What is interventional radiology for thyroid conditions?

Interventional radiology is a specialized medical field that uses imaging guidance to reduce the need for open surgery. Interventional radiology procedures are typically less invasive than traditional open surgery, leading to smaller incisions, reduced risk, shorter recovery times and less pain.

Thyroid disease among children and adolescents has increased in the past decade, so our doctors in the Pediatric Thyroid Center here at Children’s Hospital of Philadelphia (CHOP) are studying new, less invasive ways to diagnose and treat patients, and to decide who really needs surgery. Through Interventional Radiology (IR), we have had success in treating thyroid conditions using specific needle-based procedures.  

How we use IR to treat thyroid conditions 

Traditional treatment for thyroid conditions includes surgery, which results in a surgical scar, days of recovery and the potential need for thyroid hormone replacement therapy. Today, many thyroid conditions, like thyroid nodules, can be safely evaluated and treated by our interventional radiologists with minimally invasive procedures that determine the risk for cancer in the nodule, and in cases of selected nodules and lesions, even reduce their size and abnormal activity.

These are outpatient procedures performed by our dedicated team of thyroid experts, radiologists, registered nurses, physician assistants, nurse practitioners, clinical coordinators, sedation physicians and other specialists, working together to treat pediatric patients in our state-of-the-art IR suites.

The most common interventional radiology procedures for thyroid conditions include: 

Thyroid fine-needle aspiration biopsy

Thyroid fine-needle aspiration biopsy (FNA) is the best and most trusted test for checking thyroid nodules because it’s safe, reliable and accurate in finding out if cancer might be present. During the procedure, doctors use ultrasound to guide the needle to the right spot. They also use a process called Rapid On-Site Evaluation (ROSE) to make sure the sample is good enough and to give a quick, early result. If needed, they can collect another small sample during the same visit for additional testing.

Percutaneous ethanol injection

Percutaneous ethanol injection (PEI) is a simple, minimally invasive treatment for thyroid nodules that are fluid-filled (cystic) or mostly cystic. It can sometimes be used instead of surgery. During the procedure, doctors inject a small amount of sterile alcohol (ethanol) into the cyst. This causes the cyst lining to shrink and the nodule to get smaller over time.

A similar treatment, called ethanol ablation (EA), can be used for small areas or lymph nodes that contain papillary thyroid cancer. This option may be offered to certain patients with spots smaller than half an inch as an alternative to surgery or medicine. 

Laser thermal ablation

Laser thermal ablation (LTA) — also called fiberoptic thermal ablation — is a minimally invasive treatment that uses heat instead of alcohol to shrink thyroid nodules or treat cancerous lymph nodes. The laser targets the nodule directly, heating it until the tissue dies and turns into a small scar. This helps reduce the size of noncancerous (benign) nodules without harming the rest of the thyroid gland. LTA may also be used to treat thyroid nodules that make too much thyroid hormone (“hot” nodules).

Radiofrequency ablation

Radiofrequency ablation (RFA) is another minimally invasive treatment that’s also used for certain bone and abdominal tumors. Like laser thermal ablation, RFA can shrink benign thyroid nodules that cause symptoms or affect appearance, and it can treat small areas of returning thyroid cancer. Instead of using alcohol or direct heat, RFA uses radio waves (a type of sound energy) to safely destroy the targeted tissue.  

What to expect at your IR appointment

We’ll decide together — with our thyroid endocrinology team, IR team, and your family — whether an interventional radiology procedure is the right choice for your child and which specific approach to use. All IR procedures for thyroid conditions are done on an outpatient basis, so your child can go home the same day. 

Scheduling your child’s appointment

• If your care team has referred your child for an IR procedure, please call the IR nurse scheduler at 215-590-7000 (press #1 at the first prompt, press #2 at the second prompt).
• The nurse scheduler will ask questions about your child's medical history, medications and previous reactions to sedation or anesthesia in the past.
• You will receive special instructions, including making sure your child does not eat or drink before the procedure, particularly if they will be sedated or undergo anesthesia.
• IMPORTANT: Your referring physician must fax us a copy of a procedure request form stating the type of procedure your child needs and the reason for it. We cannot schedule an IR exam without this form.
• About two weeks before your child's appointment, we will send you additional instructions about the specific procedure your child will complete. Please keep these instructions in a safe place where you can refer to them before your appointment.
• Please tell the IR team if your child has special needs. Our goal is to make this experience as stress free as possible for both you and your child.  

Arriving for your child’s appointment

• Please arrive 45 minutes before your scheduled appointment time. It is important that you arrive on time, or your child’s procedure may be canceled.
• Check in at Outpatient Registration, on the third floor of the Main Hospital on CHOP’s Philadelphia campus.
• Please bring proof of insurance and a copy of your referral, if required by your insurer. 

When your registration process is complete, we will notify IR. A member of the IR clinical staff will come to the central registration area and bring you and your child to a room for IV placement or other preparations. 

Preparing your child for their IR appointment

Our certified child life specialists can help you prepare your child for and support them during their IR procedure. We can also arrange to have a child life specialist at your child's appointment to explain the procedure in developmentally appropriate ways and help them to better cope with the stress of the hospital experience. 

For answers to specific questions about your child’s procedure at CHOP, please call the Interventional Radiology Nurse scheduler at 215-590-7000.  

Follow-up and outcomes 

The type of follow-up care your child needs after an image-guided procedure depends on their specific condition. For example, thyroid nodules that are noncancerous but cause symptoms can be treated in a few different ways — with ethanol ablation, thermal ablation, or sometimes a mix of both. The choice depends on what the nodule is made of. If the nodule is mostly cystic, we usually recommend ethanol ablation. This treatment works very well, with success rates between 85% and 98%. 

For nodules that are mostly solid, this treatment is also very effective — about 98% of patients see their nodule shrink by at least half in size.¹ 

We generally treat benign, predominantly cystic thyroid nodules with ethanol ablation and perform a follow-up ultrasound six months after the procedure. If the outcome is successful, your child will typically only need clinical follow up.

For nodules that are mostly solid and noncancerous, we’ll continue to follow your child’s progress over a longer period. This usually includes a checkup within the first month or two after treatment, and then more visits around six to 12 months later. During these visits, we’ll use ultrasound to see how much the nodule has changed in size. We consider the treatment technically successful if the nodule shrinks by at least half. Clinical success means your child is feeling better — with less pressure in the neck and improvement in any visible swelling. 

Thyroid cancer that comes back after treatment (recurrent) can be managed using ethanol ablation or thermal ablation. Right now, CHOP uses ethanol ablation, but we plan to offer laser thermal ablation for this purpose soon. After ablation, fewer than one in four patients need another surgery to remove remaining cancer. 

If your child’s thyroid cancer is treated with one of these IR procedures, we’ll continue to monitor their progress over time. This includes regular blood tests to measure thyroglobulin levels and follow-up ultrasounds to check how well the treatment worked. The first follow-up visit usually happens three to six months after the procedure, and then every six to 12 months, depending on how active the cancer appears to be. 

Reference

1. Jung SL, Baek JH, Lee JH, et al. Efficacy and Safety of Radiofrequency Ablation for Benign Thyroid Nodules: A Prospective Multicenter Study. Korean J Radiol. 2018;19(1):167-174.