General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement

Abstract

Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules. Summary: This consensus statement is organized around three key themes: (1) safety of ablation techniques and their implementation, (2) optimal skillset criteria for proceduralists performing ablative procedures, and (3) defining expectations of success for this treatment option given its unique risks and benefits. Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided. Conclusions: Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. Careful patient and nodule selection are critical to the success of these procedures as is extensive pre-procedural patient counseling. Although these emerging technologies hold great promise, they are not without risk and require the development of a unique skillset and environment for optimal, safe performance and consistent outcomes.

Keywords: ablation; benign thyroid nodule; thyroid nodules; ultrasound.

FIG. 1.

Initial management algorithm for non-functioning benign thyroid nodules.

FIG. 2.

The danger triangle concept is applicable to ablation at the level of the upper tracheal rings and cricothyroid joint. In the lower neck, the concept of a “danger zone” is more appropriate as the recurrent laryngeal nerve is often laterally placed at these levels, especially on the right. CCA, common carotid artery; TR, trachea.

FIG. 3.

Operations and process flow chart for implementing a new TA program. A sample flow chart of the operations and processes involved in implementing a new TA clinical program is shown. To ensure safe implementation, the various points in the flow chart should all be addressed. Additional considerations of highlighted points are summarized in Table 5. *The process of billing, payment, and appeal is also a pre-procedural consideration and may occur before performance of the ablation procedure. BP, blood pressure; PCP, primary care physician; TA, thermal ablation; TFT, thyroid function tests; US, ultrasound.

FIG. 4.

Strength of consensus from Delphi survey. FNA, fine needle aspiration; RFA, radiofrequency ablation.