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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 5  |  Page : 960-966

Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition)


1 Department of Ultrasound, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, China
2 Department of Surgical, Zhejiang Provincial People's Hospital, China
3 Department of Surgery, Sun Yat-Sen University Cancer Center, China
4 Department of Surgery, First Affiliated Hospital of Kunming Medical University, China
5 Department of Surgery, Sino-Japanese Friendship Hospital of Jilin University, China
6 Department of Surgery, The Second People's Hospital of Fujian Province, China
7 Department of Ultrasound, Shanghai Changzheng Hospital, China
8 Department of Ultrasound, Chinese PLA General Hospital, China
9 Department of Surgery, Guangdong Academy of Medical Sciences, China
10 Department of Invasive Therapy, Affiliated Ruijin Hospital of Shanghai Jiaotong University, China
11 Department of Surgery, Shanghai Jiaotong University School of Medicine Renji Hospital, China
12 Department of Ultrasound, The First Affiliated Hospital of Dalian Medical University, China
13 Department of Surgery, Chinese PLA General Hospital, China
14 Department of Surgery, Cancer Hospital Affiliated to Harbin Medical University, China
15 Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China
16 Department of Surgery, Zhuhai People's Hospital, China
17 Intervention Therapy Department, Sun Yat-Sen University Cancer Center, China
18 Department of Surgery, Affiliated Ruijin Hospital of Shanghai Jiaotong University, China
19 Department of Surgery, Qianfoshan Hospital Affiliated to Shandong University, China
20 Department of Surgery, Fourth Affiliated Hospital of Harbin Medical University, China
21 Department of Ultrasound, The Second Affiliated Hospital of Zhejiang University School of Medicine, China
22 Department of Ultrasound, The First Affiliated Hospital of Zhejiang University, China
23 Department of Endocrinology, Guangdong General Hospital, China
24 Department of Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, China
25 Intervention Therapy Department, Renji Hospital Affiliated to Shanghai Jiaotong University, China
26 Department of Surgery, Xiangya Hospital Central South University, China
27 Department of Surgery, West China Hospital of Sichuan University, China
28 Department of Ultrasound, Sichuan Cancer Hospital, China
29 Department of Surgery, Henan Cancer Hospital, China
30 Department of Ultrasound, Fujian Cancer Hospital, China
31 Department of Surgery, Sichuan Cancer Hospital, China
32 Department of Ultrasound, Yantai Affiliated Hospital of Binzhou Medical University, China
33 Department of Surgery, Longhua Hospital Shanghai University of Traditional Chinese Medicine, China
34 Department of Surgery, Tongji Meidical College Huazhong University of Science and Technology, China
35 Department of Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, China
36 Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), China
37 Department of Surgery, The First Affiliated Hospital of Zhengzhou University, China
38 Department of Surgical, The Second Affiliated Hospital of Nanchang University, China
39 Department of Surgery, Ningxia People's Hospital, China
40 Department of Ultrasound, Affiliated Ruijin Hospital of Shanghai Jiaotong University, China
41 Department of Endocrinology, Peking University First Hospital, China
42 Department of Ultrasound, The third affiliated hospital, Sun Yat-sen University, China
43 Department of Thyroid and Neck Cancer, Tianjin Medical University Cancer Institute and Hospital, China
44 Department of Ultrasound, Shanghai Sixth People's Hospital, China
45 Department of Surgery, Hubei Cancer Hospital, China
46 Department of Surgery, Peking University First Hospital, China
47 Department of Integrated Chinese and Western Medicine, Fudan University Shanghai Cancer Center, China
48 Department of Oncology, Shandong Provincial Hospital, China
49 Intervention Therapy Department, Henan Cancer Hospital, China
50 Intervention Therapy Department, Cancer Hospital Chinese Academy of Medical Sciences, China
51 Department of Invasive Therapy, The First Affiliated Hospital of Fujian Medical University, China
52 Department of Ultrasound, Shanghai Tenth People's Hospital, China
53 Intervention Therapy Department, Zhongda Hospital Southeast University, China

