- Surgery removes the whole nodule, and ablation shrinks it and leaves the gland in place. They serve different cases.
- The five questions: whether it is benign with two biopsies, whether it causes symptoms, what it is made of, how big it is and whether anything forces surgery.
- Cystic nodules and those producing hormone autonomously have other first options before radiofrequency.
A few years ago the conversation was short: if the nodule caused symptoms, it was removed. Today there is a second option for benign ones, and that calls for a longer and more careful conversation. These are the questions asked at the consultation, in this order.
What each one offers
Surgery
- Removes the whole nodule and allows the pathologist to examine it
- General anesthesia and usually one night in hospital
- Incision in a neck crease, with a fine scar
- If half of the thyroid gland is removed, about one in four people later needs thyroid hormone
- It is what is indicated when cancer is suspected or confirmed
Radiofrequency ablation
- Shrinks the nodule from within, and the body reabsorbs it over months
- Local anesthesia, outpatient, no incision
- The gland is preserved and most people keep their function
- One to two in ten nodules regrow in long-term follow-up
- Only for confirmed benign nodules
Which one fits your case is determined by your biopsy and your nodule, more than by a table like this one.
1. Is it benign, and with how many biopsies?
Ablation yields no specimen for the pathologist, so what is known about the nodule is known beforehand. Guidelines require two matching benign biopsies, and one is enough in the spongiform nodule, in the partially cystic one with a A bright artifact behind a dot on the ultrasound, associated with benign content. and in the one producing hormone autonomously. With an indeterminate result, Bethesda III or IV, ablation is not the first line. And if cancer is suspected, the question is already answered: surgery is indicated, and it is performed by a surgical oncologist.
2. Does it cause symptoms or show?
Pressure when swallowing, a feeling of tightness in the throat or a visible swelling in the neck. If none of those symptoms is present, the guidelines' answer is clear: it is not treated, it is monitored. The European Thyroid Association records it this way: an asymptomatic lesion is not ablated. Monitoring is also a medical decision, and often the right one.
3. What is it made of?
This is where radiofrequency stops being «the answer to everything». If the nodule is mostly fluid, both guidelines put Injection of ethanol into a cystic nodule, guided by ultrasound, so the fluid does not build up again. first, a simpler technique, and radiofrequency is the next step. And if the nodule produces hormone autonomously, an A nodule that produces thyroid hormone autonomously, without responding to the pituitary. It can cause hyperthyroidism., the European guideline puts radioiodine first, and ablation is considered if the patient declines it or is not suited. The technique is chosen by what the nodule shows.
4. How big is it?
Guidelines say nodules over 2 cm that keep growing may be considered for ablation. There is no written upper limit, but there is one fact: those over 20 mL in volume shrink less and may need a second session. In a very large nodule, surgery may be the more direct option, and in a medium one, ablation is usually enough.
- 70.9 %is the median volume reduction at 12 months after ablation, and 78.4 % of nodules shrink by half or more.Russell JO et al. Surgery. 2024, 175(1): 139-145. 620 nodules at three North American centers.
5. Is there anything that forces surgery?
- High-risk ultrasound features or a suspicious biopsy: surgery is indicated.
- Dense calcifications that prevent moving the electrode inside the nodule.
- A follicular neoplasm, which only surgery can classify.
- Pregnancy or a pacemaker: the monopolar electrode is contraindicated, and another technique is considered or the procedure is postponed.
- Kim JH et al. 2017 Thyroid Radiofrequency Ablation Guideline: Korean Society of Thyroid Radiology. Korean J Radiol. 2018, 19(4): 632-655.
- Papini E, Monpeyssen H, Frasoldati A, Hegedüs L. 2020 European Thyroid Association clinical practice guideline for the use of image-guided ablation in benign thyroid nodules. Eur Thyroid J. 2020, 9(4): 172-185.
- Russell JO et al. Surgery. 2024, 175(1): 139-145.
- Cooper D et al. Thyroid Res. 2024, 17: 18.
