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Percutaneous Ablation of Benign Thyroid Nodules: A Novel & Effective Alternative to Surgery

Dec 29 | 2:30 PM

In clinical practice, long-term management of benign thyroid nodules is a challenge. For the management of benign thyroid nodules with compressive symptoms or aesthetic problems, percutaneous thermal ablation is an effective alternative to surgery. Join us as Dr. Gaurav Gangwani discusses in-depth about this novel approach using some real life case examples.

[Music] good evening everyone uh myself dr vishali on behalf of team netflix i would like to welcome you for a session on percutaneous ablation of benign thyroid nodules a novel and effective alternative to surgery so for today's session we have with us dr gavra gangwani who is an interventional radiologist and his speciality is a unique one very performant ablative invasive interventions which allows immediate recovery for the patients he is a consultant interventional radiologist at bhaktivedanta hospital mumbai he completed his dnb radiology from saint stephen's hospital and then completed his fellowship in vascular and interventional radiology from sir gangaram hospital he has numerous publications to his name in various national and international journals dr gangwani had expressed interest in conducting a session on netflix by filling the form on the app if anyone from the audience would like to do the same you can fill out the application form and will surely get in touch with you so we would like to thank dr gangwani and we really appreciate your interest in conducting a session on netflix i think we can start with your session yeah i'll just start with the present day option you can use yeah sure yes yeah so good evening dear colleagues and friends a very interesting uh poll there with interesting mix of answers but yes most of the answers were almost tilting towards the right answer so let's see about this topic of percutaneous appellation of benign thyroid nodules is it just a new gimmick irs want to sell or is it something that is tangible and there to stay and uh is this title befitting can it really be an alternative to surgery or so this presentation with a lot of literature as well as some clinical scenarios let's talk about it so just a short introduction on thyroid nodules not unknown to us as doctors because it is one of a very common presentation of patients coming to us so it is a common disease of the adult so it is uh traditionally a disease of the middle age or elderly found more commonly as age progresses uh although i am seeing a lot of young people now presenting with hydro nodules so that statistics may soon change by uh personal experience i can say that uh and yes even in my personal experience it matches with literature females are more prone to getting thyroid nodules than males in fact my last four consecutive cases of thermal ablation in mumbai all have been female patients so yes it is probably more common in females the incidence of palpable nodules when the patient actually can feel the swelling or see the swelling and presence to the endocrinologist or the ent surgeon or the physician is around three to seven percent in the entire population but uh that being said these are just larger nodules which are large enough to be visibly seen or clinically palpated if you see if i do a sonographic evaluation or a screening randomly of the entire population there are studies which say that the incidence actually ranges between 20 to 76 many studies even in asia show that 76 percent of the population may have incidental nodules although subcentimetric or small so not saying that they will require treatment or they are important just that the number is that huge 7 of 10 people or more can have thyroid incidental thyroid nodules so it is a very common uh condition and it's very good if we are primed about the newer therapies that are coming in newer but established therapies so let's see more on that uh of course we should know that a benign thyroid nodule can also grow so just a interval growth rate does not mean that the nodule is turning malignant of course sudden increase in size or growth is a suspicion but uh benign thyroid nodules of course grow like many other benign diseases fibroid in your muscles and so on and depending on the age the earlier radiation exposure uh kind of therapy kind of drugs taken early so malignancy rate can vary amongst these nodules even if they are benign they can turn malignant potentially in future and the rate coated in literature is five to fifteen percent but usually if it's a colloid and there are not many risk factors then it's probably one to two percent so with that introduction let's move forward and let's see a very common clinical scenario in fact this was one of the first patients who presented to me when i shifted to mumbai for this indication so this was a 35 year old female with a midline neck swelling she came to me for a ultrasound neck which showed a solid solitary thyroid nodule it was about 20 cc in volume uh all the features uh it was a hyperlink nodule wider than tall very smooth hello rim so when i did this classical tie that scoring which is now a standard rather than uh option for uh sonography of the