Thyroid Nodule Ablation

Average outcomes: required 1.3 sessions, VR of 80% at 12 mo, 95% at 5 yrs
Single session: VRR 67% at 5 yrs, 82% if nodule <10 mL, 75% if 10-20 mL, 65% if >20 mL
Ablation has similar outcomes to resection for T1N0M0 T1a and T1b papillary thyroid carcinoma. Ablation had less blood loss, hospital stay, and faster recovery but more recurrence in theory due to microscopic additional lesions not visible on US being removed with surgery.

Benign biopsy x 2, only one if AFTN
US with volume estimation (large =>20 mL), features, location relative to critical structures
Symptoms score (0-10)
Cosmetic score (1-4):
- 1 - no palpable mass
- 2 - palpable without cosmetic issues
- 3 - cosmetic issue with swallowing only
- 4 - readily detectable
Labs: CBC, PT/INR, TSH, T4, T3
Optional: CT/MRI or nuclear medicine studies

Anesthetize skin and pericapsular anesthesia, also works to hydrodissect away critical structures like the carotid artery
- Some use a mixture of 1% lidocaine + 0.5% bupivacaine + D5
Advance ablation probe via a transisthmic approach, medial to lateral, for stability and pointing away from tracheoesophageal groove
Moving shot working posteromedial to anterolateral due to shadowing posterior to ablation zone and to avoid danger triangle at medial aspect of thyroid with recurrent laryngeal nerve.
Remove ablation probe and apply dressing.

Major (1-2%): nodule rupture, nerve injury > hypothyroidism, seed tracking, tracheal/esophageal injury

Minor (1-2%): pain, hematoma, skin burn, N/V, vasovagal, transient thyroiditis, fever, coughing, lidocaine toxicity