100 Cases! Dr. Emad Kandil Discusses nPulse Thyroid Nodule Ablation

Its Me Jen Again (00:00)
You're listening to Save Your Thyroid with Jennifer Holkem the podcast dedicated to expanding your treatment options for keeping your thyroid intact. Our mission is to empower you with the knowledge needed to avoid unnecessary surgery and to maintain your long-term health. Today, I welcome back a pioneer in the field of thyroid interventions, Dr. Emad

the chief of endocrine surgery at Tulane University,

Dr. Kandil has consistently been at the forefront of non-surgical technology. We're here to celebrate and dissect a massive milestone. Dr. Kandil has now completed over 100 cases using InPulse, nanosecond pulse field ablation technology. In this episode, we're going to get into the clinical weeds of what he's learned from those first 100 patients. We'll cover precision and safety.

How this non-thermal ablation differs from thermal RFA, especially for nodules near danger zones, like the recurrent laryngeal nerve. Case diversity, which nodules are best suited for impulse, including malignant, toxic, and very large nodules? The insurance frontier,

An honest look at the current state of coverage and reimbursement for the submerging technology. New ways to access care from Dr. Kandil Whether you're a patient looking for alternatives,

or clinician following the data, into the future of thyroid care. Let's get started. Welcome to the podcast, Dr. Kandil

Emad Kandil (01:25)
Well, Jen, thank you for having me again.

always fun to talk to you updates.

Its Me Jen Again (01:30)
we've got lots to talk about today. And the first thing we're going to talk about is this new number you've achieved, this milestone as a high volume surgeon, entering as a pioneer into the field of non-surgical technologies. So now you've completed a hundred cases of NSPFA.

Emad Kandil (01:49)
as you know, we've been doing very well with including thermal ablation that started initially with radiofrequency ablation and then we moved later on to microwave ablation in some difficult cases or cases that did not respond well to the radiofrequency ablation. And we had good results with this and we completed over a thousand of these cases and patients were happy.

However, we continue to have some patients on some cases that are tough cases to treat. For example, when you have tumors close to the nerve or with extensive vascularity or very large tumors. In these cases, the thermal ablation can be not as effective and patients are not

Its Me Jen Again (02:19)
Mm-hmm.

Right.

Emad Kandil (02:36)
as satisfied as the standard usual cases. So now this new technology add really significant advantages with adding significant safety to do things that we were.

making sure that we don't encounter doing what we do. For example, when you treat a patient, as much as you want to get a good response and a good results and a good shrinkage and a higher volume reduction rate and make everybody happy, at the same time, you want to avoid complications. I would never have a 60, 70 % volume reduction rate.

Its Me Jen Again (03:08)
Absolutely.

Emad Kandil (03:14)
with no complication versus a 99 % volume reduction rate with a complication. Well, now we have this new technology that can provide significant safety that we can treat these patients that we struggle with. And it's just, I'm excited about that. So I believe now we definitely over 2000 cases in general, but ⁓

I included the nanopulse in my paradigm of treatment options. initially, I was just very slow with it. And I learned a lot during the process. It's a very new invention. And it's really a nice, minimally invasive approach. But we did not know much about it. And during the process, I actually kept learning and improving.

and I started to do a lot more. So I can tell you that when I started doing Nanopulse, I've been doing it now for well over a year, it was really just a very small percentage of cases. So I will have 12 cases booked in the morning and maybe one case Nanopulse and that's it. Just trying to test it out and all that.

I'm a very data driven and I want to make sure I'm not just like a cowboy here. I want to make sure that we are getting some results and stuff. But then I started to keep increasing. I see patients and I see earlier results and we'll talk about that. And I kept increasing and almost right now, the most significant number of cases are done by Nanopulse if I'm able to get, for example, the insurance to approve it and stuff like that.