thyroid nodule so that showed it to be tyrants too in a while we'll see what is tied ads and how do you score these nodules so but tyrese 2 means that it was mostly benign there was hardly any suspicion that it would have been malignant so it was meaning the patient did not have much problems but basically she was a model and she wanted cosmetic relief she didn't like this sudden swelling which was gradually progressing and before it rose to dramatic proportions she wanted it treated and treated without a scar because of a profession so uh while doing the fnc incidentally she inquired about this therapy and which she had just probably seen on the net browsing for any minimally invasive alternative without scar and there we uh i counseled her of the same and i informed her how i have been lucky to be one of the few people in india to be doing this and then we planned and did the procedure but so the scenario is uh how do we approach such a patient the thyroid function tests are normal there's a solitary nodule which is hundred percent benign proven on ultrasound as well as definitely and the patient does not want to scar so before we see the answer to that question and of course i have already revealed what i did but before we go into the details let's just see how do we screen a thyroid nodule and on sonographic evaluation so we basically like any other sonography we see for the size of the nodule the shape of the nodule the margins the echogenicity and texture of the nodule uh if how is the composition is it uh solid is it mixed not even solid systemic is it system are there any ecogenic foci or micro calcifications within and based on each of these principles we assign some points to the uh parameter that we study so and then we sum the points so suppose the summation of all these points is zero then it is one nodule it is hundred percent belonging you don't need to fna if it's tied at two uh two points again it is not suspicious at all you don't need a fnsc like our patient which we discussed uh although for uh we'll come to that so if but if it's three points or beyond then depending on the size of the nodule you may need a definition because the suspicion of cancer keeps increasing so for those of us who did not answer thyroids please know that like we have byrads for breast imaging we now have a very established scoring system validated across many countries tire ads and this is to be used while reporting if your radiologist is not using this urge him or her to read up and use this it standardizes the reporting and helps us make treatment decisions on whether we need to follow up or do a fnsc or not do an fnc so once we know that an audio is benign based on sonographic tyrants or based on fnsc what next so there are multiple treatment options available uh of course like we said the most so much of the population has asymptomatic nodules and you don't really need to treat them but if it's symptomatic then the options that existed traditionally were surgery hemi thyroidectomy most commonly done there were some obsolete options which were tried but did not really stand the test of time suppression of tsh using lipothyroxine radioactive iodine which really did not work to that extent for benign nodules and of course these novel options have come up of chemical absolute ethanol ablation or thermal ablation which includes radio frequency or microwave or laser evolution so let's just see today our main focus is since i'm an interventional radiologist on the chemical of the thermal ablation of thyroid modules and let us see a lot more on the topic so when do you need to treat a benign nodule uh most of these nodules are asymptomatic sometimes even incidentally detected cosmetically not visible so you don't even need to treat them but whenever there is a chance or that you feel potentially based on the sonographic features that although the fnc says benign but due to the size and all due to the heterogeneity there is chances of malignancy or the patient because of the size of the benign nodule is having pressure symptoms compression on the airway causing difficulty in breathing or compression upon the esophagus causing dysphagia that is one very important indication for which many patients come to us and of course nowadays we are getting many young patients with cosmetic issues saying that because of their career as a aerospace or a model they don't they don't want a scar whatsoever neither do they want that swelling or lump which is seen which affects their profession so they want us to and of course even if someone is not in such a glamorous profession who would like a scar or a smith like neck swelling so everybody would want a cosmetic relief from a visible thyroid nodule as this patient so of course that is a very important indication so traditionally if like we saw many most of the other measures that were tried did not really uh were sustainable did not give tangible results and that is why the only proper traditional treatment that was offered and is still offered to date for even treatment of benign non-cancerous proved nodules is hemi thyroidectomy surgery so although uh the incisions are getting smaller there is robotics entering into even thyroid nodule uh hemithyrotectomies there is now trans oral