Benign (non-cancerous) thyroid nodules are common and usually do not require treatment.  If they are causing symptoms, such as pain or pressure, or cosmetic issues, the following are less invasive treatment options (less pain and scarring) that may offer an alternative to surgery and radioiodine therapy (RAI). 

Ethanol ablation  

This is used as a non-surgical treatment usually for cystic (i.e. pure cyst) or predominantly cystic benign thyroid nodules.  This involves draining the cyst of fluid under ultrasound guidance then injecting ethanol immediately back into it.  It causes the walls of the cyst to stick together and it stops the cyst from recurring. It can be quite effective in shrinking large cysts. 

Patients who may be suitable for ethanol ablation would typically have symptoms (normally a feeling of compression), a cyst of 2cm or greater which is macrocystic (this means the cyst should really be in one or possibly two parts). Other cysts can have a honeycomb-like structure which makes them impossible to drain.  

It is also sometimes used in patients with recurrent thyroid cancer in the neck and lymph glands. This involves injecting ethanol in the lymph gland with the cancer cells and, in theory, the ethanol destroys them. However, the quality of studies is variable, so most doctors would say definitive treatment for lymph glands with thyroid cancer cells usually requires an operation. 

Ethanol ablation for benign thyroid nodules is performed by radiologists, and sometimes by surgeons, and is available in some NHS centres across the UK, including Birmingham, Edinburgh and Newcastle. 

Thermal ablation

Percutaneous Radiofrequency Ablation (RFA) for the treatment of benign thyroid nodules 

In this procedure, a thin electrode or needle is inserted into the nodule under local anaesthetic. Ultrasound is used to guide it into position. The needle sends out an alternating current at the frequency of radio waves that heats the nodule to destroy it. This is known as ablation. The aim is to shrink the nodule to relieve symptoms and improve appearance. RFA can be used where the nodule is solid, with some cystic components. Not all nodules are suitable for RFA treatment. This depends on many factors including size, location, the appearance of nodules, and the symptoms being treated. Careful assessment is required as some nodules are adjacent to the carotid artery or laryngeal nerve and there is a very small risk of stroke or damage to the voice box.  

There is only a limited number of centres that routinely do radiofrequency ablation although a trial of RFA is likely to start in the next year or so and it is hoped that this treatment will be rolled out across many centres in the UK after that. The experience of RFA is currently greatest around London where centres such as University College London Hospital and the Royal Berkshire Hospital offer it on the NHS. 

RFA leaflet from The Royal Berkshire NHS Foundation Trust    

NICE guidance on RFA 

Ultrasound-guided Percutaneous Microwave Ablation for the treatment of benign thyroid nodules 

In this procedure, a thin wire is inserted into the nodule under local anaesthetic. Ultrasound is used to guide it into position. It sends out microwaves that heat the nodule to destroy it (ablation). The aim is to shrink the nodule to relieve symptoms and improve appearance. 

This is still a very new procedure that is currently being performed by the interventional radiology department at King’s College Hospital NHS Trust, London. 

The National Institute for Health and Care Excellence (NICE) is carrying out a project on the procedure 'Ultrasound-guided Percutaneous Microwave Ablation for Benign Thyroid Nodules'. The aim of the project is to consider how well the procedure is working and whether it is safe enough to be used more widely in the NHS in the future. 

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