SURGICAL PERSPECTIVE
The Adoption of Ultrasound-guided Radiofrequency Ablation
of Thyroid Nodules in the United States
Jennifer H. Kuo, MD, MSY and James A. Lee, MD
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Keywords: radiofrequency ablation, RFA, thyroid nodules
(Ann Surg 2021;273:e10–e12)
T hyroid nodules are a common clinical problem with up to 19% to
68%1 of the population having 1 lesions detected on examina-
tion or with high-resolution ultrasound. Fortunately, thyroid cancer is
found in only 5% of all thyroid nodules, and of the approximately
130,000 thyroid operations performed each year, two-thirds are
benign disease on final pathology.2 Although most benign nodules
can be safely observed, a portion of these nodules requires definitive
management due to significant size, continued growth, compressive
symptoms, cosmesis, and/or autonomous function leading to hyper-
thyroidism. Surgical resection has been the mainstay of treatment for
these benign, but problematic nodules. Although associated with
excellent outcomes in experienced hands, thyroid surgery carries a
low risk of complications that include recurrent or superior laryngeal
nerve injury leading to voice changes, hypoparathyroidism, bleeding,
infection, hypothyroidism with need for thyroid hormone supple-
mentation, and unsightly scarring.2 In contrast to patients with
thyroid cancer, these risks may be less acceptable to patients with
benign disease. In an era when the medical field is treating thyroid
cancer less aggressively, we are also considering ways to treat benign
thyroid disease less invasively.
Introduced in the early 2000s, ultrasound-guided percutaneous
ablation of thyroid lesions has emerged as an alternative to surgery in
patients with benign thyroid nodules. Of the myriad ablation meth-
ods, the most commonly used technique is radiofrequency ablation
(RFA). An expanding body of evidence shows that RFA and other
percutaneous interventions are effective treatments for benign solid
thyroid nodules, toxic adenomas, and thyroid cysts resulting in
overall volume reduction ranges of 40% to 70% with durable
resolution of compressive and hyperthyroid symptoms.3–5 In addi-
tion, RFA has been used as an effective treatment for locally recurrent
thyroid cancers in patients who are not good surgical candidates.6
These percutaneous techniques have been steadily gaining accep-
tance in Europe and Asia during the last 20 years, but adoption has
been slow in the United States. However, in 2018, Hamidi et al7
published the first US institutional experience of 14 patients who
received RFA, reigniting interest in the procedure. Since that time,
the use of RFA has grown rapidly and at the time of the writing of this
article, dozens of US physicians from various disciplines (endocrine
surgery, otolaryngology, endocrinology, and interventional
From the Section of Endocrine Surgery, Columbia University, New jYork, NY.
jhk2029@cumc.columbia.edu.
Reprint Requests: Reprint requests will not be available from the authors.
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The authors report no conflicts of interest.
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-0e10
DOI: 10.1097/SLA.0000000000003930
e10 | www.annalsofsurgery.com
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radiology) have started to offer RFA for the treatment of select
benign thyroid nodules.
Table 1 summarizes our single-institution experience with the
RFA of 25 nodules in 16 patients since starting our program in
August of 2019. Most of these patients had thyroid nodules that were
benign on fine-needle biopsy and were either enlarging, symptom-
atic, or toxic nodules. One patient had a metastatic recurrent thyroid
cancer. After an in-depth informed consent discussion, these patients
were elected to have RFA over surgical resection or surveillance of
their disease. The RFA procedures were performed in our outpatient
procedure room under local anesthesia using internally cooled 18G
electrodes (star RF electrode, STARmed, Seoul, Korea), 7 cm in
length with a 5 to 10 mm active tip size according to nodule size,
composition, and function, powered by the VIVA Combo RF gener-
ator (480 KHz; STARmed). All of the patients tolerated the proce-
dure well with minimal pain and were able to complete the planned
ablation session in full. With a mean follow-up time of 1.1 months,
our mean nodule volume reduction at 1 month post procedure is
52.9%. Both of our patients with toxic adenoma(s) were euthyroid at
1 month and all of the patients who have had 3-month follow-up were
euthyroid (n ¼ 7). This is in contrast to an estimated rate of
hypothyroidism requiring thyroid hormone supplementation of
30% after thyroid lobectomy.8 Of note, no patients have had com-
plications outside the immediate periprocedure period listed in
the table.
Our preliminary experience with RFA mirrors the generally
good outcomes reported in the significant international experience.
