Table 1.
Summary of recommendations
| Recommendation 1 | In adult patients with benign thyroid nodules that cause pressure symptoms and/or cosmetic concerns and decline surgery, image-guided thermal ablation (TA) should be considered as a cost- and risk-effective alternative option to surgical treatment or observation alone (1, ØØOO) |
| Recommendation 2 | We recommend against the use of TA for asymptomatic lesions (1, ØØØO) |
| Recommendation 3 | Before TA of thyroid lesions, a benign cytological diagnosis is needed; a repeat FNA is suggested for cytologically benign nodules with the exception of spongiform nodules and pure cystic lesions (EU-TIRADS Class 2); we recommend against TA for nodules with high-risk US features (EU-TIRADS Class 5; 1, ØØØO) |
| Recommendation 4 | Patients should be carefully informed before the procedure, orally and in writing, about the TA treatment options, their potential efficacy and side effects, the therapeutic alternatives, and the necessity of being compliant (1, ØOOO) |
| Recommendation 5 | Before the TA procedure, thyroid and vocal cord function, comorbidities, and contraindications to TA treatment should be evaluated; laryngoscopy is recommended in patients with hoarseness, previous neck surgery, or with nodules close to critical structures (“danger areas”; 1, ØØOO) |
| Recommendation 6 | Local subcutaneous and pericapsular anesthesia is recommended before TA procedures; Mild conscious sedation may be considered, especially in case of HIFU treatment (1, ØØOO) |
| Recommendation 7 | At the end of the procedure, clinical and US evaluation is recommended in order to rule out potential early adverse effects and define the extent of the ablated area; patients should be instructed to present for clinical and US assessment if severe pain, local swelling, or fever occur within the first week after TA (1, ØØOO) |
| Recommendation 8 | Early-term (e.g., 3 months) and intermediate-term (e.g., 6 and 12 months) clinical, biochemical, and US evaluations are recommended; long-term follow-up monitoring is suggested, in the absence of symptoms every 1−2 years, in order to reveal regrowth (1, ØØOO) |
| Recommendation 9 | Based on direct comparison studies, and balance between efficacy and side effects, LTA and RFA are recommended as the first-line TA treatment modalities (1, ØØØO) |
| Recommendation 10 | Based on studies to date, MWA should at present be considered a second-line TA procedure in patients who are not suitable for or decline other TA procedures, or for participants in protocolled clinical studies (1, ØØOO) |
| Recommendation 11 | Based on its lower efficacy, higher cost, and limited reported trial evidence, as compared to RFA and LTA, HIFU should be considered only for selected nodules in patients who are not suitable for or decline other TA procedures, and for participants in protocolled studies (1, ØØOO) |
| Recommendation 12 | In multinodular goiters, due to lack of evidence of efficacy and the expected need of repeat treatment, TA should be restricted to patients with a well-defined dominant nodule or those who are not candidates for thyroid surgery or radioactive iodine treatment, as a palliative therapy option (1, ØØOO) |
| Recommendation 13 | Because of higher cost and complexity, as compared to aspiration and EA, TA procedures are not recommended as a first line treatment for pure or dominantly cystic thyroid lesions (1, ØØØO) |
| Recommendation 14 | LTA and RFA should be considered therapeutic options for cystic lesions that relapse after EA and for those that would remain symptomatic due to a large residual solid component (1, ØØØO) |
| Recommendation 15 | We recommend against TA as first-line treatment for large AFTN; due to the low rate of restoration of normal thyroid function, TA should be considered only for patients who decline or are not candidates for RAI therapy or surgery (1, ØØØO) |
| Recommendation 16 | TA should be considered in young patients with small AFTN and incomplete suppression of perinodular thyroid tissue due to the higher probability of normalization of thyroid function and the advantage of avoiding irradiation and restricting risk of late hypothyroidism (1, ØØOO) |
| Recommendation 17 | Treatment with a combination of LTA or RFA and RAI may be considered in selected patients with large AFTN that cause local pressure symptoms in order to achieve a more rapid volume reduction and use of a lower RAI activity (2, ØØOO) |
ØOOO, very-low-quality evidence; ØØOO, low-quality evidence; ØØØO, moderate-quality evidence; ØØØØ, high-quality evidence.