Benigne niet functionerende schildklier nodus met mechanische klachten

• Pain
• Sensation of a lump in the throat
• Dysphagia
• Irritative cough
• Cosmetic concerns

Autonomously Functioning Thyroid Nodule (AFTN)

• TSH normalization in 40-90% of cases
• Smaller nodules (<12 ml) respond better

Papillary Thyroid Microcarcinoma (PTMC)

Extrathyroidal (PTC) recurrence

Parathyroid Adenoma

Recurrent thyroid carcinoma in inoperable high-risk patients is beyond the scope of this protocol.

A benign thyroid nodule diagnosis is confirmed through cytology with a Bethesda 2 result. Only a single biopsy is needed if ultrasound shows multiple benign characteristics: partially cystic or spongiform, iso-echogenic, wider-than-tall, well-defined borders, and absence of calcifications, according to the TI-RADS scoring system. In uncertain cases, a second cytological biopsy is conducted

• Significant calcifications
• Extensive retrosternal extension
• Cystic > solid composition
• Anticoagulation
• Anticoagulant medication should be paused according to guidelines on anticoagulation for procedures. Coagulation status should be assessed prior to the procedure.
• Metal Objects in the Body
• The procedure cannot be conducted if the patient has metallic implants, such as a pacemaker, ICD, neurostimulator, insulin pump, or cochlear implant.

• Single benign biopsy result if ultrasound indicates Benign characteristics
• Ultrasound: cystic?
• Symptom Score (VAS)
• Cosmetic Score (1-4)
• Laboratory Tests
• CBC, coagulation status
• Serum TSH, free T4, T3
• Thyroid antibodies if indicated
• MRI or CT for infraclavicular extension
• 99mTc-pertechnetate or I-131 thyroid scan for AFTN

• Place cooling packs in the freezer
• 30 minutes before procedure:
• Midazolam 7.5 mg
• Paracetamol 1 g
• Cefazoline 2 g iv

• 2 sterile drapes with adhesive strips
• Sterile gauze
• Sterile adhesive strips for securing wires
• 10 cc syringe, drawing needle for anesthetic
• Blue needle for anesthetic
• Sterile cover for transducer
• Sterile gloves
• Treatment needle and infusion set
• Chlorhexidine 0.5% in alcohol 70%
• Bandage, gauze
• Scissors
• Ultrasound device
• Cooling pump
• RF lesion generator
• Medications and infusion fluids
• NaCl 0.9% (1L bags from freezer)
• Lidocaine 2%, 1 ampul
• Bupivacaïne 2,5 mg/ml
• Glucose solution

• Place the patient in a supine position with a rolled towel under the neck for slight head extension.

• Measure and save nodule volume with ultrasound at the start.
• Determine puncture site with ultrasound (consider chest proximity).
• Disinfect skin and cover the area with sterile drapes.
• Clean ultrasound probe with alcohol.
• Apply local anesthetic (lichen and bupivacain) to thyroid capsule.
• Inject the glucose solution around the thyroid gland
• The RF needle is sharp enough for puncture.
• Connect RFA and irrigation system: blue to blue, white to white. Insert into RF lesion generator, groove up, press without twisting.
• Flush cooling system until temperature drops.
• Set ablation to continuous; initial wattage depends on needle length (5 mm = 20 W, 7 mm = 25 W, 10 mm = 50 W, 15 mm 80 W). Higher wattage is faster but potentially more painful. Impedance should range between 70-110 during ablation.
• Specialist cues start; press the activation button for 1 second. If impedance spikes, the technician stops the device. The system shuts off at 999 Ω impedance with an error message.
• Maintain temperature as low as possible, ideally below 25°C (device reads 5°C as the lowest).
• Using the moving shot technique, the specialist targets the thyroid nodule with a needle that emits radiofrequency (RFA) to ablate the tissue.
• After the procedure, nursing staff retrieves the patient.

• Turn the generator on continuance, start wattage is dependant on needle length; 5 mm 20 W, 7 mm 35 W, 10 mm 50 W and 15 mm 80 W.
• Adjust wattage if pain occurs.
• Monitor patient’s voice during the procedure.
• In case of cystic cavities, aspiration and ablate (in stead of separate alcohol injection)

• The patient applies pressure to the wound for 30 minutes with a bandage and rests for 2 hours post-procedure. Food and drink are allowed afterward.
• Measure blood pressure and heart rate every 30 minutes during the 2-hour observation.
• 1000 mg Paracetamol four times daily on the day of and day after the procedure; 500 mg Naproxen as needed.

• A follow-up phone consultation will be conducted 14 days post-procedure by Dr. Hoogenberg, with an outpatient visit scheduled at 6 months