SAVE YOUR THYROID GLAND WITH RADIOFREQUENCY

1) Radiofrequency Ablation (RFA): general information

Radiofrequency thermal ablation of thyroid nodules is an outpatient procedure that is carried out under ultrasound guidance, without the need to make surgical incisions. By means of a needle-electrode heating nodular tissue, the volume of benign thyroid nodules is reduced by at least 80%. The reduction in volume of the nodule is generally sufficient to make the compressive symptoms disappear and obtain excellent aesthetic results. RFA improves the quality of life (Health Related Quality of Life, HRQoL). Micropapillary cancers disappear (90 -100%) after RFA procedure. 

2) When RFA is indicated?

Radiofrequency thermal ablation is indicated for the treatment of solid or partially cystic benign nodules of the thyroid gland. Also, in Autonomously Functioning Thyroid Adenomas (AFTN) RFA obtains good outcomes.

Before RFA surgery, it is necessary to determine the nature of the thyroid nodule by ultrasound-guided fine needle aspiration biopsy (FNAB) and/or by needle biopsy with core needle (Core Needle Biopsy, CNB).

The best results are obtained on nodules of volume < 30 ml, oval shaped and colloid-cystic spongiform echostructure. RFA is increasingly used for the ablation of micropapillary malignant tumors (MPTC) or lymph node metastases not responsive to radioiodine nor eligible for surgery.

3) How is radiofrequency ablation performed?

The most commonly used technique is monopolar radio frequency (Fig. 1). During surgery, the patient is part of a circuit that includes a radio frequency generator, a needle electrode and two dispersion plates placed on the patient’s thighs. In bipolar radiofrequency, the circuit opens and closes on the tip of the needle without passing through the patient’s body. It produces reduced ablations and should be reserved for patients with pacemakers or implanted defibrillators.

The needle electrode is introduced into the nodule under ultrasound guidance. The high frequency electromagnetic waves emitted by the electrode heat the nodule inducing necrosis of the treated tissue, that will be replaced over time by fibrous-scar tissue. This results in a significant shrinkage of the thyroid nodule. A saline cooling system controls the temperature at the tip of the needle during treatment to avoid the carbonization process.

The procedure is performed on an outpatient basis, without the need for general anaesthesia with intubation. The patient is placed on the bed in a supine position, head hyperextended. The operator administers ultrasound-guided local anaesthesia with lidocaine at 2% (short action) and ropivacaine at 10% (prolong action). The anesthesiologist canulates a vein and sedates the patient with Fentanyl, Midazolam 3-5 mg, followed by low dose Propofol pump infusion.

Oxygenation is maintained by means of “goggles” connected to oxygen cylinder. Vital signs, including respiration, ECG, partial oxygen pressure, and blood pressure, are monitored by the anesthesiologist for the duration of the surgery. Sedation is necessary to facilitate maneuvering and to reduce spontaneous swallowing. Sedation causes loss of consciousness and even anterograde amnesia. The patient does not retain any memory of the surgery and does not experience of any intraoperative pain while maintaining a certain reactivity.

The procedure, including set-up times, has a variable duration of about 60-120 minutes. It is repeatable on particularly large nodules or in cases of relapse. At the end of the procedure, a steroid and analgesic therapy is administered via the venous route. After the RFA surgery the patient is kept in observation in the recovery room for 1-2 hours. Finally, before discharge the patient undergoes an ultrasound thyroid check.

4 How are vital structures of the neck preserved in RFA minimally invasive surgery?

Thyroid nodules appear near neck structures that must be preserved: common carotid artery, internal jugular vein, vagus nerve, brachial plexus, cervical sympathetic, trachea, recurrent laryngeal nerve, esophagus, muscle fascia and muscles. Ultrasound visualization under technologically advanced equipment allows the preservation of these structures. The hydrodissection technique (separation of the recurrent laryngeal nerve from the thyroid nodule by cold glucosate solution +2 C infusion) minimizes the risk of recurrent laryngeal nerve dysfunction that moves the vocal cord.

5) What are Risks and side effects of RFA?

Performed properly with the appropriate technique, complications and side effects are of minimal relevance. They include:

• Neck discomfort
• Pain radiating from the jaw
• Skin bruising
• Pinpoint skin burn
• Pericapsular or intranodular bleeding
• Dysphonia (hoarseness) usually transient, due to simple overheating of the recurrent laryngeal nerve, innervating the vocal cord. Infusion of cold glucose solution +2 °C minimizes the risk. Very rarely voice change is permanent.
• Hypo/hyperthyroidism/autoimmune thyroiditis: are observed in 1% of cases, are usually transient, have as markers antithyroid antibodies that are periodically checked in each patient.

6) What does Post-operative therapy consist of ?

At the time of discharge a post-operative ultrasound is performed, comparing the preoperative images with the post-operative ones. The patient is issued a discharge letter that briefly describes the RFA intervention and the outcome.

Some drugs are prescribed to patients:

• Corticosteroids in various dose and duration to reduce postoperative edema and to prevent late colliquation, to be taken at breakfast
• A pump inhibitor (lansoprazole) to be taken on an empty stomach in the morning with water 1 hour before breakfast to obtain gastroprotection, for the duration of corticosteroid treatment.
• Antalgic (paracetamol 1 g) or anti-inflammatory drugs (ketoprofen, ibuprofen, etc.) are administered in rare cases of persistent pain.
  
  

7) What are the advantages of minimally invasive and ultrasound-guided thermal-ablative surgery over traditional surgery?

Traditional surgery consists of lobectomy or total thyroidectomy. Transaxillary or transoral robotic surgical variants have been proposed. Minimally-invasive video- assisted surgery, MIVAT (Minimally Invasive Video Assisted Thyroidectomy), is also practiced. Any surgery involves a skin incision and a hospital stay. Most importantly it involves the loss of a thyroid lobe or the entire thyroid.

The advantages of ultrasound-guided radiofrequency ablation are:

• No scars
• Preservation of the thyroid gland
• Preservation the normal function of the thyroid gland.
• No need to take any substitution therapy with thyroxine
• Minimal side effects
• Absence of general anesthesia, drainage tubes, hospitalization
• Fast recovery to routine daily (work and leisure) activities
• The ablation results in an average mass reduction of 80% already in the first year, but the effects are remarkable already in the third month. With the passage of time the ablated mass is further reduced
• The equivalence between surgical therapy and thermo-ablative therapy has been demonstrated
• Minimized aggression
• Improving the quality of life