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Thyroid nodules are surprisingly common, and over half of the US adult population has one or more. Surgery has been the go-to treatment for thyroid nodules for decades. However, new non-surgical treatment options like radiofrequency ablation are becoming more popular, especially for treating asymptomatic and benign nodules.

In this Q&A, we’ll discuss radiofrequency ablation, including the evidence supporting its effectiveness for treating thyroid nodules. You can use the information below as a guide for more in-depth conversations with your healthcare provider. 

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A thyroid nodule forms when your thyroid cells start growing abnormally, causing a lump to form within your thyroid. The majority of thyroid nodules are benign (non-cancerous). However, about 5% (1 in 20) of thyroid nodules are cancerous.

Most thyroid nodules don’t cause symptoms. But, if they grow large enough, they can cause discomfort or become visible. In these cases, individuals may report:

• Pain in the neck area
• Sensitivity to scarves, necklaces, turtlenecks, and ties
• Problems breathing, especially when lying down
• Difficulties swallowing
• Swollen neck
• Change in voice, especially hoarseness
• Visible goiter

Sometimes, thyroid nodules affect the amount of thyroid hormone your thyroid produces. These types of nodules are called autonomously functioning thyroid nodules (AFTN) and are sometimes referred to as toxic nodules. A change in thyroid hormone levels can result in a thyroid disorder such as hyperthyroidism (too much thyroid hormone) or hypothyroidism (too little thyroid hormone). Depending on the type of thyroid disorder, individuals may experience other symptoms. For instance, hypothyroidism generally causes weight gain, while hyperthyroidism causes weight loss.

Thyroid nodules are generally discovered during routine physical exams or imaging studies such as x-rays, MRIs or CT scans for other conditions. People with Hashimoto’s thyroiditis – an autoimmune thyroid disorder – or who have iodine deficiency (rare in the US) are at a greater risk of developing thyroid nodules.

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Radiofrequency ablation, or RFA for short, is a non-surgical treatment option for benign thyroid nodules.

During the RFA procedure, the provider inserts a thin needle into the thyroid nodule. This is done under ultrasound guidance, which helps visualize the placement of the needle in the nodule. Once the needle is in place, a small electric current passes through it, generating heat that burns the abnormal cells inside the nodule. As a result, the thyroid nodule’s size shrinks.

Most evidence supporting the use of RFA for thyroid nodules comes from outside the US. RFA is not yet widely available in the US. But, it is gaining acceptance as an appropriate alternative to surgery.

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Evidence shows benign thyroid nodules shrink 50% to 90% after RFA. The amount of shrinkage depends on the provider’s technique and the characteristics of the thyroid nodule.

In the short term, RFA is very effective. Yet, experts are still determining how many treatments may be necessary to see sustained long-term effects. For instance, four years post-RFA, an impressive 94% of thyroid nodules still maintained a reduction in volume. But, roughly 6% of nodules had regrowth, requiring additional treatment.

The nodule size and type appear to affect the success rate. Smaller nodules generally respond better and can be treated with one RFA treatment. Larger nodules may need more than one RFA treatment. And AFTN –  nodules that change thyroid hormone production – appear to be harder to fully treat by RFA. Experts believe this may be related to increased blood supply to this type of nodule and the chance of leaving abnormal cells of the nodule during the RFA procedure.

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RFA has several significant benefits. First, RFA is a minimally invasive procedure. It can take place in an outpatient procedure at a day surgery clinic. Unlike surgical options, RFA doesn’t require general anesthesia. Your healthcare provider will use local anesthesia – a numbing agent – at the site of the injection or moderate sedation. You will usually be able to go home shortly after the procedure. RFA also costs less than thyroid surgery, an added benefit.

RFA targets the abnormal cells in your thyroid and not the healthy ones. Because of this, RFA helps to preserve thyroid function, preventing the development of hypothyroidism. (Keep in mind that there are different causes of hypothyroidism, such as Hashimoto’s. So, while RFA doesn’t trigger hypothyroidism, you still may develop it due to another reason.)

Finally, RFA may be an option for those who aren’t candidates for surgery or want to avoid hypothyroidism or cosmetic damage to their neck. 

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The answer to this question isn’t straightforward, as it depends on the characteristics of the thyroid nodule.

RFA is the first-line treatment option for non-functioning benign thyroid nodules. These nodules don’t interfere with thyroid hormone production or cause symptoms. In contrast, surgery is generally still considered the first option for those with symptomatic thyroid nodules or cancerous ones.

The most common surgery for removing thyroid nodules is called a thyroidectomy. This surgical procedure involves removing all or part of the thyroid gland. Because of this, the amount of thyroid hormone your thyroid produces post-thyroidectomy decreases. As a result, you may develop hypothyroidism and need life-long treatment with thyroid replacement medication. RFA, on the other hand, protects the healthy thyroid tissue and doesn’t affect thyroid function.

People who have been treated with RFA for their thyroid nodule report less hoarseness, post-op pain, and incidents of hypothyroidism than those undergoing a thyroidectomy. Both RFA and thyroid surgery are equally effective in managing thyroid nodule symptoms.

