Recently I interviewed Dr. Angela Mazza, as we chatted about radiofrequency ablation. If you would prefer to listen the interview you can access it by Clicking Here [1].
I’m really excited about this interview here. I have Dr. Angela Mazza, who is a triple Board-certified doctor in endocrinology, diabetes, and metabolism as well as internal medicine, anti-aging, and regenerative medicine. Dr. Mazza’s broad medical background includes significant research in both basic and clinical realms of endocrinology. Dr. Mazza is the founder of Metabolic Center of Wellness in Oviedo, Florida, where she spends a great majority of her time caring for persons with autoimmune thyroid disease, thyroid nodules, and thyroid cancer.
Highly regarded for her individualized approach to patient care, Dr. Mazza empowers each person to achieve their unique goals by providing education, lifestyle management, and support. Dr. Mazza believes that hormonal changes that happen in men and women as they age play a huge role in their overall health, longevity, and quality of life. Her passion is helping her patients achieve metabolic and hormonal balance. We are going to be chatting about radiofrequency ablation (RFA). I’m really excited. Thank you for joining us, Dr. Mazza.
Dr. Angela Mazza:
Thanks so much for inviting me. I’m happy to be here.
Dr. Eric:
I gave your background, but how did you start helping people with radiofrequency ablation? There still aren’t a lot of doctors that do this in the United States. I know you are currently the only one in Central Florida who does this procedure. If you could talk about how long you’ve been doing it and how you started incorporating this into your practice.
Dr. Angela:
I have been taking care of patients with thyroid nodules for years. Up until a few years ago, this therapy of RFA wasn’t even available or FDA-approved in the United States. Before that time, I was having to send patients to surgery for nodules that couldn’t otherwise be treated. Unfortunately, going into surgery, oftentimes they’d end up on thyroid hormone replacement for something that should have been so easy to treat.
RFA has been used for years even here in the United States for different tumors like liver, lung, kidney, or even in the heart and varicose veins. It wasn’t until 2012 that it started to be used for thyroid nodules in South Korea by Dr. Baek, who is the father of RFA for thyroid nodules. It took that long with all of the data that was happening, all the proven benefits that were going on, for the United States toapprove it.
Once I started hearing about this exciting research that was ongoing all over the world, I knew that once this was FDA-approved, I totally wanted to be able to provide it for my patients. I was doing thyroid biopsies, thyroid ultrasounds. Unfortunately, I didn’t have any choice for some nodules but to go to surgery. Once it was available, I was like, “Yes, I have to provide this.”
Dr. Eric:
I’m sure a lot of people listening are familiar with thyroid nodules, but I’m still going to ask you if you could explain what they are, how common they are, some of the common causes.
Dr. Angela:
Sure. Thyroid nodules are super common. About one in three persons sometime in their life span will have some sort of thyroid nodule. That is how common theyare. There are nodules that have different characteristics. Some nodules are more cystic; they become fluid-filled. Some nodules are more solid, and they are hard. Some are a mix of both; we call them complex. There are nodules that are more concerning or cancerous.
That is agood question. What causes thyroid nodules? Up until recently, we threw it off to iodine deficiency. That is an unfair blanket statement to say that all nodules are caused by iodine deficiency because they are all a little bit different. That doesn’t make sense. What we are finding is the thyroid is so sensitive to inflammation. Sometimes, these nodules can be a result of inflammation in the body and can in turn cause inflammation in our thyroid.
Different nodules behave differently. These cystic nodules sometimes keep filling up with fluid, and they become a problem. Sometimes, nodules are small and don’t cause any issue, and we leave them alone and watch. Every nodule, it’s important to be able to characterize and say, “These are ones we can watch. These ones are causing issues. These ones are suspicious.” I hate to say thyroid nodules are like snowflakes, but they kind of are. They are all a little bit different. It’s a tough question to answer.
Dr. Eric:
When you do an ultrasound, and you detect thyroid nodules, it sounds like maybe not all of them require follow-up. It depends on the characteristics.
