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Objectives: Cytologically indeterminate thyroid nodules (Bethesda class III or IV) carry a 10-40% risk of malignancy. Diagnostic lobectomies are frequently performed but negative surgeries incur unnecessary costs on the healthcare system, potential complications, and negative impacts on quality of life. Molecular tests (MTs) have been developed to reduce unnecessary surgeries. However, well-validated, high-performance MTs are often expensive, and their cost-effectiveness has not been studied in the Asian population. This study evaluates the rate of unnecessary surgery in the setting without MT (our current practice) and the cost-effectiveness of introducing a commercially available MT for the management of cytologically indeterminate thyroid nodules in a modernized city in Asia. Methods: Management decisions and outcomes of consecutive Bethesda III or IV thyroid nodules in a tertiary endocrine surgery center in Hong Kong were evaluated. Costs of health service provided by the public health system, which covers >90% of healthcare service in the city, were retrieved. A decision tree model was developed to compare the cost-effectiveness in avoiding unnecessary surgeries of current practice versus routine MT from a public healthcare provider's perspective. In our current practice, MT was not available, and patients with indeterminate nodules received either upfront lobectomy, repeat fine needle aspiration cytology (FNAC), or active surveillance. Results: Over a 4-year period, 2157 FNACs were performed. After exclusion, 1957 FNACs were analyzed, and 18.6% were Bethesda III or IV. Thirty-six percent of these cytologically indeterminate nodules received upfront surgery, with 28% having malignancy in final pathology, that is, 72% of surgeries were unnecessary. Routine MT could reduce 82 unnecessary surgeries/year, 26% more than current practice. Routine MT resulted in an incremental cost-effectiveness ratio of Hong Kong dollar (HKD) 49,102 (US dollar [USD] 6314) per unnecessary surgery. Sensitivity analysis showed test cost of MT contributed significantly to incremental cost-effectiveness ratio. Lowering the commercial price of MT to below HKD 8044 (USD 1031) would render routine MT cost-saving. Conclusion: Currently, a high rate of unnecessary surgeries is being performed for cytologically indeterminate thyroid nodules. MT was more effective in reducing unnecessary surgeries than current practice, but at a higher cost. MT will become cost-saving if the test cost could be lowered.

Introduction: Radiofrequency ablation (RFA) is an effective nonsurgical treatment for symptomatic benign thyroid nodules. Large-volume nodules (≥20-mL) often require 2 or more radiofrequency ablation sessions to achieve desirable shrinkage but the optimal interval between sessions remains unknown. We hypothesized that early (within 6 months) retreatment could improve nodule shrinkage. This study compared the 12-month volume reduction rate (VRR) and complications between single-session radiofrequency ablation and 2-session radiofrequency ablation within 6 months for large benign thyroid nodules., Methods: Consecutive patients with cytologically proven benign thyroid nodules ≥20 mL undergoing radiofrequency ablation were prospectively assigned to undergo either single-session (group 1) or 2-session radiofrequency ablation within 6 months (group 2). All were followed up for at least 12 months after the initial radiofrequency ablation. Volume reduction rate was calculated as (baseline - current volume)/baseline volume × 100%. Complications were documented., Results: Out of 67 nodules ≥20 mL that underwent radiofrequency ablation, 43 nodules (group 1: n = 23, group 2: n = 20) from 42 patients were analyzed. Both groups had comparable baseline nodule volumes (33.2 ± 14.9 mL vs 34.3 ± 12.5 mL) and clinical parameters (P > .05). The 6-month volume reduction rate was comparable (65.7 ± 13.2% vs 68.6 ± 13.3%, P = .264) but the 12-month volume reduction rate was significantly greater in group 2 (65.9 ± 17.1% vs 75.6 ± 11.5%, P = .019). Group 2 nodules continued to shrink from 6 to 12 months (P = .012), whereas group 1 nodules did not (P = .503). Two-session radiofrequency ablation within 6 months was the only significant factor associated with a 12-month volume reduction rate of ≥75% (odds ratio 4.375, 95% confidence interval 1.210-15.812, P = .024). No vocal cord paresis or hematoma requiring reoperation occurred., Conclusion: Early retreatment with 2-session radiofrequency ablation within 6 months was safe and led to significantly greater nodule shrinkage at 12 months than single-session radiofrequency ablation., Competing Interests: Conflict of Interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Graves' disease (GD) is the most common cause of hyperthyroidism. Antithyroid drugs (ATDs) are the first-line treatment, but when discontinued, >50% of patients experience relapses. Conventional definitive treatment options include surgery and radioiodine therapy (RAI), each with its own disadvantages. Radiofrequency ablation (RFA) achieved promising short-term remission rates in a previous pilot study. The current study reports our experience of using RFA to treat relapsed GD in the largest cohort of patients with a longer follow-up period. Methods: This single-arm prospective study recruited consecutive patients aged ≥18 with persistent/relapsed GD requiring ATD from two tertiary endocrine surgery centers. Those with compressive goiter, suspected thyroid malignancy, moderate-to-severe Graves' ophthalmopathy, preference for surgery/RAI, or pregnancy were excluded. Eligible patients received ultrasound-guided RFA to the entire bulk of the thyroid gland. ATDs were discontinued afterward, and thyroid function tests were monitored bimonthly. The primary outcome was the disease remission rate at 24 months follow-up after single-session RFA, defined as being biochemically euthyroid or hypothyroid without ATD. Secondary outcomes were complication rates. Results: Of the 100 patients considered, 30 (30.0%) patients were eligible and received RFA. Most were female patients (93.3%). The median total thyroid volume was 23 mL (15.9-34.5). All completed 24 months follow-up. After single-session RFA, disease remission rates were 60.0% at 12 months and 56.7% at 24 months. Among the 13 patients with relapse after RFA, 9 (69%) required a lower ATD dose than before RFA; 2 received surgery without complications. Total thyroid volume was the only significant factor associated with relapse after RFA (odds ratio 1.054, confidence interval 1.012-1.099, p = 0.012). At 24 months, RFA led to disease remission in 100% of the 9 patients with a total thyroid volume <20 mL and 35% of patients with a total thyroid volume ≥20 mL ( p = 0.007). There was no vocal cord palsy, skin burn, hematoma, or thyroid storm after RFA. Conclusions: In a highly selected group of patients with relapsed GD and predominantly small thyroid glands, single-session RFA may achieve disease remission. Smaller total thyroid volume may be a favorable factor associated with disease remission after RFA. The results of this study need to be confirmed with a long-term clinical trial. Clinical Trial Registration: This study is registered at www.clinicaltrial.gov with identifier NCT06418919.

