Radiofrequency Ablation for Patients With Primary Papillary Thyroid Carcinoma

Eman Toraih, MD, PhD, DBio, Tulane University, New Orleans, Louisiana, discusses the use of radiofrequency ablation for patients with primary papillary thyroid carcinoma. In a meta-analysis, Dr Toraih found radiofrequency to be safe and effective for patients with T1a and T1b papillary thyroid carcinoma with high tumor disappearance and volume reduction and low complication and recurrence rates.

Transcript: 

Hello, my name is Eman Toraih, I'm an assistant professor of biostatistics at Tulane University Surgery Department. 

What is the current treatment landscape for patients with small, low-risk papillary thyroid carcinoma?

The current treatment landscape for small, low-risk papillary thyroid carcinoma [PTC] has been dominated by surgical approaches for decades. Traditionally, total thyroidectomy, which is removing the whole thyroid tissue, was the standard of care but we have seen a gradual shift towards more gland-preserving options like lobectomy. This evolution reflects our growing understanding that many small PTCs have indolent behavior with excellent long-term survival rates however, even the lobectomy is not without consequences because patients may require lifelong thyroid hormone replacement and can experience surgical complications like voice change or hypothyroidism and of course have the surgical scars. More recently, active surveillance has emerged as an option for very low-risk microcarcinoma below 1 cm, allowing some patients to avoid surgery altogether if their tumors remain stable.

Between these 2 extremes of extensive surgery and just observation, there is a growing interest in minimally invasive techniques like the radiofrequency ablation that can actually treat the cancer while preserving normal thyroid function. 

Please explain radiofrequency ablation for PTC.

Radiofrequency ablation, or RFA, is a percutaneous technique that delivers high frequency alternating electrical currents through electrodes to place it directly into the tumor, the thyroid, and these currents generate fraction. 

RFA has been safely used in medicine since [the] 1930s for various applications including treating cardiac arrhythmias, varicose veins, and various oncological lesions like the liver tumors. Its applications to thyroid disease are more recent but gaining significant attraction. The procedure is typically performed under ultrasound guidance with local anesthesia, allowing precise targeting of the tumor while minimizing damage to the surrounding healthy thyroid tissues, and that is really crucial because it allows us to treat the cancer while preserving the normal thyroid function. 

What makes RFA particularly attractive for thyroid cancer is that it's minimally invasive and preserves thyroid function. It also avoids the surgical scar and can be performed on an outpatient basis, often requiring just a single treatment session, sometimes more than 1, but patients typically experience minimal discomfort and can return to normal activities quite quickly, even on the same day. 

What were the methods and results of this meta-analysis?

Our meta-analysis was comprehensive, examining data from 20 high-quality studies that collectively included over 6,600 PTC nodules that we treated with RFA. We specifically focused on comparing outcomes between T1A tumors, which is less than 1 cm in diameter, and T1B tumors, which is between 1 cm and 2 cm, to determine both the efficacy across different tumor sizes and the safety of the procedure. 

We systematically searched major databases including only studies of patients with primary PTC and no known nodal or distant metastases and our primary outcomes included tumor disappearance rate, volume reduction rate, complications, and recurrence. 

The results were really remarkable. The pooled tumor disappearance rate was 94.3% of all tumors, but specifically 96% for T1A and 76% for T1B lesions. Importantly, this rate increased over time, reaching up to 91.5% after 48 months post-RFA. And this suggests continued improvement even after years following the treatment. Regarding the volume reduction rate, it was even more impressive, it was 99.4% for both T1A and T1B tumors, and the progression rate was extraordinarily low at just 1.33% overall with new cancer foci at around 0.8% and the prevalence of new lymph node metastasis was just 0.2% of cases. 

Perhaps most striking was the safety profile, we found that just 1.71% of the complication rates, which [are] minor issues just like the transient voice changes or neck pain and no patients required further surgical intervention for these complications or required further shift to thyroidectomy and lumpectomy. Even the saturate of the complication rate is much lower than the complication rates following thyroidectomy and lumpectomy. 

Who are the best candidates for RFA?

Based on our meta-analysis, ideal candidates for RFA are patients with confirmed low-risk PTC, specifically T1A and T1B patients, without evidence of extra thyroidal extension, lymph node involvement, or distant metastases and this includes the tumors up to 2 cm in size. 

The procedure is particularly valuable for patients who wish to avoid surgery due to concerns about scarring, voice changes, or lifetime hormone replacement therapy and it may also be excellent options for patients with significant comorbidities that will interfere with the indications of the surgeries. 

Perhaps patients should have tumors that are well visualized on ultrasound and accessible for electrode placement, and those with tumors which are close to critical structures like the recurrent laryngeal nerve, trachea, or esophagus should require careful evaluation as those patients might have multiple tumors or bilateral tumors. 

