BackTable / VI / Podcast / Transcript #182

Podcast Transcript: Thyroid Nodule Ablation

with Dr. Tim Huber

Dr. Aparna Baheti talks with Dr. Timothy Huber about performing thyroid nodule ablation procedures, including patient selection, technique pearls and pitfalls, and how to incorporate the procedure into your practice. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Indications for Thyroid Ablation

(2) Patient Workup, Contraindications, and the Danger Triangle

(3) Thyroid Ablation Procedure: Trans-isthmic Approach

(4) Patient Safety: Watch for Voice Changes

(5) The Follow-up: Considerations for Reading Ultrasounds

(6) Measures of Success and Criteria to Re-Treat

(7) Insurance Coverage: It’s Possible!

(8) Spreading the Technique: Referrals and Provider Education

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Thyroid Nodule Ablation with Dr. Tim Huber on the BackTable VI Podcast)
Ep 182 Thyroid Nodule Ablation with Dr. Tim Huber
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[Dr. Aparna Baheti]:
This is Allie Baheti coming to you from Tacoma, Washington as your guest host this week. I'm very excited to introduce our guest for today, Dr. Tim Huber from the Dotter Institute at OHSU to talk about thyroid ablation. Welcome Tim.

[Dr. Tim Huber]:
Thanks Allie.

[Dr. Aparna Baheti]:
To start, could you tell me a little bit about the residency program at OSHU?

[Dr. Tim Huber]:
Yes. So we have a great residency program here, and we offer all the different pathways. So we have IR integrated, IR independent, and ESIR. I think the big strengths of our program are kind of clinical and research. Especially, we do the full gamut of bread and butter IR including things like PAD, aortic, and venous work. We do IO. We're even doing some newer things like prostate embolization, genicular artery embolization, and obviously thyroid RFA.

(1) Indications for Thyroid Ablation

[Dr. Aparna Baheti]:
Excellent, now onto our topic for today: thyroid ablation. So tell me a little bit about your thyroid ablation practice. When did you start building up, and what kind of volume are you seeing now?

[Dr. Tim Huber]:
Yeah. So I learned the technique from Auh Whan Park at UVA when I was doing my fellowship with you. And I came out to OSHU in 2019 to start up the program out here. I met with some folks from the thyroid and parathyroid clinic. When I was interviewing, they were very excited to bring this program at OSHU.
So I started this as a collaboration with a couple of surgeons and a couple of endocrinologists out here. And it's been a really big success with all of us working together to grow this thing. So I started in 2019, kind of right before COVID took off, getting approval for the generator, kind of getting everybody up to speed on what the technique is, how did you follow up, and how to get people referred to us. And it's been really taken off since then. We've treated about 50 patients in the past 16 months. And they're really great success so far.

[Dr. Aparna Baheti]:
Okay. All right. So for the uninitiated, who've never really heard of thyroid ablation before, what are the patients that you do this on? What are the indications for thyroid ablation?

[Dr. Tim Huber]:
Great question. So they're always expanding, and we're always looking for new patient populations. But the best way to get started with this is going to be benign symptomatic thyroid nodules. So we're working on some US-based guidelines to kind of help people with indications, but generally, most practices are using the ETA, the European Thyroid Association guidelines, or the KSIR Korean Society of IR guidelines. Basically nodules over two centimeters are what are recommended to treat. Under two centimeters, it's rare for them to be symptomatic. And so once they get to be that size, they can cause compressive symptoms, things like a difficulty swallowing, pressure on the airway, or just pain or pressure within the neck.

[Dr. Aparna Baheti]:
Do you treat patients who have cosmetic concerns about lumpy bumpy thyroids?

[Dr. Tim Huber]:
That's a good question. Typically, once they get to be over two centimeters in most people that are going to be somewhat visible, and they're going to be some sort of cosmetic defect. So far I haven't had any patients who have solely cosmetic concerns. It's always been cosmetic concerns plus symptoms, but you can do this for cosmetic concerns as well.

[Dr. Aparna Baheti]:
And then talk to me a little bit about your practice in treating patients who have functional nodules.