scar less hemotherapy nevertheless still a surgery is a surgery and there are some issues associated with it uh of course unless you are doing a scar less hemotherapy through the transferal route the one of the bigger issues is the scar so as we see in this image the of the three young ladies who had these scars sometimes the skulls are hypertrophic sometimes they are colloidal scars and even if they are not and even if you try to hide them over the neck skin creases still uh scar is a scar and sometimes it's just there ah but besides the scar the major problem is that you're removing around 60 of the thyroid gland just to remove that nodule and almost 70 to 72 percent of these patients may end up with permanent hypothyroidism of course that's old data the current literature and evolving literature is suggesting that the rates are going down but still i would still say that 30 to 50 patients do face this issue of hypothyroidism for which they have to then take thyroid medications for life so the thyroid function is not preserved which is a big issue because you are removing a major part of the gland to remove that nodule ah then there is the issue of damage to the recurrent laryngeal nerve causing voice change out to the parathyroid glands affecting the calcium metabolism of course slight pain and recovery times are longer even admissions are sometimes longer so these issues are there that is why because of these issues the world has been on the search for a tangible alternative while the traditional ones did not uh really compete with surgery in terms of the efficacy these newer options uh korea south korea was the first uh in front of the whole world which came out with such huge amount of data on ablation from percutaneous ablation that it has given us such strong level one data which does not even exist for many of these standard surgeries like uh laparoscopic cholecystectomies so we have a lot of level 1a evidence now which suggests that chemical ablation or thermal ablation depending on the nodule type can completely replace a surgery it is equally efficacious sometimes more efficacious and the complication risk is almost negligible so let's see whether it's just a tall claim or if there is literature to support this so this was the one of the first few articles in 2015 where there was a comparison made between surgery methodology versus a radio frequency thermal ablation for solid thyroid nodules completely solid thyroid nodules and benign nodules of course were chosen we are not right now talking about cancer and what they found was almost all of the nodules treated with rfa completely regressed the volume reduction was uh the mean volume reduction was pre-procedure from six cc to post procedure 0.4 cc very significant p value at one year follower the incidence of complications of rfa was only one percent whereas it was six percent major complication rate post surgery okay so we have a message that we can pinch the screens to zoom in so please feel free to zoom into the slides if someone desires to see a magnified feature so the incidence of complications was almost six times lower major complications hypothyroidism or scars was not included as a complication but if you see hypothyroidism rate post surgery 72 percent of the patients faced hypothyroidism 0 of the patients faced hypothyroidism after rfa the rate of residual nodules shockingly was 12 after surgery and only 3 after rfa the reason being that uh in hemi thyroidectomy they could only remove one lobe and the isothermist and not the other lobe if there were incidental smaller nodules in the other lobe they had to leave it alone because they couldn't risk removing hundred percent of the gland whereas in rfa you can just turn the needle to the opposite lobe and just one of those nodules also so that was another advantage of course hospitalization days was almost a mean of seven days in the surgery versus only two days in the ablation group where uh to be honest i just discharged my patients first thing the next morning so in fact if i do an early case i may discharge the same day evening so it's actually a one day procedure now so conclusion of this article although yes this was one of the first few i think there were 25 patients in each arm and this was not a very high volume article but conclusion was why both are exactly equally effica effective for nodular goiter benign nodules compared with surgery we have fewer complications complete preservation of thyroid function very less hospitalization base early recovery so when you have a alternative that is equally efficacious but with so many advantages of course it is very promising and we have to consider considering it as a first line treatment option and of course korean guidelines did not stop there from that point they started getting more and more randomized data even more and more prospective non-randomized data and to the extent that they had thousands of patients undergoing rfa and it became the first line treatment in their country so while the world was still waiting and arguing that rfa or microwave cannot replace surgery they kept on even uh they were evolving their guidelines and now i think they have the version three of their guidelines coming up they have an entire website