Dr. Eren Berber, MD, endocrine surgeon, vice chair of the endocrine surgery department, and director of the ablation program at Cleveland Clinic, talks about killing thyroid nodules with ablation.
Interview conducted by Ivanhoe Broadcast News in 2022.
What are thyroid nodules?
BERBER: Thyroid nodules are growths within the thyroid that develop over time that may be benign or cancerous.
What are the signs and symptoms of a thyroid nodule?
BERBER: Some of these nodules do not cause any symptoms and then they’re just found incidentally. Some of these affect the function of the thyroid, so, the patient may present either with a hyper or hypo functioning type of clinical picture. Some patients may have some difficulties swallowing, breathing, or they might have some pressure in their neck.
Are those nodules, those growths, are they on the thyroid itself?
BERBER: Yes.
Do they vary in size?
BERBER: Yes.
How common are thyroid nodules?
BERBER: Thyroid nodules are very common, actually, but a lot of people don’t know that they have a thyroid nodule. If they get some kind of imaging, maybe they get a scan for their neck disease, like spine problems, or they’re involved in some kind of accident and somehow they get a CT scan of their neck and then these nodules are identified. So, if we did an ultrasound on everybody, the incidences could be as high as 70% of the population. But most of them don’t come to attention until patients start having symptoms.
Can some thyroid nodules affect the functioning of the thyroid?
BERBER: Yes.
Is that how you can get some symptoms of the thyroid because it’s affected by the nodule?
BERBER: Exactly.
Are thyroid nodule cancerous?
BERBER: About 5% of the nodules have cancer. If the nodules have certain appearances on the ultrasound and they have a certain size, then we would need what we call a needle biopsy, which is done under local anesthesia. Then, based on this biopsy, about 5% of the nodules have what we call thyroid cancer.
How are thyroid nodules treated, historically, and maybe also different thyroid nodules are treated differently?
BERBER: I’m going to mostly talk about those nodules that don’t affect the function of the thyroid, because that’s most of the patients that I see in my practice. And then those nodules, if the patients are having some pressure symptoms, what we call compressive symptoms, where the nodules are big enough to interfere with their breathing, swallowing or cause significant pressure, then those patients definitely need some treatment done. And the treatment is surgical removal.
How do you approach a thyroid nodule, and what treatment is needed, depending on the thyroid nodule?
BERBER: The main issue depends on whether the patient is having symptoms or not. If the patients have big nodules with comprehensive symptoms, then the patient needs thyroid surgery to remove the nodules. That either involves removing the thyroid completely or removing at least half of the thyroid. If the patients are not having these type of symptoms, then we go by what the biopsy shows us. If the biopsy – the needle biopsy is called FNA – shows us any suspicion for cancer, then these patients are also treated with surgery. Then, the question is, what do you do about the patients who have benign nodules who would like to do more about the management of their nodules and monitor them over time? The monitoring is by doing ultrasounds, initially at six months and then every year. Nevertheless, some of these patients would like to be more proactive and search for alternative options to treat their nodules. Another challenge involves those patients whose thyroid nodules that keep growing, despite benign biopsies. What do you do about those patients, as well? In these patients, surgery is a definitive treatment, but it involves going through a surgical procedure that involves certain risks and recovery. Furthermore, all of the patients undergoing removal of their whole thyroid and about 50% of patients undergoing removal of half of their thyroid glands would require to be placed on thyroid hormone for the rest of their lives. But other than surgery, we don’t have another option for these patients that allows them to be proactive in treating their nodules. In our current practice, we monitor the benign nodules in patients that do not cause symptoms. However, over the last couple of years, a new treatment was developed mostly in the Far East, where the physicians in South Korea described that if you burn these nodules with a needle under local anesthesia, instead of removing them surgically, you could actually shrink the sizes of the nodules which could help decrease the patient’s symptoms and allow the patient to be proactive in their management with an option other than thryodi surgery. Over the past couple of years, this treatment has made its way to the United States, as well. Our center at Cleveland Clinic, as well as a couple of other centers are also investigating this technology and offering this treatment to patients. This is basically an option for patients with benign nodules that are over 2 centimeters who would like to be more proactive rather than choosing ultrasound monitoring, and those patients with symptoms from benign nodules who would like to do something less invasive than a surgical operation. In these patients, burning the thyroid nodules with a technology called “radiofrequency ablation” or “thyroid nodule ablation” procedure under local anesthesia is a new option.
Can you describe how Cleveland Clinic has begun to treat those thyroid nodules in a minimally invasive way?
BERBER: These patients are seen by dedicated Cleveland Clinic endocrinologists who assess the nodules and associated symptoms and decide if the patient is a candidate for this procedure. Then, I will meet the patients in person, do my own ultrasound and give an opinion about whether the patient is a good candidate for this treatment. This procedure is done under local anesthesia with sedation available. The thyroid nodule ablation procedure is current done in the operating room. After the neck is cleaned with a sterile solution, under ultrasound guidance, we placed special “radiofrequency ablation” needles into the nodules, in the same fashion that we do a thyroid nodule biopsy. After we insert the needle into the nodules, we start the ablation process, that burns the cells inside the nodules. Treatment of a nodule takes about 10 to 30 minutes depending on its size. The procedure is very similar to a thyroid needle biopsy procedure. Then, the patients are discharged home after being observed for a few hours in the recovery room. We see these patients in our office about two weeks for their immediate post-procedure check, and then three to six months to monitor the change in the size of the nodule. The results we’re seeing are in accordance with the literature. When the nodules are treated with this thyroid nodule ablation procedure, within six months, we see up to about 50% reduction of the size of the nodule in terms of its volume.
Is the procedure considered outpatient?
BERBER: Yes.
What is the benefit of using this minimally invasive procedure to treat this type of nodule?
BERBER: Basically, this treatment allows the patients to take a more proactive role for their benign thyroid nodules that may be causing symptoms or continue to grow despite multiple benign biopsies. The risks of this procedure are less than those associated with thyroid surgery, such as bleeding and voice problems. The thyroid nodule ablation procedure is also a preferable option for patients with significant medical comorbidities or other medical problems that would put them at some risk for undergoing a more invasive thyroid operation under general anesthesia. This is an option to help with their symptom resolution with a less invasive treatment. Furthermore, the patients do not need to be placed on thyroid hormone medication for life after this treatment, in contrast to after thyroid surgery. A lot of our patients scheduled for thyroid surgery are concerned that they may have to take thyroid medication for the rest of their lives, even if only half of the thyroid is removed. Instead, by undergoing a thyroid ablation procedure that does not cause any changes in their thyroid function, they do not need to take thyroid medication for the rest of their lives. That is a significant reason for our patients to seek this treatment.
Who are the best candidates for this approach?
BERBER: The best patients are those patients with nodules that are over two centimeters with benign biopsies.
Is there anything else that you think the general public should know?
BERBER: I would say that it’s important to determine the indications for this procedure objectively so that it’s not abused., For instance, in patients with thyroid cancer, the thyroid nodule ablation procedure is not indicated. It’s also important that this procedure is done by physicians who have expertise in thyroid surgery, thyroid ultrasound, as well as ablation technologies because, despite being a minimally invasive procedure, serious complications can still occur if not done by experts. So, I think it’s important for patients to seek a center where there’s experience and expertise associated with this procedure.
Is this considered a clinical practice?
BERBER: Yes. It’s not experimental, but because the technology just came to the United States over the last year or so, we need to develop an evidenced-based approach in offering this treatment to eligible patients. Data are accumulating in the literature, both from United States and the rest of the world, which clearly demonstrate that nodules shrink over time after ablation with an acceptable risk of complications.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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