SIR 2024
Office-based Procedures
Jacob Schick, MD
Resident
Johns Hopkins University
Financial relationships: Full list of relationships is listed on the CME information page.
Sasicha Manupipatpong, MD (she/her/hers)
Integrated Diagnostic and Interventional Radiology Resident
Johns Hopkins University
Financial relationships: Full list of relationships is listed on the CME information page.
Eric A. Wang, M.D.
Attending Physician
Department of Interventional Radiology, Carolinas Medical Center
Disclosure information not submitted.
Mark L. Lessne, MD, FSIR
Vascular and Interventional Radiologist
Charlotte Radiology
Financial relationships: Full list of relationships is listed on the CME information page.
Describe indications for thyroid nodule ablation.
Describe key technical elements of performing the procedure and provide case examples.
Detail common complications and strategies to avoid such complications.
Background:
Thyroid nodules are common with an estimated prevalence of 2-6% through palpation and 8-65% upon autopsy {1}. Historically, high risk or symptomatic thyroid nodules were managed surgically or with I131 ablation. Percutaneous thermal ablation is an effective minimally invasive alternative, especially for poor surgical candidates. Accepted indications for thermal ablation include symptomatic benign and autonomously functioning thyroid nodules {2}. There is also evidence for the use of thermal ablation in small papillary thyroid microcarcinoma and post-surgical recurrence of thyroid cancer {3}.
Clinical Findings/Procedure Details:
This exhibit will emphasize history, physical exam details, pre-procedure evaluations, and imaging/biopsy results.
Thyroid ablations are typically performed with moderate sedation under ultrasound guidance. A trans-isthmic in-plane oblique approach is preferred to target the thyroid gland, increase probe stability, and enter the nodule with decreased risk of skin burn {2}. Unlike renal or hepatic thermal ablation, a “moving shot technique” instead of prolonged fixed ablation ensures sufficient treatment of the nodule while avoiding injury to critical structures {4}. Knowledge of the ‘danger triangle’ anatomy is critical to prevent procedural complications. During the procedure, the formation of gas locules creates a hyperechoic appearance and may also obscure imaging. The treatment is finished when this hyperechoic appearance transitions to hypoechoic {5}. Serial ultrasound exams for re-assessment of nodular volumes are recommended at 1, 6, and 12 months after the procedure {2}, and repeat thyroid function test lab-work at the 1 month interval.
Thyroid RFA offers fewer complications than surgery. Major complications are rare, but include voice change, and nodule rupture with or without infection {2}. Vocal cord injury results from stretching of the recurrent laryngeal nerve, thermal injury, or hematoma {5}. Nodule rupture, occurring in 0.2 percent of cases, is often managed conservatively {2}. Minor complications include hypothyroidism, hematoma, and mild skin burn. Hypothyroidism is uncommon after ablation and often transient {6}.
Conclusion and/or Teaching Points: Percutaneous thyroid ablation is a safe outpatient procedure, providing an effective minimally invasive treatment option in patients when surgery is contra-indicated or not preferred.