Dr. Angela:
That’s a good point. If some are tiny cysts with just fluid, and they have certain characteristics that we can see on the ultrasound, they may not be worth following up on because they are so benign. There is a grading system that has been developed to look at the concerning characteristics. What are ones we have to follow more closely? What are ones we have to biopsy? What are the ones that need to be addressed as far as surgical removal or some sort of more proactive therapy?
Dr. Eric:
In my practice, I see a lot of people with both Graves’ and Hashimoto’s, but I focus more on the hyperthyroid side. Other than Graves’, we do see some cases of toxic multinodular goiter. Can you talk a little bit about toxic nodules? We will get into RFA. Can it help with it? What are they? Also, for those who are unfamiliar with the term “hot nodule” versus “cold nodule.”
Dr. Angela:
Toxic nodules are essentially overactive nodules. These are nodules that are starting to make their own thyroid hormone and not listening to the signals to stop making thyroid hormone.
Toxic nodules have a distinctive look on the ultrasound. They are really hypervascular. That is what feeds into these nodules to make them keep being overactive. In certain cases, they can be quite large.
The difference between hot and cold nodules is hot nodules are considered toxic because-There is certain imaging we can order. I don’t usethis imaging as much anymore. It’s not needed. There used to be these scans called radioactive iodine uptake scans for toxic nodules. If someone shows up with a nodule, we are not really sure what it is, so before biopsy was around, we would send them for these radioactive iodine uptakes. If it was a hot nodule, it would glow, so they would call it “hot.”
They used to say that nodules that didn’t take up anything were cold, and they were suspicious. They might be cancer. We got away from calling non-functioning nodules suspicious for anything because we know that’s not true. You do a biopsy, and most of the time, they come back fine. Hot nodules light up, so we can use that term still. It also means toxic or hyperfunctioning.
Up until recently, the only treatments we had for hot nodules werewe could put people on antithyroid medicine. To cool off that overactive nodule, especially if it’s causing problems like symptoms of hyperthyroidism. If someone is feeling hyperthyroid, they are feeling hot, shaky, are having trouble sleeping, palpitations, all the symptoms that go along with overactivity. The medicine can cool that off.
But when we are talking about toxic nodules, sometimes we can get people off antithyroid medicine, as they don’t tend to shut down on their own with that type of medicine.
The second treatment is radioactive iodine. Just like that radioactive iodine uptake scan, a different amount of radioactive iodine is used to be taken up by that nodule and shut it down or essentially turn off its machinery. Sometimes that works, and sometimes it causes a whole thyroid to become underactive, which is the downside. Sometimes, these people need another dose of radioactive iodine, but it is radioactive iodine, so that carries with it its own concern.
Surgery would be the other option, to take out that side of the thyroid or the whole thyroid. Until recently, radiofrequency ablation has been a treatment option available for persons with overactive thyroid nodules. It’s a new tool in our toolbox for hot nodules.
Dr. Eric:
Which is awesome. We are going to dive into that. One thing I want to ask you, you mentioned the radioactive iodine uptake test. I still notice a lot of endocrinologists use that. It sounds like you stopped using it in your practice.
Dr. Angela:
I can’t even tell you the last time I ordered one. It’s been almost 10 years, I think. That’s why ultrasound is so great. I have an ultrasound in my office. You have nodules; let’s take a look at the ultrasound. If I am looking at the thyroid gland, and I see a nodule with super vascularity going on, it’s a toxic nodule. End of story. You don’t even really need to biopsy a toxic nodule because they are 99.9% benign.
Dr. Eric:
I’m glad you mentioned the ultrasound and biopsy. Some will justify using the radioactive iodine uptake test to give hints if it’s cancerous. Like you said, even if it’s a cold nodule, it doesn’t mean that it’s cancerous. Most of the time, it won’t be. Why not just do the ultrasound, and then depending on the characteristics of the ultrasound, determine if someone needs a biopsy? It sounds like that’s the approach you take in your practice.
Dr. Angela:
As a skilled ultrasonographer, you just get used to seeing these nodules. You can see different characteristics. Those radioactive iodine uptake scans are a pain for the patient, and they are oftentimes not accurate. It’s not worth the time and energy.
Dr. Eric:
I’m glad you mentioned that. I have been saying that for years.
Dr. Angela:
You were right.
Dr. Eric:
I try not to knock other endocrinologists who use it, but I’m not a big fan. I just don’t understand why. Another reason some will use it is to diagnose Graves’. If someone has hyperthyroidism in the presence of elevated TSI, we know they have Graves’. They don’t need the uptake for that. There are different reasons they give for doing the uptake test. To me, it just has never made sense.
Dr. Angela:
You have a case for thyroiditis versus Graves’. Even then, you will see different shades on the ultrasound. You don’t need the uptake scan.
Dr. Eric:
Let’s get into RFA. If you could describe what it is, when is it indicated.
Dr. Angela:
Sure. I mentioned that RFA has been used for years for other things. RFA is great for benign and toxic nodules, or hot nodules. Essentially, it’s using an electric current to go directly into the nodule, causingtissue- I don’t want to say damage. Essentially, it’s agitating the tissue, and it causes long-term ablation in the nodule itself. It’s great because it leaves the rest of the thyroid completely intact. You’re only working on the nodule itself.
Surgery is great for some things, but this is done in the office. There is no anesthesia. There is no downtime from work. There is no thyroidectomy scar. It’s a nice alternative that we never had until recently here in the States.
Dr. Eric:
You mentioned just before that it could help with toxic nodules, which is great.
Dr. Angela:
Right. Some nodules are more challenging than others for RFA and may require more sessions. Toxicnodules, depending on the size, because they are so vascular, oftentimes require more than one session. Still, it beats surgery and all that goes along with possible risks of surgery.
Dr. Eric:
Like a single toxic nodule will sometimes need multiple treatments.
Dr. Angela:
Depending on the size of nodules in general. I have been seeing some very large nodules and really can only ablate for a certain amount of time. You want to keep them in safe time periods because you are dealing with electric current within the nodule. You don’t want to overablate. Most nodules can be taken care of in one session.
Dr. Eric:
One of the questions I had, which I think you kind of answered, but I’ll ask it anyway: If someone comes in with not a toxic nodule but larger, benign nodules, maybe like 2-3cm or greater, and they are currently seeing an endocrinologist that is saying, “You have to take the thyroid out,” if they need to get more than one nodule removed, typically, it would be like one nodule per visit per session? Would that be fair to say?
Dr. Angela:
It depends upon the size of the nodule and the positioning of the nodule. If they are on one side, you can try to do more than one at a time. if they are on both sides or bilateral, generally, depending upon the size of the nodule, I will do one side, then the other. It’s a procedure.
We are trying to be cautious of the patient’s comfortability. The patient is awake during the surgery. I usually give a little bit of anxiolytic beforehand just because it’s nerve-wracking. You hear the generator going.
We talk to the patient during the procedure. That serves two purposes. It lets me know they are doing okay. Plus it also helps me monitor their voice during the procedure. Surgery as well, one of the things is there is a risk of damage. Very low compared to surgery. As long as we monitor the voice, it’s a good gauge of how things are going. Plus it gives me an idea of how comfortable they are.
Dr. Eric:
Should someone who goes through the procedure expect to experience any discomfort at all?
Dr. Angela:
Well, it’s kind of like the biopsy but a lot longer. If you have ever been through a biopsy, your neck is extended. Unlike a biopsy, there is a lot of numbing medicine to the area. We give about 10ml of lidocaine. That serves a number of purposes. The thyroid itself doesn’t have nerves, but the thyroid capsule has nerves. Its surrounding tissues have nerves. We inject the lidocaine. The lidocaine not only numbs the capsule, but it also separates the structure from the neck out. It separates out the carotid artery, protects the laryngeal nerve. It serves multiple purposes.
To answer your question, the patient should not have discomfort during the surgery. Pressure is normal. I am leaning on your neck with an ultrasound for up to 30-40 minutes. We take breaks. I’ll ask if they are all right, if they want a break.
Patients often comment on this. We are using a probe, not unlike aneedle that is done for a biopsy. The probe, as I am using it, I am going systematically to different parts of the nodule and ablating each area. Sometimes, they will feel a pop. That is the thyroid tissue being ablated. It’s a weird feeling. It’s not a pain, but it’s unexpected if you’re not aware of it.
Dr. Eric:
On average, how long does the procedure take? I’m sure it varies depending on the person.
Dr. Angela:
In whole, from the start, when we do a baseline ultrasound, to the end of the ablation, an hour to an hour and a half.
Dr. Eric:
Okay, that’s not too bad. Once the ablation is done, and they have just a single nodule, and they only needed that single visit, do they typically need follow-up visits after that to monitor it?
Dr. Angela:
Yes. Right after the procedure, the patient doesn’t usually have restrictions. They don’t want to do heavy lifting for a day. As far as follow-up, I recommend doing an ultrasound about two months after with some repeat thyroid function tests, at six months, then at least at 12 months.
We have a lot of patients who come from out of town for this procedure. I rely upon other ultrasound reports and ultrasound images to do follow-up on those cases. It’s nicer when I can do my own ultrasounds for follow-up. Since this is a new procedure, a lot of the radiologists aren’t used to reading what a nodule looks like after it’s ablated. It can look actually suspicious to them because some of the markers that go along with suspicious nodules can look similar to where areas have been ablated within the thyroid. That can cause a little confusion. That’s why I like to do my own if I can. As long as I have the discs to look at the images, that’s part of the follow-up.
We tend to see the best results right around six months to 12 months. Even though we’ve ablated tissue during the procedure, that can be tough to see if you are continuing to ablate tissue within the nodule up until that time period. The two-month follow-up is just so I can make sure everything looks like it’s going in the right direction.
Dr. Eric:
Makes sense. Speaking of suspicious nodules, I don’t think yet RFA is indicated for suspicious or malignant nodules. We were chatting about this a little bit earlier. I have done my research. I am sure there are a lot of studies I haven’t read. I’m pretty sure I came across one or two studies that showed it can potentially help with malignant nodules as well, at least in the research studies.
Dr. Angela:
Right. The ongoing studies are super promising. They are just looking at low risk papillary cancer. Papillary cancer is the most common type of thyroid cancer. They are looking at smaller, 1.5cm or less nodules in RFA. It’s been found to be as safe, if not safer, than surgery. A potential therapeutic option. The results thus far have beenreally good.
Dr. Eric:
Is there any chance or risk of the nodule growing back years later after removing it with RFA?
Dr. Angela:
Yes, there is a potential risk. We are trying to get everything within that nodule. Success defined as far as the research study is a volume reduction of 75% at 6-12 months. That is considered success of the RFA. That holds with it, if there is a little bit of thyroid tissue left, especially if it’s one of those more vascular nodules, there ispotential for the nodule to grow back and require another session downthe line. That’s the good thing of doing serial ultrasounds. Even doing an ultrasound once a year, you can stay ahead of this. It will be less of an RFA procedure down the line.
Ideally, that’s not the goal. I always let my patients know there is potential for some of it to grow back, especially the toxic nodules, as theyare the most challenging.
Dr. Eric:
Everything comes down to risk versus benefits. I know if I was facing thyroid surgery due to nodules, I am pretty confident I would go the RFA route. I am not saying that just because I am interviewing you. The name of my podcast is Save My Thyroid, so that’s my goal. Just like you, you try to save thyroids.
If I happen to have a nodule removed, I would hope it wouldn’t grow back, but still, if it did, I guess I would consider having it again. You have to consider the potential consequences of thyroid surgery. A lot of people who have thyroid surgery, they do okay. As you said, there is the risk of the damage to the laryngeal nerve, the parathyroid glands. Not that there is absolutely zero risk with RFA, but in comparison to surgery.
I still think in many cases, I don’t know if I should use the word “no-brainer” because I know it’s not an easy decision when choosing for some people between RFA and surgery. We were also chatting about where currently in most cases, insurance doesn’t cover it, so they might have to pay out of pocket for it. In the day of high deductibles and being on thyroid hormone replacement permanently after getting surgery, you have to look at the long picture. Even if someone’s thyroid surgery is completely covered by insurance, it’s easy to say that. I’m not in that situation, but still, I am pretty sure I wouldn’t go for surgery even if it was 100% covered, and I had to pay out of pocket for the RFA, just because of potential consequences surgery can have.
Dr. Angela:
Replacing your own thyroid with thyroid hormone replacement is tricky. Not everybody feels great on the same thing. It’s a quality of life thing after. Sometimes, people make the decision to do the surgery and get rid of the nodule and take thyroid medicine for the rest of their life. They don’t think about the long-term consequences. You know what I mean? Even the best thyroid combination, not everybody feels great afterwards.
Dr. Eric:
A question that just came up: experience. If someone does undergo thyroid surgery, they probably want to choose a surgeon who has a lot of experience. You have now been doing RFA for a while. Do you think that plays a role, too? The longer someone has been doing it, the better.
Dr. Angela:
It’s definitely a learning curve. Even from when I first started doing biopsies in fellowship, it takes a while to get good at it. Fellowship was a long time ago. The more you do them, you know what to look out for. You know potential issues during the procedure, whether it’s the generator issue or something else. There are so many steps involved that to say you are an expert right out the gate is very naïve. We have been doing them here in my office since 2019. It definitely is a learning curve, like with anything.
Dr. Eric:
I understand. Any other risks or side effects that people should be aware of with RFA?
Dr. Angela:
The most common side effects right after the procedure include tenderness. We have been working on an area of your neck up to 30-45 minutes. It is going to be a little tender. Some temporary hoarseness is not uncommon. I am not talking voice loss. Some bruising in that area. It shouldn’t be bruising all over your neck. Just some localized bruising that may extend up and down the length of your thyroid area. Sometimes, patients have a little bit of a burn mark there because of the electro going into the thyroid itself. Those are the most common side effects.
Very rare side effects include the laryngeal nerve injury. Also rare is something called capsule rupture. That happens where people are overablating a nodule for too long. The capsule gets disrupted. That is why we don’t keep the ablation time above a certain time period.
Dr. Eric:
In your office, do you do ethanol ablation?
Dr. Angela:
Yes.
Dr. Eric:
There is ethanol ablation. There is laser ablation. Can you compare the different types? Ethanol ablation is more for cysts, I think. Is that correct?
Dr. Angela:
Percutaneous ethanol injection, or PEI, those are mostly cystic nodules. Those are nodules that mainly are filled with fluid. Essentially, with the PEI, we drain out the fluid. Oftentimes, people who have had cystic nodules know that these nodules will fill up. They will have been through this before. They will have been through a biopsy, where they aspirated everything, and it grew right back. These are people who work really well for PEI or even just fluid-filled nodules.
With the PEI, we also use the ultrasound for guidance. We drain out the fluid as much as you can. Oftentimes, I will leave a little pocket because that is where I am going to put the alcohol in.We use a special kind of dehydrated alcohol. What that does is it fibroses the inside of that nodule down so it does not fill up with fluid again. That is a pretty quick procedure. That one probably is closer to the time, even less than a biopsy. Plus it’s super simple.
We might need to do another PEI if it does fill up a little bit. Some of these really large nodules, you think you got as much as you could out as far as aspiration. They find a way to fill up a little bit more. Sometimes, you have to redo it. It can sometimes burn a little bit, depending upon where the nodule is at. That’s about it.
As far as laser, laser is great for larger nodules. It’s a little more cumbersome than RFA. RFA, we are using a probe. It’s a fine needle tip that can go right into each and every section of the nodule. Laser is more like diodes. There are a few diodes that go into the nodule. You don’t have as much control.
I don’t do laser. Some people do really well with laser. When we look at head-to-head studies, RFA is still superior in efficacy than laser.
Dr. Eric:
I don’t see a lot of research, at least compared to RFA. It seems there is a lot more with RFA and thyroid nodules.
Dr. Angela:
Not as much. There are practitioners who do laser, and they have good results. At our clinic, we only do PEI or RFA.
Dr. Eric:
With the PEI, that is just for cystic nodules. If someone has a solid nodule-
Dr. Angela:
It doesn’t work as well. There are studies on more heterogeneous or complex nodules. It’s just not as good. You can instill as much alcohol into those nodules, but it’s just going to laugh at it. Nah.
Dr. Eric:
All right. Is there anything else that you’d like to discuss, or anything I didn’t ask you that I should have asked you?