[Dr. Tim Huber]:
Yeah. So this is a definitely a tougher area to treat. So you can use this technique to treat functional nodules as well. The standard is obviously surgery or radioactive iodine treatments, but there are a lot of patients that don't want to have surgery, or they don't want to isolate for the period of time that you need to with radioactive iodine or they have small kids at home, or it's just not feasible. So RFA is a good option for people who don't want those other two options. It's a little bit trickier in that you have to get a more complete ablation of the nodule. You can't leave as much residual tissue behind to get them back to euthyroid state. So you really want to shoot for like a 70 to 80% volume reduction to get a good result for those patients. So a little more challenging, not something maybe to take on as your first case, but definitely something that can be treated.

[Dr. Aparna Baheti]:
Have you treated any patients who have a thyroid malignancy?

[Dr. Tim Huber]:
Yeah. So we have treated one patient so far with a recurrent PTC. He was a candidate who basically had had multiple prior neck dissections and some radioactive iodine treatments before, and was at a point where we were kind of considering repeat neck dissection versus starting systemic options for him to locally control the nodules. So he had basically two nodes, metastatic kind of near the carotid, and one near the trachea. And so we use this as a way to slow down that growth and prevent local invasion. It can also be used for a papillary microcarcinoma and that's a little bit of a newer area. There are a few trials are going to be starting up pretty soon, kind of Mayo and Sloan Kettering, and a few other centers kicking off pretty soon here, but that's an area of active, ongoing research.

[Dr. Aparna Baheti]:
I see. Okay, so obviously not standard of care for treatment of malignant nodules, but definitely something that might be in the future?

[Dr. Tim Huber]:
Yeah. The data out of Italy and Korea are really promising. So we think that this'll be a pretty successful in the US as it rolls out.

(2) Patient Workup, Contraindications, and the Danger Triangle

[Dr. Aparna Baheti]:
What's your workup for a patient who comes to you for a thyroid ablation?

[Dr. Tim Huber]:
Great question. So we start off obviously with an ultrasound of the thyroid and of the neck to assess just the nodule composition, the vascularity, the size, and also to look for any enlarged lymph nodes in the neck that might be kind of a tip off that there could be something more than just a simple, benign nodule. Everybody needs to have, we recommend two benign FNAs, before we do RFA and that's in line with the KSIR and an ETA guidelines. There are some cases where the guidelines recommend a single biopsy being sufficient if it's a very classically benign appearing nodule, but in most cases, just to be conservative, we're recommending two prior to treatment. We do a single FNA prior to RFA for functional nodules though. That's the one kind of care area we can just do a single for functioning nodules.

[Dr. Aparna Baheti]:
Okay. So they get their FNA, and they get their thyroid ultrasound. Do you do any lab work before you do a thyroid ablation?

[Dr. Tim Huber]:
Yep. So we check TSH, in everybody, sometimes we'll add in T3 and T4. It just depends on if they're functional or non-functional. For the non-functional folks, typically just a TSH is sufficient. There's a little bit of debate back and forth throughout thyroglobulin. Is that necessary? Or about TPO antibodies, things like that. And generally, most people aren't doing any of those additional lab tests, so typically TSH is sufficient for most people.

[Dr. Aparna Baheti]:
Is there anything that you would see on your patient workup that would give you pause for doing the procedure? What I'm getting at: thyroid location or giant patient with a BMI over a hundred, or anything that has given you pause in the series that you've done so far?

[Dr. Tim Huber]:
Yeah. So patient selection, like most things in IR, is really important. I would say that the size of the nodule was one of the biggest things is going to make your life easier or hard. And so, two/three centimeter nodules are pretty easy to treat. Four and five centimeters get more challenging. 6, 7, 8 centimeter nodules are a lot tougher, and generally over seven or eight, I think surgery's probably your way to go. That being said, people are treating much larger nodules in the US, we're seeing a larger volume of disease being referred in, so definitely bigger nodules or multinodular goiter. And that's been treated with RFA, but it's a bit more challenging, usually requires more treatment sessions to get a good result. So bigger nodules are tougher. Nodules that go below the sternum, kind of subclavicular or substernal nodules, can be tough if you can't see the whole nodule, you can’t ablate safely that lower margin. So that can be a little bit challenging. Again, you can kind of stage your procedure and hopefully get that lower portion at a future procedure, but again, multiple procedures. And then any kind of intermediate grade pathology on the FNA. So Bethesda three or four categories are a little bit more indeterminate right now. We're doing some studies to figure out if those nodules are safe to treat. But right now the thinking is to probably stick with Bethesda two, the definitely benign nodules.