Date of Submission03-Aug-2019
Date of Decision19-Oct-2019
Date of Acceptance31-Mar-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dong Xu
Department of Ultrasound, .Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine(IBMC), Chinese Academy of Sciences, Hangzhou, 310022
China
Gaojun Teng
Intervention Therapy Department, Zhongda Hospital Southeast University, Nanjing, 210000
China
Huixiong Xu
Department of Ultrasound, Shanghai Tenth People's Hospital, Shanghai, 200000
China
Minghua Ge
Department of Head & Neck Tumor Surgery, Zhejiang Cancer Hospital, Hangzhou, 310022
China
Ping Liang
Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_558_19

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 > Abstract 


As a treatment option for cancer, thermal ablation has satisfactory effects on many types of solid tumors (such as liver and renal cancers). However, its clinical applications for the treatment of thyroid nodules and metastatic cervical lymph nodes are still under debate both in China and abroad. In 2015, the “Zhejiang Expert consensus on thermal ablation for thyroid benign nodules, microcarcinoma, and metastatic cervical lymph nodes (2015 edition),” was released by the Thyroid Cancer Committee of Zhejiang Anti-Cancer Association, China. To further standardize the application of thermal ablation for thyroid tumors, the Thyroid Tumor Ablation Experts Group of Chinese Medical Doctor Association has organized many seminars and finally produced a consensus to formulate the “Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition).

Keywords: Ablation techniques, consensus, guideline, nodular goiter, thyroid neoplasms


How to cite this article:
Xu D, Ge M, Yang A, Cheng R, Sun H, Wang H, Zhang J, Cheng Z, Wu Z, Wang Z, Zhai B, Che Y, Chen L, Chen L, Cheng W, Dong G, Duan P, Fan W, Fei J, Fu R, Gao M, Huang P, Jiang T, Kuang J, Li H, Li P, Li X, Li Z, Lu M, Luo Y, Qin H, Qin J, Tan Z, Tang L, Wang Z, Wang S, Wang X, Wu G, Xie X, Xu H, Yin D, Qiu X, Jichun Y, Yu J, Zhan W, Zhang F, Zhang J, Zheng R, Zheng X, Zheng Y, Zhu Y, Zou Y, Meng Z, Ye X, Li H, Li X, Lin Z, Wang L, Wang L, Yang C, Wang Y, Zhou L, Ou D, Wang J, Gao M, Xu H, Liang P, Teng G. Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition). J Can Res Ther 2020;16:960-6

How to cite this URL:
Xu D, Ge M, Yang A, Cheng R, Sun H, Wang H, Zhang J, Cheng Z, Wu Z, Wang Z, Zhai B, Che Y, Chen L, Chen L, Cheng W, Dong G, Duan P, Fan W, Fei J, Fu R, Gao M, Huang P, Jiang T, Kuang J, Li H, Li P, Li X, Li Z, Lu M, Luo Y, Qin H, Qin J, Tan Z, Tang L, Wang Z, Wang S, Wang X, Wu G, Xie X, Xu H, Yin D, Qiu X, Jichun Y, Yu J, Zhan W, Zhang F, Zhang J, Zheng R, Zheng X, Zheng Y, Zhu Y, Zou Y, Meng Z, Ye X, Li H, Li X, Lin Z, Wang L, Wang L, Yang C, Wang Y, Zhou L, Ou D, Wang J, Gao M, Xu H, Liang P, Teng G. Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition). J Can Res Ther [serial online] 2020 [cited 2020 Oct 21];16:960-6. Available from: https://www.cancerjournal.net/text.asp?2020/16/5/960/296438