and all standardized guidelines of the indications pre treatment evaluation post treatment evaluation and so on so uh by their latest revised guidelines they say that you will not uh misuse this treatment and treat every benign nodule that presents to you there are few indications based on which you will treat these patients if the patient has a symptomatic issue pressure on the trachea or the esophagus you will treat the patient if of course the patient was cosmetic relief or betterment you will treat the patient and of course if it's a hyper functioning nodule related to thyrotoxicosis uh leading to thyrotoxic causes and you know that it is a benign proven nodule and solitary nodule that is toxic based on the nuclear scan then you can of course burn it and the hyper thyrotoxic or sick features will go away but uh i can see one of these small comments on what the nodules can you burn well can you touch nodules of undetermined significance so no uh one of the mandatory criterias before touching a case for radio frequency ablation or thermal ablation is that you have to have a affinity at you two d different durations for the nodule and both definitely should say that the nodule is benign completely directs two only then you will take up the patient for this procedure if there is even the slightest suspicion of cancer you will not do ablation because then you will do a hemotherapy a frozen section and sos complete thyroidectomy because you don't want to subject a large nodule with suspicious malignancy to ablation because uh you are not only looking for volume reduction but you are actually looking to finish off the nodule as well as a lot of territory around it the normal parenchyma to get a r0 resection so of course in thyroid it means in on different sets but yeah so only benign nodules with tyrex too on ultrasound scoring meaning that they are completely benign and no suspicion of malignancy they will be taken up for fnsc and once two and s is proved that yes this is benign by bethesda grading only then you will take this module for uh ablation and mind you the majority of our cases are like that so many patients of colloid nodules are benign nodules with tyrex2 and bethesda to come to us and uh so it's not that this is very uncommon this is the most common scenario presenting to us so of course we had the revised korean guidelines over so many years and that's there but now the world has started following suit and now finally we have the italian statement which came up which said that you can treat even large uh nodules more than 20 cc but benign proven nodules when surgery is contraindicated or declined so of course they were not as outgoing as korea they said if surgery is contraindicated or declined then you go ahead and of course you can uh ablate autonomic functioning thyroid nodules that hydro hydrotoxycos is once and there was a statement on malignant modules uk has started accepting as u.s has just started trials on the topic and they are doing randomized trials of the nodules of course that is promising so uh based on the composition of the module if it is cystic or predominantly cystic that means 10 to 50 percent of the component is only solid rest of it is cystic or if it is solid more than 50 of the nodule is solid then it is known as a solid nozzle so based on this composition how do we decide which treatment is the best for this patient uh of course we are talking about the ablation treatment so for a cystic thyroid nodule if it is completely cystic if you see the volume reduction it is almost for either whether it is ethanol ablation or rfa the volume reduction is usually more than 80 85 so and this therapeutic success rate is achieved in almost 95 patients in each army which is a huge success rate and again this is old data this is 2014 or 15. so but if you look at the newer data so let's see the newer article on the same rct rfa versus ethanol ablation we see that the volume reduction is almost to the tune of 95 percent on an average therapeutic success rate meaning the volume is shrunken to more than 50 of his actual size original size is 100 that means each of the patient will get complete relief from their symptoms from their cosmosis cosmetic issues and they will have a significant volume reduction and there was zero complication rate in these arms again 30 patients in each arms sorry 21 patients in each arm and zero complication rate so when you have a procedure that is promising a therapeutic success rate of 100 and complication rate of 0 and it is achieving volume reductions of ranging from 94 to 97 percent completely treating the symptoms completely giving cosmetic relief so it is very difficult to argue against it but the only issue with cystic nodules is that ethanol is very cheap absolute alcohol where the chemical ablation mode whereas rf your microwave ablation do add a huge cost to it so when you see the cost effectiveness then ethanol scores over when you can achieve the same therapeutic success rate and zero complications even with ethanol then why go for the cosmetic of costly uh thermal ablation for the same so cystic nodules stick with chemical ablation and do it over with ethanol no need to get the patient's pocket out what to do when it's a predominantly cystic