Thyroid nodule rupture after radiofrequency ablation: case report and literature review

Abstract

Purpose: Radiofrequency ablation (RFA) is an effective and safe modality for the treatment of thyroid nodules. Nodule rupture is a major complication of RFA. There is little known on the natural history of nodule rupture due to a lack of clinical experience and no consensus on its management. A comprehensive review of nodule rupture presentation, diagnosis, and management is needed.

Methods: We report a case of nodule rupture and conduct a literature review. A total of 33 patients experiencing nodule rupture after RFA were included, and their clinical presentation, management, and outcomes were collected and analyzed.

Results: Nodule rupture presents with acute swelling (90.3%) and pain (77.4%) within 7 months of RFA procedure, most commonly due to disruption of the anterior thyroid capsule (87%), and can be diagnosed with ultrasonography. Most ruptures can be managed conservatively, exemplified by our reported case. There are no reported cases of long-term sequalae.

Conclusion: Nodule rupture is the second most common major complication of RFA. Based on the available evidence, we propose a treatment algorithm for nodule rupture and recommendations for future data collection to address gaps in our understanding of rupture etiology and effective management.

Keywords: minimally invasive techniques; radiofrequency ablation; thermal ablation; thyroid nodule; thyroid nodule rupture.

Figure 1

Baseline ultrasound demonstrates 4.2 cm solid homogenous, mildly hypoechoic nodule thyroid nodule replacing the majority of the left thyroid lobe in (A) longitude and (B) transverse views with (C) scant peripheral vascularity.

Figure 2

Photograph of patient neck at (A) 7 days post-RFA at time of initial complaint of transient redness and discomfort with spontaneous recovery and (B) at time of recurrent symptoms of pain, swelling, and redness at 1 month post-RFA prompting CT neck demonstrating findings of nodule rupture.

Figure 3

Ultrasound 7 days post-RFA with patient reported symptoms of transient erythema and fullness. Ultrasound without extrathyroidal mass but classic artifacts typical of immediate post-RFA including areas of (A) hyperechoic and hypoechoic changes with a non-distinct anterior border (B) without evidence of active bleeding.

Figure 4

Four weeks post-RFA contrasted neck CT demonstrating a 3.3 cm × 2.1 cm × 3.5 cm (AP × TR × CC) low-density perithyroidal fluid collection with peripheral enhancement (arrow) deep to the sternocleidomastoid muscle with disruption of the anterior capsule (Asterix) associated with edema and reticulation of the overlying subcutaneous tissue and skin (arrowhead) consistent with nodule rupture. Features of the nodule rupture are shown in (A) transverse, (B) coronal, and (C) sagittal planes.

Figure 5

Serial ultrasound changes for 1 year following initial RFA procedure measured at time post-rupture, monitoring nodule rupture resolution.

Figure 6

Locations of nodule rupture on normal thyroid ultrasonographic imaging with arrows indicating anterior rupture (blue), medial rupture (yellow), and posterolateral rupture (pink).

Figure 7

Progression of anterior nodule rupture with sinus track development. (A) 60 days post-RFA procedure, (B) 67 days post RFA, (C, D) 82 days post-RFA.

Figure 8

Proposed treatment algorithm for nodule rupture post-RFA.