 > Introduction Top


In recent years, the incidence rate of benign thyroid nodules and thyroid microcarcinoma has showed an upward trend. Surgical operation remains the preferred option for treating thyroid tumors (especially thyroid cancers).[1],[2],[3] However, with characteristics such as minor trauma, fast recovery, good repeatability, better appearance, and better preservation of thyroid function, image-guided thermal ablation (radiofrequency [RF], microwave, and laser) has been developed for the treatment of some benign thyroid nodules, low-risk papillary thyroid microcarcinomas (PTMCs), and metastatic cervical lymph nodes in the past few years.[4],[5],[6],[7],[8],[9] Since the publication of “Expert consensus on thermal ablation for thyroid benign nodules, microcarcinoma, and metastatic cervical lymph nodes (2015 edition)” in 2016,[10] there have been plenty of discussions on the use of thermal ablation treatment for thyroid nodules.[9],[11],[12],[13] With the passage of time and development of clinical practices, in order to show the new recognition about thermal ablation for thyroid nodules, Chinese experts in this field decided to release this consensus based on the diagnosis and treating principles for thyroid cancers, medical ethics, and Zhejiang consensus (2015 edition). We hope to further improve the diagnosis and treating principles of thyroid benign and malignant nodules, as well as further standardize medical practices.[14],[15]


 > Preoperative Assessment Top


Thermal ablation of thyroid nodules is a technical approach that applies the method of in situ inactivation in vivo to achieve local radical cure for cancers. Therefore, preoperative oncology assessment should be a prerequisite for treatment. All patients are required to undertake a needle biopsy in order to obtain satisfactory pathological results before surgery. Fine-needle aspiration (FNA) biopsy for cytology and the Bethesda reporting system for cytopathology diagnosis are recommended. Core needle biopsy can also be applied for histopathological examination. Benign nodules are those under the FNA Bethesda Class II. As for malignant nodules that meet ablation conditions, a clear diagnosis of FNA is also required for patients to be well informed and make choices before surgeries.


 > Indications and Contraindications Top


Benign thyroid nodules

Indications

Indications should meet item 1 to item 3 at the same time, and meet one of the conditions under item 4.

(1) The nodule is considered benign by ultrasound and finally recognized as Class II by FNA and by cytopathological Bethesda reporting system,[16.17] or it is diagnosed as a benign node by preoperative histological biopsy and pathological examinations;[18] (2) patients have no history of radiotherapy in childhood;[19] (3) patients themselves require to take minimally invasive interventional treatment after being fully informed, or just refuse to undergo surgery or clinical observation; (4) it is necessary to meet one of the following conditions: (1) patients have hyperthyroidism caused by autonomously functioning thyroid nodules; (2) patients have subjective symptoms (e.g., foreign body sensation and uncomfortableness or pain in the cervical region) which are distinctly related to thyroid nodules, or patients who require treatment because of a poor appearance; and (3) nodules recurred after surgery, or their volume increased significantly.[17],[18]

Contraindications

Contraindications are any single of the following conditions:

(1) A large retrosternal goiter is found or most thyroid nodules are located behind the sternum (for patients who cannot tolerate surgery or anesthesia, fractional ablations or palliative therapy can be considered);[20],[21] (2) lesion's contralateral vocal cord is dysfunctional; (3) presence of a severe blood coagulation disorder; and (4) dysfunction of important organs.

Papillary thyroid microcarcinoma

There is not enough medical evidence to prove the effectiveness of thermal ablation in the treatment of PTMC, and thus thermal ablation is not recommended as a routine treatment for PTMC. Most experts in this consensus claim that a prospective clinical study should be carried out to explore the effectiveness and safety of thermal ablation under specific conditions (strictly following relevant laws and regulations, medical ethics, and ethical review processes and ensuring that patients are fully informed). In this way, we can determine whether thermal ablation therapy is suitable for the treatment of thyroid cancer and its indications can also be clarified. However, for doctors to carry out such a study, they must have the title of deputy chief physician or above and must have specialized in the ablation treatment of thyroid cancer for more than 2 years.

Indications

Indications should meet the following nine items at the same time.