Objectives: Graves' disease (GD) is the most common cause of hyperthyroidism. Antithyroid drug (ATD) is often the first-line treatment but  > 50% patients suffer a relapse when ATD is discontinued. Surgery or radioiodine remains the current options of definitive treatment in these patients. This pilot study examined the short-term efficacy of single-session thyroid radiofrequency ablation (RFA) as a novel definitive treatment for persistent/relapsed GD., Methods: Consecutive patients with persistent/relapsed GD requiring ATD were considered. Those with a clear surgical indication, either thyroid lobe volume  ≥ 20 mL; those who were pregnant or lactating; and those who had any severe medical conditions that would pose extra treatment risks were excluded. Eligible patients received ultrasound-guided RFA of the entire bulk of thyroid gland. Thyroid function tests were monitored bi-monthly. The primary outcome was disease remission rate, defined as a state of biochemical euthyroidism or hypothyroidism without ATD. Secondary outcomes were complication rates., Results: Of the 68 patients considered, 15 (22.1%) patients were eligible. Most were females (93.3%). The median age was 37 (IQR 31-48) years old. The disease remission rates were 79.0% at 6 months and 73.3% at 12 months. Among the 4 patients who relapsed after RFA, three required less ATD dose than before RFA. RFA was well-tolerated in the ambulatory setting. There were no vocal cord palsy, skin burn, hematoma, or thyroid storm after RFA., Conclusions: In well-selected patients, single-session RFA of the thyroid gland may be a potential treatment for patients with persistent/relapsed GD. It is a safe and well-tolerated ambulatory procedure., Key Points: • Radiofrequency ablation of the thyroid gland is an efficacious treatment for persistent/relapsed Graves' disease in well-selected patients. • Radiofrequency ablation of the thyroid gland for the treatment of persistent/relapsed Graves' disease is a safe and well-tolerated ambulatory procedure. • Radiofrequency ablation of the thyroid gland may be a potential alternative treatment for well-selected patients with persistent/relapsed GD who do not wish to undergo either thyroidectomy or radioactive iodine or continue antithyroid drugs., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Background: We previously showed that higher SARS-CoV-2 viral load correlated with smaller thyroid volumes among COVID-19 survivors at 2 months after acute COVID-19. Our current follow-up study evaluated the evolution of thyroid volumes and thyroiditis features within the same group of patients 6 months later., Methods: Adult COVID-19 survivors who underwent thyroid ultrasonography 2 months after infection (USG1) were recruited for follow-up USG 6 months later (USG2). The primary outcome was the change in thyroid volume. We also reassessed thyroiditis features on USG, thyroid function and anti-thyroid antibodies., Results: Fifty-four patients were recruited (mean age 48.1 years; 63% men). The mean thyroid volume increased from USG1 to USG2 (11.9 ± 4.8 to 14.5 ± 6.2 mL, p  < 0.001). Thirty-two patients (59.3%) had significant increase in thyroid volume by ≥15%, and they had a median increase of +33.3% (IQR: +20.0% to +45.0%). Multivariable logistic regression analysis showed that only higher baseline SARS-CoV-2 viral load independently correlated with significant thyroid volume increase on USG2 ( p  = 0.022). Among the seven patients with thyroiditis features on USG1, six (85.7%) had the features resolved on USG2. None had new thyroiditis features on USG2. All abnormal thyroid function during acute COVID-19 resolved upon USG1 and USG2., Conclusion: Most COVID-19 survivors had an increase in thyroid volume from early convalescent phase to later convalescent phase. This increase correlated with high initial SARS-CoV-2 viral load. Together with the resolution of thyroiditis features, these may suggest a transient direct atrophic effect of SARS-CoV-2 on the thyroid gland with subsequent recovery of thyroid volume and thyroiditis features., Competing Interests: The authors declare there are no competing interests., (©2023 Fung et al.)