2020 European Thyroid Association Clinical Practice Guideline for the Use of Image-Guided Ablation in Benign Thyroid Nodules

Abstract

Standard therapeutic approaches for benign thyroid lesions that warrant intervention are surgery for cold and either surgery or radioiodine for autonomously functioning thyroid nodules (AFTN). Image-guided thermal ablation (TA) procedures are increasingly proposed as therapy options for selected clinical conditions. Due to mounting scientific evidence and widening availability, ETA considered it appropriate to develop guidelines for the use of TA in adult patients. TA procedures are well tolerated, but a dedicated training of the operators is required and information on possible complications needs to be shared with the patients. The following factors should be considered when weighing between observation, surgery, and TA for benign thyroid nodules. In solid non-hyperfunctioning nodules, TA induces a decrease in thyroid nodule volume, paralleled by improvement in symptoms. Nodule re-growth is possible over time and may necessitate repeat treatment, or surgery, in a dialogue with the patient. In AFTN, radioactive iodine is the first-line treatment, but TA may be considered in young patients with small AFTN due to higher probability of restoring normal thyroid function and avoidance of irradiation. In cystic nodules, ethanol ablation (EA) is the most effective and least expensive treatment. TA may be considered for cystic lesions that relapse after EA or have a significant residual solid component following drainage and EA. TA should be restricted to benign lesions that cause symptoms or cosmetic concern. Presently, laser and radiofrequency ablation are the most thoroughly assessed techniques, with similar satisfactory clinical results. Microwaves and high-intensity focused ultrasound therapy options remain to be fully evaluated.© 2020 European Thyroid Association Published by S. Karger AG, Basel Recommendation 1. In adult patients with benign thyroid nodules that cause pressure symptoms and/or cosmetic concerns and decline surgery, image-guided TA should be considered as a costand risk-effective alternative option to surgical treatment or observation alone (1, ØØOO).Recommendation 2. We recommend against the use of TA for asymptomatic lesions (1, ØØØO).

Novel Approaches for Treating Autonomously Functioning Thyroid Nodules

“…Prior to RFA treatment of AFTN, confirmation that the nodule is benign on at least one US-guided FNA or core biopsy is recommended, unless there are concerning features on ultrasound in which case two biopsies should be obtained ( 43 , 44 ). Nodules that are benign on FNA but that have suspicious US features (EU-TIRADS 5), the latest European Thyroid Association Guidelines strongly recommend (moderate quality evidence) against thyroid ablation to avoid potential delay in treatment of a malignant lesion ( 62 ).…”

Placing Thermal Ablation for Benign Thyroid Nodules into Context

“…In the present issue of European Thyroid Journal, Papini et al [1] published guidelines for the use of thermal ablation (TA) in benign thyroid nodules, sponsored by the European Thyroid Association (ETA). The guidelines highlight the state-of-the-art in TA, clearly define the standard technical procedures, and the indications for which such techniques should be routinely used.…”

Thermal Ablation in Thyroid Nodules > 3 cm: When is a Single Benign Cytology Sufficient?

“…Ethanol ablation is recommended as the first-line treatment for benign cystic TN. Recent position statements [1][2][3][4], including that of the Thyroid Section (German Society for Endocrinology), the Thyroid Working Committee (German Society for Nuclear Medicine), and the German Association of Endocrine Surgeons (CAEK) for the German Society of General and Visceral Surgery (DGAV) published in this journal [4], considers image-guided thermal ablation (TA) an effective and safe treatment option in patients with symptomatic benign TN or esthetic repercussions. For now, TA is only recommended for benign TN [1][2][3][4].…”

“…There was only one malignant tumor (1.1 %) among 86 ATN, which was a follicular variant of papillary carcinoma in a EU-TIRADS 5 nodule. Using the (more rigorous) TIRADS 2 [3] or ATN (except for EU-TIRADS 5) criterion, no case of malignancy was found among 194 nodules > 3 cm with benign cytology. Applying the TIRADS 2 or 3 [1,2,4] or ATN (except for EU-TIRADS 5) criterion, only one cancer (0.4 %) was seen among 247 nodules > 3 cm with benign cytology.…”

“…It should be remembered that, at least in the case of nodules that are not EU-TIRADS 5, some position statements even do not recommend the first FNA before TA [2,4]. Second, it must be defined whether non-autonomous EU-TIRADS 3 nodules require, as recommend by some [3], or not, as accepted by others [1,2,4], a second cytology before TA.…”