nodule again for a predominantly cystic nodule also the therapeutic success rate was almost 90 to 200 percent for both arms and complication rate was almost the same ranging from zero to one uh zero to four percent so they concluded that it's practically the same so again you can go for ethanol and if after ethanol ablation and destroying the destroying the cystic part if there is residual solid component which you feel can be problematic in terms of its growth in future or it is still causing residual symptoms then you can do rfa as a rescue line therapy so that only for those selected patients you offer thermal ablation and add the cost to the patient for example this study did a study for 137 patients who had predominantly cystic nodules mixed nodules and they did ethanol ablation for them 110 patients completely uh got cured of the nodule both cystic as well as the solid components 37 patients had residual nodules or sometimes residual symptoms and then rfa was done for them and completely they were cured and even after the combined therapy complete there was no complication and therapeutic success rate was 100 percent this is an example the image a shows that the nodule is predominantly cystic and there is a small solid component in the center uh image b shows that the cystic nodule is completely treated with absolute alcohol it's collapsed and we can't see it anymore the black part but we can see the white uh solid nozzle now so that was treated with rfa image c shows the first pass and the first session which burnt half of the nodule and it looks black now hypoequic and image d shows that hundred percent of the nodule is now hypoechoic after all dark after the second pass so you have actually burned the entire solid nodule and that will shrink with time so when it comes to predominantly cystic nodule rather than uh ethanol versus thermal fighting against each other it is ethanol ablation first followed by using thermal ablation as a rescue measure for residual solid nozzles if it's there and as you would have guessed if it's a complete solid nodule or a predominantly solid nozzle where the solid area is more than 50 rather than the cystic then you will not go for ethanol because the ethanol uh volume reduction rate is only 38 to 47 so alcohol the chemical cannot destroy complete solid tissue then we would rather go for a thermal ablation the older uh volume reduction rates were 84 to 87 percent which were again huge newer ones say it is as good as 9200 percent so if it's a solid or a predominantly solid nodule hands down thermal ablation either rf or microwave scores over ethanol ablation and you will not go for ethanol you will go for rfa despite the cost needless to say that rfa and microwave are equally efficacious and rfa has code over laser studies show that even three cycles of laser are not as good as one cycle of rfa so and chinese data shows that microwave is as good as rfa in fact all of my 30 cases have been with microwave application in different institutes i because it's the more novel therapy even compared to rfa mode determine zone of ablation i go for microwave for all my cases so conclusion is if it's a cystic nodule go for ethanol chemical ablation if it's a mixed nodule you can go for ethanol ablation first and then if there is a residual component do rfa for the microwave for the solid part and if it's a predominantly solid or a complete solid knot will go for rfa or a microwave straight away that means thermal ablation so just some short details on the technique we usually use a trans ischemic approach where we go from the midline through the isthamus into the nodule and start burning the nodule we'll just see this is how it's done we go through the isomers towards one of the areas we start burning that area and then we retract one centimeter burn another centimeter of circumference then retract one more and so on this triangle that we see is the danger triangle because this is a trachea esophageal groove and we can see the circled uh recurrent angel nerve position there we have to stay away from that because we don't want to burn the recurrent angel now and cause voice change because there are a lot of techniques like hydro dissection where we can push the nodule away from this nerve and then we can easily burn that area so they can be done after even a little experience so we'll just ask the team to play this video and uh just show us an animation on how this works so that we can compete yeah so this is how the simple electrode or antenna enters the thyroid through the stomach and finally the nodule we connect this antenna to a generator microwave or rfa we start it and this is the heat that has started committing emitting from the tip of the antenna and it has burnt the inferior part of the nodule we retracted it we put it in the superior part of the nodule again switched on the generator burned the superior part as well and the module is nicely burnt so of course it's this is done in two sessions we do it in multiple passes and very small one centimeter circumferences by three months six months eventually the nodule shrinks and disappears so there's no need of a major surgery or a scar for the same so uh here in the image a we see the small local long needle that is going