Benign autonomously functioning thyroid nodules (AFTN)

When looking specifically at AFTN, surgery may be the better option. As mentioned, these nodules tend to increase thyroid hormone production, resulting in hyperthyroidism over time. In these types of nodules, studies show that RFA reduces thyroid nodule size and improves symptoms but doesn’t always correct thyroid function. About 50% of those with a medium-size AFTN saw normalization of their thyroid function after RFA treatment. This percentage increases up to 80% for smaller nodules.

Surgical removal of the thyroid appears to be more effective at relieving hyperthyroid symptoms in those with AFTN compared to RFA. Close to 96% of individuals undergoing surgery have resolution of hyperthyroid symptoms, compared to just over 50% of those who underwent RFA. Because of this, RFA is considered a second-line treatment option for those with AFTN.

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Like any procedure, RFA isn’t without complications or side effects.  Following RFA, the most common complaint is pain and discomfort around the area where the procedure was performed. Pain is reported by around 18% of patients after RFA. The pain can range from mild to moderate and usually resolves within a few days. Over-the-counter pain medications are generally recommended to alleviate this discomfort.

Other more common side effects and minor complications of RFA include:

• Swelling and bruising at the site of the RFA treatment. This is normal and typically resolves within a few days to a week.
• Hoarseness and voice changes, which typically improve within a few days or weeks.

Some people experience fever, cough, nausea and vomiting, and transient thyroiditis after RFA, and it usually resolves pretty quickly.

While rare, there are several more serious or major complications after RFA.   

• Skin burns and blisters are rare but can occur at the site of the RFA treatment. These thermal injuries usually happen due to improper positioning of the electrode or excessive energy delivery.
• Recurrent nerve damage is also rare, but in a very small percentage of cases, damage to the nerves and vocal cords can occur during RFA, leading to permanent voice changes or difficulties swallowing.
• RFA can disrupt the nerve pathway from your brain to the face and eyes, resulting in one side of the face to droop.
• There is a slight risk of damaging blood vessels near the thyroid nodule, resulting in a hematoma or rupture of the nodule. Both complications require further intervention.

The complication rate is directly related to the experience of your practitioner with the RFA and other thyroid procedures, so it’s essential to choose a doctor with a depth of RFA experience. 

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At this time, there is not enough evidence to support RFA for nodules that test positive for thyroid cancer. New data for using RFA in low-risk cancer looks promising, but more studies are needed. At this time, surgery remains the best option for malignant nodules.

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If you have a thyroid nodule or symptoms of one, your healthcare provider will likely order the following tests:

• A test panel of thyroid biomarkers, including Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4), and Thyroid Peroxidase antibodies (TPOAb).
• A thyroid ultrasound
• A biopsy of the nodule
• Thyroid scan

While ultrasound, biopsy, and scans are done in a hospital or clinic setting, measuring your thyroid biomarkers can be done from the comfort of your home. Paloma’s at-home testing kit tests your thyroid biomarkers to help determine how well your thyroid functions. Home tests are less invasive than a blood draw as they only require a blood sample from a finger prick. Results from these tests will give your provider the information they need to advise you on your treatment options.

Please note: Paloma Health is an excellent option for those with hypothyroidism looking for high-quality thyroid care. Want to learn more? Schedule a free consultation today.

At this time, Paloma Health’s thyroid experts don’t provide treatment for people with thyroid cancer or those who have undergone treatment for thyroid cancer.

Free T3

Free T3 is a hormone produced by the thyroid gland. Levels of this fluctuate when individuals have an under or overactive thyroid gland.

TSH

Thyroid-stimulating hormone, TSH, is the hormone responsible for controlling hormone production by the thyroid gland. The hormone TSH is considered the most sensitive marker for screening for thyroid diseases and conditions. Our thyroid panel is ideal for TSH testing at home and will tell you how your levels compare to normal TSH levels.

TPO Antibodies

Thyroid peroxidase antibodies are antibodies that can bind to thyroid enzymes, suppressing thyroid function. They are elevated in a condition called Hashimoto's disease, which is the most common type of hypothyroidism in the USA.

Free T4

Free T4 is the predominant hormone produced by the thyroid gland. Levels fluctuate when individuals have an under or overactive thyroid gland. Testing your free T4 with this thyroid function test lets you see if your thyroid hormone production is at a normal level.

Reverse T3

Add-on

RT3 is a metabolite of T4. Typically, when T4 loses an atom of iodine—a process known as monodeiodination—it becomes (T3), the active thyroid hormone.The body also converts T4 into rT3, which is an inactive form of T3 that is incapable of the metabolic activity that is normally carried out by T3.

Vitamin D

Add-on

Some observational studies have found low blood levels of vitamin D in patients with hypothyroidism and Hashimoto’s as well as hyperthyroidism due to Gravesʼ disease. It is not clear from these studies if low vitamin D is a cause, a consequence or an innocent bystander in the development of these common thyroid conditions.

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