(1) Nonpathological high-risk subtype;[22],[23] (2) tumor diameter ≤5 mm (diameter ≤1 cm for tumors surrounding tissues that are not close to the capsule), and the distance between nodules and posterior medial capsule should be >2 mm;[24],[25] (3) the thyroid capsule should and surrounding tissues should not be invaded;[26],[27],[28],[29] (4) the lesion is not located in the isthmus; (5) no multifocal thyroid cancer; (6) no family history of thyroid cancer; (7) no history of cervical radiation exposure in adolescent period or childhood;[30],[31] (8) no evidence of lymph node or distant metastasis; and (9) patients refuse to undergo surgery and follow-up visits after being fully informed.[32]

Contraindications

Contraindications include any single of the following conditions:

(1) Metastasis in the cervical region or distant metastasis is found;[33],[34] (2) the volume of the tumor progressively increases in a short period of time (>3 mm in 6 months);[35] (3) pathological high-risk subtype (high cell subtype, columnar cell subtype, diffuse sclerosis, solid/island type, and eosinophilic subtype);[36],[37],[38] (4) lesion's contralateral vocal cord appears dysfunctional; (5) occurrence of a severe blood coagulation disorder; and (6) dysfunction of important organs.

Metastatic cervical lymph nodes

Surgical dissection should be the preferred treatment when metastatic lymph nodes are found at the initial diagnosis of thyroid cancer. Obviously, these patients cannot receive ablation treatments, but for patients who are found to have metastatic cervical lymph nodes after undergoing surgical dissections, there are many guidelines or consensus which consider thermal ablation as a treatment.[39] This consensus believes that surgical treatment is still the preferred treatment for thyroid cancer recurrence and metastatic lymph nodes, but patients with the indications described below can choose thermal ablation treatment after being fully informed.[40],[41]

Indications

Indications should meet the following conditions at the same time:

(1) Cervical lymph nodes have recurred and metastasized after radical treatment; (2) imaging examination suggests metastasis and the metastatic lymph node is diagnosed by FNA; (3) evaluation shows that patients cannot tolerate surgery or they refuse surgical treatments;[9],[42] (4) the iodine 131 treatment is ineffective for metastatic lymph nodes or patients refuse to take iodine 131 treatment; and (5) metastatic lymph nodes can be separated from large blood vessels, allowing important nerves to have a safe operating space.[42],[43]

Contraindications

Contraindications should meet one of the following conditions:

(1) The lesion is located in the VI area and lesion's contralateral vocal cord appears dysfunctional;[9] (2) there is a severe blood coagulation disorder; and (3) dysfunction of important organs.


 > Preoperative Preparation Top


(1) Patients should undergo physical examinations before undergoing surgery and their medical histories should also be taken. For those who have cardiovascular diseases, cerebrovascular diseases, or diabetes, related treatments should be applied to adjust their physical conditions; (2) preoperative examination of routine blood, blood type, urine routine, routine stools, coagulation function, infectious diseases, thyroid function, parathyroid hormone, calcitonin, tumor markers, chest radiograph, electrocardiogram, pulmonary function, laryngoscope, cervical enhanced computed tomography/magnetic resonance, and contrast-enhanced ultrasound (recommended but not restricted) should be performed; (3) the patient or his/her legal representative should be fully informed of the disease severity, treatment purpose, treatment risk, current treatment status, and alternative treatment methods before surgery, and a signed informed consent must be obtained; (4) patients should be fasted for >4 h before and after surgery. Local anesthesia is usually used for surgery, while local nerve block, general intravenous anesthesia, and acupuncture combined anesthesia can also be selected (or adjusted) according to patients' specific conditions and their pain tolerance; and (5) a venous channel should be established for the intravenous administration.


