Non-surgical management of thyroid nodules – the role of ablative therapies

Context After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma (PTC) surgery or RAI (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (e.g. scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks. Cases We present 4 cases of thyroid lesions causing concerns (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients’ attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation – RFA – being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects and conclude with a simplified description of how these procedures are performed. Conclusions Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.