towards the edge of the thyroid gland to start hydro dissection we inject dextrose which is a bad collector of uh thermal heat and we start injecting it so that a space is created between the thyroid gland or the thyroid globe and vital structures so we push the gland away from the danger triangle we push the gland away from the carotid arteries in image b we see the carotid and the vagus nerve so basically the character sheet structures the vegas now is highlighted with the red arrow and we see the danger triangle which is shown as a red triangle in near the tracheoesophageal group medially so these are the two structures we want to save so again we will do hydro dissection and push these structures away from the thyroid lobe zone c and d we see how zone c image c we see how the needle is completely pushed in deep towards the lateral and inferior edge of the nodule and we have just started the burning process and indeed we see how we are withdrawing it and increasing the cloud of thermal ablation proximally now so this is called a moving shot technique where we start pulling the needle back while switching on the generator to burn one centimeter circumference in every 10 seconds we'll see this second video now to see how in a real life scenario this happens how sonography you know during live sonography we can see the nodule burning part of the nodule burning through the antenna so this is the nodule here we are seeing how with the sonography probe we are first using a very thin 26 gauge needle to inject local anesthesia so that the patient does not feel any pain from the antenna that we will be using which is slightly thicker almost 18 gauge so basically this was the moving shot technique how we were burning one centimeter circumferences from the antenna tip and we're drawing the needle while burning proximally and proximally once we finish one line we go superficial second line and once we finish the entire axial plane we go cranial encoding so this is how the tip of the antenna the cloud of thermal heat and the air bubbles are forming and a small territory of the thyroid nodule is getting destroyed and now we are retracting the antenna proximally and burning one one centimeter circumference uh through that line where the antenna has entered while we're drawing it so it's very titable and very measurable the area that we burn around the tip so we are not really extending heat to the existing tissues and burning something else it's that closely directed so it's very safe this is how it's done we just keep retracting and burning one centimeter at a time a circumference of air bubbles once we are done through that line we just go superficial do start a second line and in this way we cover the whole axial plane from posterior to anterior once that's done we just touch upon the edges and the margins to completely ablate them and then linear quartal sections and then we are done so it's on an average of 20 to 30 minutes procedure the antenna is taken out compression is given for 15 minutes and you're done there's no scar it's just a needle puncture so if we can run back to the presentation so this was it about the role in benign thyroid nodules so like we said most of the data shows how it is very efficacious even the data of more than three thousand patient shows that still the recurrent narration of policy rate is less than four patients amongst three thousand even that was transient so very promising uh literature uh even my personal experience more than 30 patients now it has been very promising not a single complication and 100 efficacy rates so uh the indication even in malignancy now they are studying the role of rfa or of course not as a primary malignancy but definitely if its recurrent malignancy then and the patient is a non-surgical candidate you can use this thermal ablation to destroy the recurrent nodules in the tumor bed or the lymph nodes of course they should not be like 17 or 18 lymph nodes usually three to four recurrent nodules you can completely destroy and beyond the neck there should be no metastasis so many people have been doing this as a palliative or a curative option in the current third nodules and you will be surprised to see that when people have tried to see complete disappearance of nodules by doing the ablation now the latest data is showing that 82 to 94 percent of uh nodules are getting completely disappeared that is the success rate which we can achieve even in malignant recurrences so and the recurrence after that is one of 35 patients or four of 61 patients that good so actually a patient who has a recurrent disease non-surgical candidate out of 60 patients 56 can be saved and completely cured by just this abolition even if they are non-surgical candidates so why not offer it so uh same data again this was our first case in bhaktivedanta very close to me so because this was when i started here in media road and this was the original patient we discussed who had a 22 cc nodule and post procedure the first uh third month follow-up this was just a 4.4 cc nodule remaining so more than 80 volume reduction and by the ninth month or twelfth month i'm sure this is going to be a peanut size nodule or disappear completely uh this is just a bonus case where uh this was a 80 year mail presented sent to me by the ent surgeon because the patient had a parathyroid adenoma on the right side pth levels were 1700 plus due to the age and multiple comorbidities and the high pth hypercalcemia they did not want to give him anesthesia and do surgery for him we did a microwave ablation for the same 20 minutes intervention in and out under local anesthesia patient got discharged next morning post procedure pph same evening just 35 from 1700 it jumped down to 35 patient was discharged next day and no scar of course and we tolerated it 1280 at 80 years age and now uh three weeks later it is still 35 the pth so he's completely cured of his primary hyperparathyroidism from the the current calculi from the bony moon bony lesions hyperparathyroidism features at least we have stopped the metabolic part now we will start on the road to recovery but yes just with the needle of course my colleagues in medanta have a lot of rfa cases but this was probably the first microwave case of parathyroid and nodule ablation using microwave from india so that's it about the presentation uh thanks a lot i hope i have kept in time yes so it's still 8 45 i think we can take questions yes sir do you want me to run yeah yeah so the first question again what is incidence of thyroid nodules by usg detection of random population so this question had a very mixed bag of answers in the beginning yeah usually 10 to 14 18 24 to 76 but i'm sure after this presentation we do know that a lot of people have thyroid incidental thyroid nodules and if you start detecting usg screening then you will detect them in many let's see so yes i think it was 18 to 24 initially now we have it on 20 to 76 yes so that is the right answer 2276 percent what is sonographic scoring system for thyroid nodes i think it would be 100 now yeah i'm also expecting the same for this at least especially there in the initial present part of the presentation i don't expect that they will get it wrong yes so that clearly indicates we have a very attentive audience with us initially it was quite a mix of torrent and thirst as well but now it's tired all the way yes the next is what are potential complications equally of hemi thyroidectomy [Music] so it's all of the about quite changed initially it was hypothyroidism was on the way now it's all of the above i think many people think that hypothyroidism and scar are not complications that's why i've included sequelae what are the potential side effects of thyroid nodal ablation actually i think the last option in this is slightly glitched it's actually none of the above but that's fine i mean it's a good trick question for everybody should be thinking why should anything or be in this list because none of these complications right so irrespective of the vote everybody i think gets the mark for this poll yeah yeah i think they understood the all of the above to me and that's why no no yeah right yeah the same case again a 30 year old female modeling as a profession presence with 22 cc rightlook thyroid nodal and pressure symptoms fnsc done twice such as of thyroid to nodal what is the treatment you would recommend surprisingly many patients manipulate dog audience doctors got this right even in the pre-presentation yeah right he understands the importance of cosmesis today where you don't want to scar you don't want hypothyroidism in a young patient so that is good yes yes sir yeah 74 percent feels it's radio frequency or microwave ablation great so so we can go for the questions now dr surendra is asking usually how many settings are needed for a node say 3 centimeter an approximate cost to patient for sitting so for a 3 centimeter module i'm assuming the volume to be between 7 cc to 21cc the single session suffices even for nodules as large as 25 cc's or single session surfaces these are huge nodules if you consider that volume so single session completely suffices the cost uh of course depends on the institution the package and so on but uh if i talk about the hardware the antenna plus the machine rental for rfa is around 60 to 70 000 to the hospital depends whether your hospital charges at a 10 markup or mrp and for the microwave application it is between 1.3 to 1.5 lakhs because it is more normal and very costly antenna uh that being said these costs are workable there are very good distributors who coordinate with us for poor patients we have done microwave ablation uh for eight patients for liver uh metastasis as well as thyroid nodules or even on uh mathematically scheme basis for free that is a government scheme which gives a very short package but even in that we have been able to squeeze it so it's uh adjustable but yeah so if i have to give an answer the package including everything the hardware and the procedure would be around between 1.8 to 2.5 lakhs depending whether you're doing rf or a microwave uh i hope dr surender the question was answered also dr priya darshani had the same question cost of microwave or rfa so we've answered that as well the next question is by dr coleman does patient experience any shock or current while burning like during the ablation uh not at all actually yes that was initially a concern during rfa because rfa the mode of conduction of heat is conduction of heat so that's why we have grounding pads kept on the patient's thigh so that the current escapes from them and patient does not get any experience any shock despite that occasionally thigh burns or mild current have been known earlier now the newer probes that is completely eliminated from microwave because the mode of con conduction of heat is convection energy and not conduction the chances are zero no current no shock we do it under local anesthesia okay one more question dr abhijit wants to ask rfa probe and microwave which are the brands that you use yes so rfa i usually go with the boston one uh and for microwave i go with the canyon one there is of course micronic as well as eco probes for microwave available even boston has a lot of options like novomi and boston and so on but my choice for rfa is boston and for canyon microwave it's canyon okay dr harpal had asked a question which you had answered right the follicular lesion of undetermined significance that is the category three what is the further workup required surgery or ablation yeah so uh like i said right now the guidelines say that if it's on fnac again like we have tired scoring on sonography to suggest whether you have to leave the nodule alone whether you have to do a fnsc or whether you have to follow up the module similarly once you do a fnac then there is this coding known as methyl scoring which again shares the probability of malignant chance in the nodule so if it's bethesda two uh that means a benign nodule on uh fnsc then then only then you will proceed with ablation if it's four or five you will proceed with thyroidectomy if it's three meaning it's a follicular lesion of undetermined significance then neither refinancing or biopsy is going to differentiate between a follicle adenoma and a carcinoma because you require a surgical specimen with the capsule and vessels for that so then you will only go for hemi thyroidectomy you will send it for frozen if the frozen says it is hundred percent adenoma not a carcinoma then you stop there if it says no it is a carcinoma then you do a total thyroidectomy so then you won't go for ablation now that being said if a patient is for some reason a non-surgical candidate then i would rather than leaving it and allowing the risk of cancer to spread i would as in as will go for ablation why not and uh the therapeutic success it may not be 100 it may be 95 but better save 95 patients rather than zero so only for a non-surgical patient i might go out of the guidelines otherwise bethesda do okay i hope dr harpal your question was answered we have a question from dr santosh what are the indications for rfa or microwave ablation for any case yeah so like i said in the presentation korean guidelines and now international guidelines very clearly say one the patient either has a symptomatic issue uh difficulty in breathing difficulty in swallowing or dysphagia so pressure symptoms due to size of the nodule second a cosmetic concern the lump is significantly visible and the patient does not want it either due to professional just out of design and third if there is a growth and although affinity say is negative but there is a patient is very apprehensive about malignancy chances so you can as well offer it to a deciding patient so patient choice is considered for the indications and fourth if it's a hypertoxic nodule if the nuclear scan shows that this is a hot nodule benign but this is causing the hypothyroid toxic causes or graves disease then you can just do the ablation and burn it off the symptoms will completely resolve okay we again have a similar question that how much cost of equipment for rfa in microwave application yeah so forget the package but that depends on the hospital but the equipment is around 60 to 80 000 for rfa and between 1.2 to 1.5 lakhs for microwaves okay yeah so we have many positive comments uh dr kommel says great session dr surendras is amazing dr priya says wonderful session and clear-cut presentation about the topic rajya is saying great sessions all and all a very positive response from the audience and it was quite clear from the poll results that yes the audience was paying attention dr santos says thank you for answering uh dr munee says can ent surgeons do it be honest india does not have any regulation saying who can or cannot do this procedure so i don't see any reason why not if they are trained in using a ultrasound probe and doing the fnsc then they can it requires some intricacies and details into preventing nerve damage preventing uh carotid sheath damage but with some training i think it can be done so there's no legal rule preventing them from doing it of course there are pnd rules on who can use ultrasound machine but they can be registered and they can't do it technically okay well thank you so much sir this was a very informative session on a topic that was not much known to anybody it definitely proves that it can be a good uh alternative to surgery saves the patient from scar the hospital admissions and everything so thank you so much sir thank you so much for this opportunity it's a very good platform very glad that so many doctors are attending it with such enthusiasm so very good initiative thank you

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