Importantly, patients should understand that RFA is still considered an alternative approach and not yet universally adopted as a standard of care, and long-term outcomes beyond 5 to 10 years are still being gathered, and so appropriate candidates should be willing to commit to regular follow-up imaging and monitoring. 

Can you discuss the efficacy and safety of this procedure further?

The efficacy of RFA for treating PTC is compelling. Our time series analysis showed that tumor disappearance progressively increases over time from 61.8% at 12 months to over 91% at 48 months, and this really suggests that the therapeutic effect continues well beyond the initial treatment and not just at the time of the treatment application. Also, the volume reduction was even more dramatic because it reached up to 99.4% across all tumor sizes. 

What's particularly noteworthy is that these excellent results were achieved with minimal rest and with only the 1.71% complication rates. Other reported complications like hematoma, skin burns, or transient thyroid function changes are even rarer.  

The recurrence and progression rates were also remarkable, reaching 1.33% overall. With T1B tumors was around 4.2% compared to T1A which was 1.11%, and this compares favorably to reported recurrence rates after lipectomy, which ranged around 1.6% to 5.6% in various studies. 

How is this meta-analysis “game-changing”?

This meta-analysis is game-changing in several ways. 

First, it represents the largest, most comprehensive analysis to date with over 6,600 treated nodules across 20 studies and this provides much more robust, evidence-based than previously smaller studies. Additionally, we specifically address the efficacy and safety differences between T1A and T1B tumors demonstrating that RFA is effective not just for the microcarcinoma, less than 1 cm, which was previously reported in the literature, but also for larger tumors up to 2 cm. And this significantly expanded the potential patient population that could benefit from this approach. 

We also meticulously eliminated duplicate patient cohorts from single-center studies, which were conducted by the same research groups which has led to compromising the rigor of previous meta-analysis in the field, which have included multiple studies with duplications. And this methodological strength greatly enhanced the reliability of our findings. 

This represents a fundamental shift in how we might approach thyroid cancer treatment, moving from just an organ sacrificing approach to a precision tissue preserving that prioritizes both cancer control and quality of life in these patients.

This is why we consider this study as a game-changing for our patients. 

What are the next steps for this research/treatment?

The next steps for this research fall into several categories. 

First, we need prospective, multicenter studies with standardized protocols to validate these findings in diverse patient population and practice settings because most of the studies that were included in our meta-analysis were from Asian studies, so we need to have more diverse perspectives in this regard. 

Also, we need longer term follow-up data extending beyond 5 to 10 years to fully establish the durability of these results and confirm the long-term oncological safety of this approach. Additionally, a refinement of patient selection criteria is critical. We need to better understand which patients are ideal candidates and which may better serve it by traditional approaches, and this includes developing risk stratification models, incorporating not just the tumor size as our meta-analysis, but also includes molecular markers, imaging characteristics, and patient factors as well. 

Also, there is one point that's really important, we need the standardization of techniques, the trainings of the doctors and quality metrics for performing these RFAs is essential before wide spreading adoption for these, and this includes establishing consensus guidelines on procedure parameters and follow up protocols and definition of success. 

What are some key considerations for clinicians utilizing this treatment?

For clinicians considering RFA for patients with low-risk PTC several key considerations are really important. First, the proper patient selection is critical, and ideal patients have confirmed PTC tumors less than 2 cm without evidence of extrathyroidal extension, lymph node metastasis, or distant metastasis. 

Second, the operator experience matters significantly and the learning curve of thyroid RFA is steep, and outcomes is likely better in the hands of experienced operators. Patients need thorough counseling about the relative neutrality of this approach compared to surgery with transparent discussion of the available evidence, potential risks, and the concomitant to long-term follow up following the RFA. 

Is there anything else you would like to add about this research or treatment?

I would like to emphasize that while our research demonstrated the promise of RFA for thyroid cancer, this approach represents support of a broader evolution towards more personalized and less invasive cancer care. One size never fits all in medicine and RFA adds an important option to our treatment toolkit without necessarily replacing existing approaches of surgery. 

The technology for RFA continues to improve with innovations in electrode design, energy delivery system, and real-time monitoring potentially enhancing outcomes further. And these technological advances coupled with growing experience and refined techniques suggested that results may continue to improve over time. 

Finally, I want to emphasize that while our findings are exciting, implementation should be thoughtful and gradual and centers adopting this approach should do so as part of a systematic program with appropriate training, quality metrics, and outcomes tracking because the ultimate goal is not just simply to adopt a new technology, but rather to improve the lives of our patients by offering treatments that effectively control cancer while minimizing impact on their quality of life. 

RFA represents a significant step towards the ideal [treatment] of patients with low-risk papillary thyroid carcinoma. Thank you.

Source:

Toraih E, Hussein M, Elshazli R, et al. Therapeutic outcomes and safety of radiofrequency ablation for primary papillary thyroid carcinoma: A game-changing meta-analysis. Radiotherapy & Oncology. 2025;205(110706). doi: 10.1016/jradonc.2025.110706