However, there are several factors that should be considered before
widespread adoption of these percutaneous techniques. Although
conceptually simple, ultrasound-guided RFA is a technique that
requires a unique blend of skills- proficiency with ultrasound,
expertise conceptualizing lesions in 3 dimensions, precise fine-motor
skills, and the ability to interpret and react to multiple data streams at
once (ie, real-time imaging, fluctuating impedance values, tactile
feedback, and patient movement and symptoms). Regardless of
training background and experience, even clinicians who are already
facile with diagnostic ultrasound and fine needle aspiration biopsy
will be required to learn a new skillset. They will need to master the
new ablation technology and think about aspects of a nodule that may
not have been of concern before (eg, feeding arteries and marginal
veins, relationship with the isthmus to plan a trans-isthmic technique,
and hydro-dissection of planes to create a safety barrier to protect
critical structures like the recurrent laryngeal nerve). In addition, they
will have to learn how to ablate while the electrode is in motion. This
so-called ‘‘moving-shot technique’’ is different from the standard
ablation technique of other tumors where the electrode is inserted
into the middle of the tumor and kept still during the ablation. These
considerations make learning and mastering RFA of thyroid nodules
a challenging proposition that requires careful training.
Although RFA of thyroid nodules is generally regarded as a
safe procedure, it is not without risk. Complications have been
reported in 4% to 30% of patients in which RFA has been performed
by experienced physicians and include pain, nerve injury and voice
Annals of Surgery  Volume 273, Number 1, January 2021
Annals of Surgery  Volume 273, Number 1, January 2021 RFA of Thyroid Nodules

TABLE 1. Patients Who Have Undergone Radiofrequency Ablation at the Columbia Thyroid Centerz
Post-Procedure 1 mo
No. Largest Diameter Nodule Cosmetic Immediate Nodule TSH
Patient Indication Nodules of Nodule, cm Volume, cc Score Complications Volume/VRR% mIU/L
37F Large solitary nodule 1 4.3 11.6 3 Dizziness 9.4/19.0y —
64F Toxic MNG in the setting of 1 1.7 1.7 0 None 0.5/72.7 0.51
previous right
hemithyroidectomy
59F Nontoxic MNG with large 1 4.0 11.5 2 Discomfort during RFA 4.7/58.9 —
symptomatic nodule
45F Large solitary nodule 1 2.6 3.7 1 None 1.9/47.4 —
28F Large solitary nodule 1 6.4 53.5 3 None 30.4/43.1 1.29
36F Nontoxic MNG (right sided 2 2.6 5.7 2 None 2.9/37.6 —
nodules) in the setting of left 2.7 4.7 2.3/58.7
vocal cord paralysis from PDA
ligation
54F Large solitary nodule 1 4.3 23.2 3 Discomfort during RFA 11.4/50.7 —
74F Toxic MNG 3 1.8 0.9 0 None 0.4/58.9 0.66
3.2 5.7 3.6/36.5
1.4 2.0 0.3/86.0
46F Large MNG 3 4.0 10.6 3 Mild swelling for 48 hours 2.2/79.3
3.1 7.6 5.5/27.4
4.8 52.4 11.9/77.2
25F Large solitary nodule 1 4.7 24.6 2 None 14.8/39.6
48F Large solitary nodule 1 3.4 6.4 2 Discomfort during RFA 3.6/43.1
57M Large solitary nodule 1 6.4 53.2 3 None 30.8/42.0
31F Recurrent PTC in thyroid bed 1 1.1 0.23 n/a None 0.07/67.9
45F Large MNG 2 4.3 9.44 2 Discomfort during RFA 3.6/61.7
1.9 1.95 0.8/56.4
50F Large MNG 2 3.3 10.9 3 None 3.19/70.7
2.8 3.75 1.18/68.6
42F Large MNG 3 2.2 3.1 3 None 2.7/12.0
3.4 13.6 6.55/46.7
3.9 12.3 5.5/59.2
MNG indicates multinodular ratio; PTC, papillary thyroid cancer.

VRR, Volume reduction ratio ¼ [1(post-RFA volume/pre-RFA volume)]  100%.
yEvidence of marginal re-growth due to previously hidden inferior feeding artery; nodule volume/VRR% at 3 months is 5.7/50.9%.
zAll RFA procedures performed with internally cooled 18G electrodes (star RF electrode, STARmed, Seoul, Korea) powered by the VIVA Combo RF generator (480 KHz;
STARmed).

change, hematoma, skin burns at the puncture site, thyrotoxicosis,
edema, and fever.9 The rare incidence of more severe complications
including esophageal or tracheal perforation, infection, abscess
formation, and permanent recurrent nerve injury is likely higher
in less experienced hands. In addition, it is likely that undertreatment
of individual nodules with RFA may be more of an issue in less
experienced hands. Several studies with longer follow-up periods of
2 to 3 years have reported regrowth of previously ablated nodules in
up to 35% of patients.10 Regrowth happened more frequently in
larger nodules, nodules that were ablated with too low energy, and
in nodules with inadequate ablation of the margins of the nodule.
Certain techniques can help prevent this regrowth, but generally
require a more advanced technical skill and experience. As more and
more clinicians explore this technique, it will be critical for experi-
enced operators to ensure adequate training protocols and best
practices to maximize patient safety.
