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

Catherine F Sinclair^{1

2}, Jung Hwan Baek³, Kathleen E Hands⁴, Steven P Hodak⁵, Timothy C Huber⁶, Iram Hussain⁷, Brian Hung-Hin Lang⁸, Julia E Noel⁹, Maria Papaleontiou¹⁰, Kepal N Patel¹¹, Gilles Russ^{12

13}, Jonathon Russell¹⁴, Stefano Spiezia¹⁵, Jennifer H Kuo¹⁶

Affiliations

¹ Icahn School of Medicine, New York, New York, USA.
² Department of Otolaryngology, Monash University, Melbourne, Australia.
³ Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
⁴ Thyroid Center of South Texas, San Antonio, Texas, USA.
⁵ Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA.
⁶ Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
⁷ Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
⁸ Department of Surgery, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
⁹ Department of Otolaryngology Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
¹⁰ Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA.
¹¹ Division of Endocrine Surgery, Department of Surgery, New York University Langone Health, Bethesda, Maryland, USA.
¹² Thyroid Diseases and Endocrine Tumors Department, Pitié-Salpêtrière Hospital, Paris, France.
¹³ Institute of Cancer IUC, Clinical Research Group Thyroid Tumors No. 16, Sorbonne University, Paris, France.
¹⁴ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
¹⁵ Endocrine and Ultrasound Guided Surgery Operative Unit, Ospedale del Mare, ASLNA1Centro, Naples, Italy.
¹⁶ Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, New York, USA.

PMID: 37642289
PMCID: PMC10611977
DOI: 10.1089/thy.2023.0281

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

Catherine F Sinclair et al. Thyroid. 2023 Oct.

. 2023 Oct;33(10):1150-1170.

doi: 10.1089/thy.2023.0281. Epub 2023 Sep 14.

Authors

Affiliations

¹ Icahn School of Medicine, New York, New York, USA.
² Department of Otolaryngology, Monash University, Melbourne, Australia.
³ Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
⁴ Thyroid Center of South Texas, San Antonio, Texas, USA.
⁵ Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA.
⁶ Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA.
⁷ Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
⁸ Department of Surgery, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
⁹ Department of Otolaryngology Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
¹⁰ Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA.
¹¹ Division of Endocrine Surgery, Department of Surgery, New York University Langone Health, Bethesda, Maryland, USA.
¹² Thyroid Diseases and Endocrine Tumors Department, Pitié-Salpêtrière Hospital, Paris, France.
¹³ Institute of Cancer IUC, Clinical Research Group Thyroid Tumors No. 16, Sorbonne University, Paris, France.
¹⁴ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
¹⁵ Endocrine and Ultrasound Guided Surgery Operative Unit, Ospedale del Mare, ASLNA1Centro, Naples, Italy.
¹⁶ Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, New York, USA.

PMID: 37642289
PMCID: PMC10611977
DOI: 10.1089/thy.2023.0281

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.

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Conflict of interest statement

To minimize to the greatest extent possible any potential influences of conflicts of interest on the opinions herein expressed, no personal financial conflicts of interest were permitted of the Task Force chairs. At inception of formation of the statement writing group, competing interests of the authors were reviewed by the Guideline Chairs, ATA Guidelines and Statements Committee, and Board of Directors of the ATA.

Given that the focus of the Statement is on principles of procedural safety, and not intended to be a guideline that recommends procedural indications or outcomes, all declared potential financial competing interests were deemed non-exclusionary for participation in the writing group. No potential competing interests were acquired during the development of the guidelines. All identified potential financial competing interests are declared in the Supplementary Data S1. No external funding from industry was received by the ATA or by authors for statement development.

Figures

**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.

See this image and copyright information in PMC

References

1. Che Y, Jin S, Shi C, et al. . Treatment of benign thyroid nodules: Comparison of surgery with radiofrequency ablation. AJNR Am J Neuroradiol 2015;36(7):1321–1325. - PMC - PubMed
1. Hussain I, Zulfiqar F, Li X, et al. . Safety and efficacy of radiofrequency ablation of thyroid nodules-expanding treatment options in the United States. J Endocr Soc 2021;5(8):bvab110. - PMC - PubMed
1. Bernardi S, Dobrinja C, Fabris B, et al. . Radiofrequency ablation compared to surgery for the treatment of benign thyroid nodules. Int J Endocrinol 2014;2014:934595. - PMC - PubMed
1. Yue WW, Wang SR, Li XL, et al. . Quality of life and cost-effectiveness of radiofrequency ablation versus open surgery for benign thyroid nodules: A retrospective cohort study. Sci Rep 2016;6:37838. - PMC - PubMed
1. Jin H, Lin W, Lu L, et al. . Conventional thyroidectomy vs thyroid thermal ablation on postoperative quality of life and satisfaction for patients with benign thyroid nodules. Eur J Endocrinol 2021;184(1):131–141. - PubMed

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources