adjacent nodules.

Podcast Contributors

Dr. Tim Huber discusses Thyroid Nodule Ablation on the BackTable 182 Podcast

Dr. Tim Huber

Dr. Timothy Huber is an interventional radiologist at Oregon Health & Science University in Portland, Oregon.

Dr. Aparna Baheti discusses Thyroid Nodule Ablation on the BackTable 182 Podcast

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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