While hormone supplementation (using levothyroxine – synthetic thyroid hormone) has been more commonly used in the past as a treatment for benign thyroid nodules it is no longer routinely recommended due to its modest effects on nodule shrinkage and possible side effects with prolonged use including bone thinning (osteoporosis) and irregular heart rhythms. It can also result in symptoms of hyperthyroidism (thyroid overactivity) such as anxiety, sweating and palpitations. Levothyroxine is most commonly used as thyroid hormone replacement for those with an underactive gland (hypothyroidism).
Current active treatment options:
When benign nodules cause local symptoms or cosmetic concerns or a nodule is hot (meaning that it is independently producing excess thyroid hormone) then treatment can be considered.
Surgery
Surgery is the most common procedure performed for benign thyroid disease. The whole gland (thyroidectomy) or part of the gland (hemithyroidectomy or lobectomy) can be surgically removed. Surgery has good outcomes and is safe with a small risk of causing a serious complication such as parathyroid gland injury (which affects blood calcium levels) or nerve injury (leading for example to a hoarse voice). A more common risk of partial thyroid gland removal (hemithyroidectomy or lobectomy) is thyroid underactivity (hypothyroidism) which can occur in up to 15% to 30% of these cases. Clearly removal of the whole gland will always result in thyroid underactivity and the need for thyroid hormone replacement.
Radiofrequency ablation (RFA)
Thyroid RFA is a NICE (National Institute for Health and Care Excellence) recommended minimally invasive technique since 2016. RFA is most commonly performed under local anaesthetic as a day-case procedure. It is the most widely available ablative technique. Insertion of an RFA needle generates heat in the tissue and over time shrinks the nodule. Generally RFA achieves volume shrinkage anywhere between 50% to 90% with a single treatment. It is safe and effective at relieving local symptoms, improving cosmetic appearance and improving health related quality of life. RFA is also a second line treatment option for smaller active or hot nodules which are producing hormone. Thyroid ablation is an organ sparing technique. In other words the risk of hypothyroidism following ablation is very low (around 1%).
Microwave ablation (MWA)
MWA is a NICE recommended minimally invasive technique since 2022. It is most commonly performed under local anesthetic as a day case procedure. Just like RFA insertion of a microwave antenna (needle) generates heat in the tissue and over time shrinks the nodule. Similar volume shrinkage to RFA can be achieved. It is safe and effective at relieving local symptoms, improving cosmetic appearance and improving health related quality of life. MWA is also a second line treatment option for smaller active or hot nodules which are producing hormone. Thyroid ablation is an organ sparing technique. In other words the risk of hypothyroidism following ablation is very low (1% or less).
Ethanol ablation
Ethanol (or alcohol) ablation is a much more simple and quicker technique than RFA or microwave ablation. It is reserved for nodules that are entirely or mainly ablation fluid filled (cystic). The fluid content of the nodule is aspirated with a needle under local anaesthetic and alcohol is injected into the cyst. This injures and scars the wall of the cyst, preventing fluid reaccumulation. The cyst therefore shrinks. It is highly effective in carefully selected patients.
Radioactive iodine (RAI)
Radioactive iodine or radioiodine treatment (RAI) is a first line treatment for benign hot or active nodules (autonomously functioning thyroid nodules – AFTN) and multi-nodular goitres (enlarged thyroid glands containing numerous nodules). A small dose of radioactive iodine when taken orally is absorbed almost entirely by the thyroid gland. RAI can both shrink the thyroid gland and reduce excessive thyroid hormone production. Over the longer term it carries a risk of thyroid underactivity (hypothyroidism) and potentially the need for lifelong thyroid hormone replacement treatment.
Thyroid artery embolization
Thyroid artery embolization (TAE) is a relatively new minimally invasive technique that is being used in limited numbers across the world. It is best suited for patients with large benign multi-nodular thyroid goitres (large gland with multiple thyroid nodules) who either wish to avoid surgery or are unfit for surgery. A small tube inserted in to an artery at the wrist or groin can be used to guide a fine catheter (or tube) in to one or more thyroid arteries. Small specialised particles or beads are then carefully injected under X-Ray guidance to reduce the blood supply to the gland to cause shrinkage. Very few TAE procedures have been undertaken in the UK and more evidence is needed on how effective it is. Dr Ahmad is the chief investigator for the TArGET trial, the UKs first study assessing TAE treatment.