 > Operational Approaches Top


(1) A preoperative ultrasound examination from multiple angles and aspects should be performed to identify the lesion's location and size, as well as its relationship with the surrounding tissues. Moreover, the therapeutic scheme and thermal ablation mode or approach also should be developed according to the lesion's size and location; (2) the patient should be placed in supine position to extend the neck, and local anesthesia should be administered from the puncturing point to the peripheral capsule at the thyroid's anterior border, after performing routine disinfection and draping; and (3) 2% of lidocaine or its diluent should be injected between the thyroid anterior capsule and the anterior cervical muscles for local infiltration anesthesia and separation under the guidance of ultrasound. Then, 10–20 ml of normal saline or sterilized water (0.5 mg epinephrine can be added) should be injected between the thyroid outboard capsule and the common carotid artery, the thyroid posterior capsule and trachea/esophagus, the thyroid and parathyroid, the thyroid posterior capsule and recurrent laryngeal nerves, and the metastatic lymph node and surrounding tissues (few adjustments can be made according to the specific position of the tumor) to form a liquid separation zone for the protection of the carotid artery, esophagus, parathyroid gland, recurrent laryngeal nerve, and other surrounding organs and tissues; (4) under the guidance of imaging techniques (ultrasound is recommended), a safe and close path (the needle should puncture through isthmus primarily, or the needle can also puncture through the lateral cervical region instead according to specific conditions) should be selected to keep away from important areas such as blood vessels, trachea, and nerves in the cervical region;[44],[45] (5) the “mobile ablation technique” is recommended for ablation of benign mass lesions;[46] the lesion can be divided into multiple units and then can undergo ablation one by one through movement of the heat source. It is necessary to ensure that the lesion has been completely ablated in three dimensions. For lesions with small volumes or malignant lesions, the “fixed ablation technique” can be used to fix the heat source in the lesion and continue ablation. Moreover, multitarget ablation should also be considered according to specific conditions. The ablation area for patients with malignant tumors should be extended to achieve local radical cure;[47] (6) the output power of thermal ablation (RF, microwave, and laser) needs to be gradually adjusted from low to high, and the specific output power range and start–stop time must be controlled according to the thermal ablation options, lesion sizes, surrounding tissues, and values recommended by manufacturers;[48],[49] (7) thermal ablation should be stopped if the real-time ultrasound shows that the lesion has been completely covered by the strong echo generated by thermal ablation.[50] After ablation, enhanced imaging examination (contrast-enhanced ultrasound is recommended) should be performed to assess the effect of thermal ablation and ensure the safety of the operation;[51] and (8) operators qualified for thermal ablation should refer to the Management Standards for Tumor Ablation Treating Techniques (2017 Edition).


 > Evaluations of Therapeutic Effects Top


(1) Imaging examinations of lesions should be performed before, during, and after ablation. Ultrasound imaging examination is recommended (contrast-enhanced ultrasound is the best), and examination results should be regarded as the main evaluation indexes for therapeutic effects immediately after ablation and during the follow-up visit period;[52] (2) during follow-up visits at 3, 6, and 12 months after thermal ablation, the imaging examination (ultrasound is recommended) should be applied to observe the necrotic condition of the lesion and lesion size, and then calculate the volume and reduction rate of the nodule. The reduction rate of ablated lesions: ([preoperative volume − volume during follow-up visits]/preoperative volume) × 100%;[53] (3) related complications and their treatment and recovery conditions should be recorded. During follow-up visits, patients with thyroid tumors and cervical metastatic lymph nodes need checking of thyroid function indicators and corresponding tumor markers; and (4) qualified medical institutions can consider carrying out a biopsy and pathological examinations after operation (generally during the reexaminations at 1 and 3 months after operations) to determine the authenticity of therapeutic effects.