Although there is a clear learning curve to obtain the technical
mastery of this combination of skills, even more nuanced is understand-
ing the clinical indications for the procedure, appropriate patient selec-
tion, and proper counseling of patients. Acceptable indications for RFA
are quickly evolving, but are best established for symptomatic benign
nonfunctioning solid nodules (>75% solid) that have been confirmed to
be benign on fine needle aspiration biopsy, or autonomously functioning
thyroid nodules, especially for patients who may not be good candidates
for radioactive iodine ablation or surgery. RFA can also be performed on
recurrent thyroid cancers in the thyroid bed and cervical lymph nodes for
patients at high surgical risk or who refuse surgery, although proximity to
the recurrent laryngeal nerve does increase the risk for nerve injury and
may require some advanced techniques (ie, hydrodissection). There is
also emerging preliminary data that RFA may also be an acceptable
option for treatment of papillary microcarcinomas. Appendix A, http://
links.lww.com/SLA/C164; http://links.lww.com/SLA/C165 summa-
rizes the international experience and existing literature for these various
indications. Although there are no absolute contraindications to RFA,
ethanol ablation is likely a more cost-effective treatment of predomi-
nantly cystic thyroid nodules with similar good outcomes, and there is
some scant evidence that RFA may promote faster growth of follicular
neoplasms and therefore should not be used to treat indeterminate
nodules. Additionally, the use of monopolar electrodes (only ones
available in the United States) for pregnant women or patients with
electrical devices such as a cardiac pacemaker is not recommended
because there is insufficient evidence regarding safety of monopolar
electrodes in these patients. Future availability of bipolar electrodes may
be a safer option for these patients. An appropriate informed consent
must discuss the short- and long-term advantages and disadvantages of
both radiofrequency ablation and surgery in order for the patients to
make informed decisions regarding which approach is best suited for
them. Given the complexities of such decision-making, patients are
likely best served in tertiary referral or high-volume centers that have a
multidisciplinary team that works together to counsel patients regarding

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Kuo and Lee
the appropriate indications, benefits, and hazards of the procedure.
Equally important is the ability of the multidisciplinary team to be
able to effectively address potential complications, and to provide
follow-up to fully evaluate the safety of the procedure and long-term
outcomes.
RFA, as well as other percutaneous interventions, offer a
promising alternative treatment for benign thyroid nodules. A wealth
of international and a growing US experience have shown that RFA
can be safe and effective. As we expand our experience with
percutaneous ablation of thyroid lesions, we must determine how
best to fit these interventions into management algorithms and
standards of care for our patients. As with any new technology or
therapy, patients are best served by a cautious and judicious adoption
process that prioritizes safety and excellent outcomes.
REFERENCES
1. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid
Association Management Guidelines for Adult Patients with Thyroid Nodules
and Differentiated Thyroid Cancer: The American Thyroid Association
Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid
Cancer. Thyroid. 2016;26:1–133.
e12 | www.annalsofsurgery.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 273, Number 1, January 2021
2. Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon
experience for clinical and economic outcomes from thyroidectomy. Ann
Surg. 1998;228:320–330.
3. Baek JH, Lee JH, Valcavi R, et al. Thermal ablation for benign thyroid
nodules: radiofrequency and laser. Korean J Radiol. 2011;12:525–540.
4. Dobnig H, Amrein K. Monopolar radiofrequency ablation of thyroid nodules:
a prospective Austrian single-center study. Thyroid. 2018;28:472–480.
5. Deandrea M, Trimboli P, Garino F, et al. Long-term efficacy of a single session
of RFA for benign thyroid nodules: a longitudinal 5-year observational study. J
Clin Endocrinol Metab. 2019;104:3751–3756.
6. Lim HK, Baek JH, Lee JH, et al. Efficacy and safety of radiofrequency
ablation for treating locoregional recurrence from papillary thyroid cancer.
Eur Radiol. 2015;25:163–170.
7. Hamidi O, Callstrom MR, Lee RA, et al. Outcomes of radiofrequency ablation
therapy for large benign thyroid nodules: a Mayo Clinic case series. Mayo Clin
Proc. 2018;93:1018–1025.
8. Stoll SJ, Pitt SC, Liu J, et al. Thyroid hormone replacement after thyroid
lobectomy. Surgery. 2009;146:554–558. discussion 558-560.
9. Baek JH, Lee JH, Sung JY, et al. Complications encountered in the treatment
of benign thyroid nodules with US-guided radiofrequency ablation: a multi-
center study. Radiology. 2012;262:335–342.
10. Sim JS, Baek JH. Long-term outcomes following thermal ablation of benign
thyroid nodules as an alternative to surgery: the importance of controlling
regrowth. Endocrinol Metab (Seoul). 2019;34:117–123.
ß 2020 Wolters Kluwer Health, Inc. All rights reserved.