[Dr. Aparna Baheti]:
Anything in the patient history that would modify your approach? For example, pregnancy or if they have pacemakers?

[Dr. Tim Huber]:
Yeah. So there are two contraindications. Well, one's absolute, and one's sort of relative contraindication to the RFA system. So pregnancy is an absolute contraindication. No one's tested it in pregnant patients, but no one's going to, and so we recommend not treating pregnant patients with the system. Pacemakers, you have to do some adjustments to where you place the electrode grounding pads, so typically we have grounding pads on the outside of the thighs. For people with pacemakers, you can do a modified placement and put them up on the shoulders, on the back. And so the rep can sort of walk through the protocol there, and there are a few different protocols that are online that they've done before that have been successful. You have to decrease the wattage and that can be a little bit more of a hassle, but it can be done.

[Dr. Aparna Baheti]:
And then how about a location of the thyroid nodule? You've already kind of spoken about the ones that go below the sternum, but how about the just deep, deep nodules? Are you allowed to ablate those?

[Dr. Tim Huber]:
So really you shouldn't be ablating, anything that you can't see. So as long as you can see the nodule, or at least the portion nodule that you're ablating, that's fine. But if there's a portion of nodule that is just too deep for your ultrasound unit to kind of register clearly or to see the tip of your electrode well, then I would stay away from that, but that's really the only sort of limit.

[Dr. Aparna Baheti]:
Okay. Could you touch a little bit on the danger triangle? I remember Dr. Park always talking about that way when he talked about thyroid ablations.

[Dr. Tim Huber]:
Yeah. So there's a term, they throw around in the thyroid literature that you'll see if you start reading the papers, and they it called the danger triangle. And basically it's where the recurrent laryngeal nerve lives. And basically it's a triangle that's bordered by the thyroid gland and the trachea. And so we know that's anatomically where the recurrent laryngeal nerve is going to be, and that's basically the big concern during most thyroid surgeries that you ding the recurrent laryngeal nerve and paralyzed vocal cord. So when we do the technique that we, recommend it's this trans-isthmic approach that we talk about, and that's kind of going from a medial to a lateral approach with your electrode. It makes it really, really hard, I find, to direct the tip of my electrode back into that danger triangle. So when Dr. Beck was developing this in Korea, he sort of thought of that and kind of developed it in this way to prevent damage the recurrent laryngeal nerve.

(3) Thyroid Ablation Procedure: Trans-isthmic Approach

[Dr. Aparna Baheti]:
I see. That kind of brings us to the procedure. 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, basically 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 maneuverable 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 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.

(4) Patient Safety: Watch for Voice Changes

[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 of 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.

(5) The Follow-up: Considerations for Reading Ultrasounds

[Dr. Aparna Baheti]:
I sounds like, I want to knock on wood here, but 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. It 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.

(6) Measures of Success and Criteria to Re-Treat

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

[Dr. Tim Huber]:
Yeah. So the papers 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 retreat 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 reablate 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.

(7) Insurance Coverage: It’s Possible!

[Dr. Aparna Baheti]:
Well, that's pretty much all the questions I had about the procedure itself and all the clinical stuff about it. I'd like to talk a little bit more about how, for example, how a private practice radiologist could make this a part of their practice? So starting off with the big thing that drives us is reimbursements. So do any insurance companies in the US cover it right now?

[Dr. Tim Huber]:
So it's a great question. Everyone wants to know that. The answer is it's complicated. They don't cover it easily by and large. A few of them have come around and are working with us a little more carefully, a little more closely. And we're having some success there. So the way we do it here is that I submit everything to insurance before the procedure and have worked through the appeals process on the front end. And in general, I'm able to get approval for the procedures usually with one or two rounds of appeals. Usually it's denied as investigational, but after submitting documentation references, they'll usually accept that it's legitimate. Other practices have taken more of a cash only self-pay model. And I see that's probably the majority of places are doing that around the country. It just limits how many patients can have access to the procedure. And I kind of wanted to keep it as open to as many people as we could here. So that's why I opted for the insurance, which has been successful, but a lot of work on my end to be honest.

[Dr. Aparna Baheti]:
Oh, I bet. Nobody likes to talk to those insurance companies about anything. can you give me kind of like a market, if you feel comfortable, can you give me a range of kind of what people are charging for self-pay out in the community?