 > Notes for Attention Top


(1) If patients feel pain or are uncomfortable during ablation, the output power for ablation should be decreased or suspended, the method of anesthesia can be changed, and fractional ablation may be applied if necessary;[54],[55] (2) during the operation, vital signs (e.g., blood pressure, heart rate, respiration, and SpO2) should be monitored closely; (3) before the operation, patients and their families should be informed that the ablation may not be completed due to the large tumor size or other factors and thus the patient may require multiple or fractional ablations. Some patients may even need to undergo clinical surgeries. In addition, the tumor may recur or enlarge after ablation, so postoperative follow-up visits are required; and (4) before the operation, patients and their families or legal representatives should sign informed consents after being well informed.


 > Complications After Thermal Ablation and Treatment Methods Top


Hemorrhage

Most of the ablations have a coagulation function, and so the incidence rate of postoperative hemorrhage is low. Hemorrhage occurs mostly on the surface of the gland, while a few can occur in the gland or in the sac. The damage of subcutaneous blood vessels in the puncturing process may cause skin ecchymosis in rare cases. Some hemorrhages can be stanched by thermal ablation. In cases of already-formed hematomas, dynamic observation via ultrasound can be performed, and the bleeding can be further controlled by local compression. After controlling the hemorrhage, compression bandage and an ice compress should be applied to prevent re-bleeding, after which the hematoma will be self-absorbed. However, in rare cases such as uncontrollable hemorrhage, timely surgical decompression should be carried out, especially when the patient is breathless.

Pain

A small number of patients will experience mild or radiation pain after surgery, which most patients can tolerate. Such pain will be gradually reduced over time.[56] For a small number of patients with persistent pain, further investigation to reveal the causes is necessary and, if necessary, pain can be relieved through methods such as stopping ablation, additional anesthesia, and cervical plexus block.

Injury of recurrent laryngeal nerve and superior laryngeal nerve

Improper thermal ablation or tumor adhesion can damage the superior laryngeal nerve and recurrent laryngeal nerve. In some cases, during thermal ablation, heat is transmitted through the thyroid tumor and its surrounding tissues, causing injury of the recurrent laryngeal nerve and superior laryngeal nerve. Injury to the recurrent laryngeal nerve often causes ipsilateral vocal cord paralysis or sometimes unilateral vocal cord paralysis without any symptoms. Most patients with unilateral vocal cord paralysis have symptoms such as voice fatigue and more serious hoarseness. Generally, these symptoms will gradually decrease over time, and most patients recover within 3–6 months. During this period, hormones and neurotrophic drugs can be given. Injury to the bilateral recurrent laryngeal nerve and respiratory problems can lead to severe upper airway obstruction, often requiring emergency tracheotomy or tracheal intubation. Damage to the external laryngeal branch will mainly lead to paralysis of cricothyroid muscle and decreased vocal cord tension of the affected side. When speaking, symptoms such as low voice, weak voice, narrow voice range, shortened maximum vocalization time, and inability to speak loudly or shout may appear.

Uncontrolled tumor

If thermal ablation fails due to the specificity of the tumor or if unpredictable conditions occur during surgery such as surgical complications, timely preparation for surgical treatment is required in some situations (under such conditions, in order to reduce local adhesions, it is recommended to consider surgical treatment at 3 months after ablation for elective surgeries that will not affect the survival and quality of life).

Acknowledgment

This taskforce wishes to thank Mr. Ming Gao, Mr. Gaojun Teng, and Ms. Ping Liang for their patient support and help. This guideline was not funded by any organizations and also received no support from any commercial sources. However, we would like to thank The Thyroid Tumor Ablation Experts Group of Chinese Medical Doctor Association, the Society of Thyroid Cancer of China Anti-Cancer Association, the Committee of Interventional Ultrasound for Chinese College of Interventionalists, the Committee of Tumor Ablation Therapy for Chinese College of Interventionalists, the Society of Interventional Therapy of China Anti-Cancer Association and the Society of Minimally Invasive Therapy on Cancer of China Anti-Cancer Association for their valuable suggestions and constant support. This guideline was supported by two funds of National Natural Science Foundation of China (No. 81871370) and Zhejiang Provincial Natural Science Foundation of China (No. LSD19H180001).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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