Dr. Angela:
Probably some people ask, “Who is a good candidate for RFA? Who would not be a good candidate?” Candidates that are really good are people who have a nodule that’s bothersome, whether it’s cosmetic, you see it from the outside; whether it’s compressing. Sometimes, people can have large nodules that can press on the windpipe and can make breathing or swallowing difficult. Some of those nodules, when they are very large, when you are lying flat, you can’t breathe or have trouble exercising because they are pressing on the windpipe. These people are great candidates for RFA.
People who have pervious thyroidectomies, they don’t want to damage or lose the remaining function of the thyroid they still have. This is being looked at for recurrence of thyroid cancer. That is something to consider.
There are people who are really afraid of surgery or just don’t want to have surgery. These are people who are good for RFA.
That’s the list of potential good candidates.
People who aren’t ideal candidates are people who have pacemakers or defibrillators or have severe heart disease. People who are on blood thinners that can’t be stopped for a couple days before the procedure. Patients who are pregnant. As of right now, those are probably not the best candidates.
Dr. Eric:
It sounds like if someone has a partial thyroidectomy, and they have some nodules on the thyroid that’s left, they can undergo RFA rather than get the other half of the thyroid removed.
Dr. Angela:
Yeah. That thyroid is working well, so you want to preserve what you have and save the rest of your thyroid.
Dr. Eric:
This was wonderful. I was really excited to chat with you about RFA. I’m sure we will hear more about it in the future. Now, it’s a really good option for a lot of people who are potentially facing thyroid surgery just because there are still a lot of endocrinologists who aren’t aware of it. Is it safe to say that the average endocrinologist is not aware of it, or maybe they are aware of it but aren’t too familiar with it, so that’s why they are still going to recommend the surgery route?
Dr. Angela:
It’s kind of mixed. I honestly think that a lot of endocrinologists don’t know about it. I think some endocrinologists are waiting for more data although there is a lot of data already, but they are not convinced because they haven’t seen enough patients go through it to say, “I had this patient do RFA. They did great.” The more we get the word out about it, the more we educate other providers about it, I think it’s going to be more acceptable because they will see the results are really good. If patients themselves had an option, I think they would prefer not to have surgery rather than have it if at all feasible.
Dr. Eric:
I agree. I hate mentioning it here, but I think I feel the need. You would hope that in many cases, endocrinologists are going to do what is best for the patient. My guess is also surgery is a lot more profitable than RFA. You would hope that’s not why they are recommending surgery. As RFA becomes more popular, you will see more and more endocrinologists incorporating it or referring out. Still, I’msure there are some who- I don’t know how much the average surgery is, but compared to RFA- Anyway, I wanted to bring that up to say that most endocrinologists have that motive to make money off the surgery. That’s why they recommend radioactive iodine-Radioactive iodine probably isn’t that profitable. Surgery, I imagine, is.
Dr. Angela:
If you’re in a hospital-based practice, maybe they don’t do referrals. If you are coming to an endocrinologist, we should be able to give all the options. If you are going to an ENT or surgeon, they will recommend surgery.
Dr. Eric:
That’s what they do.
Dr. Angela:
Yeah. As I mentioned, too, when we were speaking earlier, right now, this is all very patient-driven. Patients who are being proactive about their health and wanting other options, these are the patients that are going for the RFA. They know that surgery is not what they want. They want other options. Even when their doctors are telling them to get the surgery, they are finding more research.
Dr. Eric:
Thank you so much, Dr. Mazza. Where can people find out more about you? I know you also have your own podcast.
Dr. Angela:
Our website is MetabolicCenterForWellness.com. We do have a podcast once a month. It’s me and my friend Dawn, who is a friend as well as a patient. She gives a patient’s perspective. It’s called Thyroid Talk with Dr. Angela Mazza. We try and make it fun, as fun as certain topics can be.
Dr. Eric:
I’ve listened to a few episodes. I enjoyed it.
Dr. Angela:
It’s a little silly sometimes. What are you gonna do? I have a YouTube channel. It’s just Dr. Angela Mazza.
Dr. Eric:
It really was a pleasure chatting with you about RFA.
Dr. Angela:
Thank you so much. I really appreciate the invite.