[Dr. Tim Huber]:
Yeah, so I can kind of give you a rough kind of low/high, I've heard low end being around 3 and high-end being 10 or 12.

[Dr. Aparna Baheti]:
Okay.

[Dr. Tim Huber]:
So definitely a huge range depending on the market.

(8) Spreading the Technique: Referrals and Provider Education

[Dr. Aparna Baheti]:
Sure. And then how do you get these patients? What's your major source of referrals?

[Dr. Tim Huber]:
So I've been super lucky here in partnering with the thyroid and parathyroid clinic, because they had a whole slew of patients who basically needed something done for their thyroid nodules and didn't want to have surgery. And so they were just following them. And so when I started, we had a whole backlog of patients ready to treat, that's not common for most people.

[Dr. Aparna Baheti]:
Yeah, that sounds very lucky.

[Dr. Tim Huber]:
It was very fortunate. And since we got things going, the referrals kind of just rolled in. That being said, what I hear from people around the country is that once they publicized that they have the system in place, or they're going to be getting RFA at their practice, patients find them very quickly and their slots fill up very quickly. So the patients who want to have this are very motivated and they're looking for providers that will do the procedure. And so they have support groups. They're getting the word out on their own and they'll find you.

[Dr. Aparna Baheti]:
Oh, yeah, I bet. I wonder if there's a subreddit on Reddit about you somewhere, that's driving a bunch of your patient referrals.

[Dr. Tim Huber]:
Maybe Facebook. I don't know. We'll see. I haven't looked deep enough to find out.

[Dr. Aparna Baheti]:
Have you done any direct to patient marketing?

[Dr. Tim Huber]:
We haven't had to yet. We've talked about it, but so far we've had enough referrals coming in from around the state and around the area with basically just sort of grand rounds lectures, and just reaching out to different large practices in the area.

[Dr. Aparna Baheti]:
So when you go out and speak to these practices, what's the reception that you get? Are they hesitant to refer? Do they feel like there's a role?

[Dr. Tim Huber]:
Yeah, it's been mixed. There are definitely those endocrinologists and surgeons who don't buy it yet and want to see more data and aren't really so sold on it. I will say that compared to the east coast, I feel like in Oregon, at least people seem to be a bit more open-minded or at least open to other alternative options, which is, I think also helped our referrals. But we've gotten a decent number of referrals from endocrinologists and ENTs that we've never actually interacted with, but patients want it and have sought them out to get referrals to us. So, I am finding that as we do this procedure and get our data out there more and more, people are definitely coming around and referring more and more patients to us.

[Dr. Aparna Baheti]:
And then can you give me a little bit of information about future directions of thyroid ablation? If I wanted to start doing this next month in my OBL, what kind of resources should I look in?

[Dr. Tim Huber]:
So a two part question, I'll start with the future directions part first. Cancer is definitely the next area of growth for this technology, but there are a few other areas as well, like parathyroid adenomas or parotid tumors are also showing some early promise and being able to treat with RFA. And how did you get started with this? A lot of resources out there. There's a ton of papers from Italy and Korea describing the technique, describing their outcomes with benign disease and even some malignancy. If you want more US-based literature, there's a growing amount of literature from US-based populations, which is great. So expect more and more papers to come out in the next couple of years on outcomes in the US. You can look in this last August's seminars in IR for how-to paper for me and Dr. Park. And there'll be an upcoming TVIR edition dedicated to thyroid ablation, coming out hopefully next year.

[Dr. Aparna Baheti]:
Are there any courses around the country that a provider can go to learn this?

[Dr. Tim Huber]:
Yeah. So there are actually a lot of hands-on courses being offered around the country, more on the east coast. We were getting one set up here at OSHU, kind of in the middle of COVID, but with the recent round of restrictions, we haven't been able to go live just yet, but we're hoping to start offering some hands-on training here as well.

[Dr. Aparna Baheti]:
Great. Well, Tim, thanks for coming on the show. I've learned a lot today just getting our feet wet with this whole thyroid ablation, but I think it's going to be something amazing that IRs can offer in the near future on a large scale. And thank you for being a thought leader in this area.

[Dr. Tim Huber]:
Thanks for having me on the show. This has been great and glad to get the word out to more people. And hopefully we can support more people to get this started with in their practices.

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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Thyroid Nodule Ablation Procedure Prep