We still need to learn a lot more about this, but I'm very excited about including this. This is really a significant addition to the field. Jen, you really did a huge impact on the field by really bringing knowledge to patient and information about their treatment options. And it's amazing what you've done to the field. Like I can tell you, most of my patients...

are out state patients, like literally maybe over 70 % for sure. I love them when I ask them, how did they learn about us? Well, most of them learn about this from you. And so really, I feel it's impressive. one can do, for example, as a surgeon, certain number of cases per lifetime. But the impressive part here that we are part of evolution.

It's impressive. mean, really things that we used to always treat with surgery and we thought we were very good with this and we can do a very safe operation, but patients can suffer afterwards. Now we can actually provide good outcome without any side effects related to the surgery.

Its Me Jen Again (05:53)
That's an amazing thought. first of all, congratulations on the milestone and thank you for the kind words about my work. It means a lot to me. I think that it would be really helpful for the viewers who are new because as you said, there's been a lot of growth in our communities. So we've got a lot of new viewers who are probably watching this video and have never heard of nanopulse, nanosecond pulse field ablation or NSPFA.

now called N-Pulse. So if you could kind of give an overview of how this technology works and why it doesn't have the same side effects or risks that we were just discussing with the thermal ablation technologies.

Emad Kandil (06:32)
Very good. Well, how about if we start just going back in history? So, ablation when we started doing these, I actually started doing this over like a decade ago doing ethanol ablation, which is chemical ablation. We try to destroy the cells and cause apoptosis, death of the cells with chemical injury. The problem this is did not work very well except in cysts and in solid nodules did not have good results. And the problem that side effects can be really detrimental.

because the ethanol can cause a significant chemical injury to the nerve and it can take a very long time to recover, if it will recover. So it really did not do very well in the field. Then we, the FDA approved the thermal ablation with the radio frequency ablation. And we learned that we can do this with some safety measures and then microwave introduced, which can provide more energy and be maybe.

better options to avoid the heat sink effect. But both radio frequency or microwave are thermal injury. Even cryo, which is not something exists in the US, it's cold, but it's a thermal. But basically with a thermal injury, the heat that generated from these technologies that we introduce into patients will cause eventually coagulation necrosis. Basically, again, death of the cells.

but it will basically destroy everything, the cells, the connective tissue, and everything. And the patient can really suffer from the side effects, really kind of like you cause significant inflammation, and this inflammatory process eventually will subside, but it takes time. And in many cases, actually, for large nodules, for example, we write a prescription for steroids to decrease the inflammatory process and help these patients to...

recover from this process while they are looking forward for the outcome. The problem with the thermal injury though that for safety measures, we wanted to always make sure that we're away from vital structures. That include the recurrent laryngeal nerve that can important for the voice quality and important for swallowing. If the nerve is injured, patient not just can be hoarse but short of breath.

cannot swallow, can aspirate, it can be a life-threatening. It's a very, very significant complication to deal with. And it might take some time to recover and thermal injury can take a while to recover. But also it's been reported that patient can have complication of injury to a trachea, to the esophagus, and without careful meticulous approaches, it's been reported that patient can have also Horner syndrome, from injury to the sympathetic chain.

and the carotid sheath, and these are mostly common with like inexperienced operator and stuff like that, but they're very, very serious complications.

But now, if we are able to provide the same treatment approach to cause regulated cell death, apoptosis without the heat, without the side effect, that would be awesome. So here's where NSPFA comes in, which is a nanopulse technology. It's basically an electrical pulse that cause the regulated cell death, apoptosis. We call this apoptosis.

by creating some pores into the cell membranes or into the nucleus. And eventually, the machinery within the cell will stop working and the cells will just basically get necrotic and die. The good thing here that there is no heat, there is no thermal energy. So all the complications that I mentioned earlier with injuring the nerves and the surrounding structures can be almost...

0%. Again, I've done the 100 cases, by the way, is the largest number globally. The largest series published from the clinical trial in Italy was 20 something patients. So we still need to do more and more to get to learn about this. But so far, so good. I mean, this has been proven to be a very safe approach, significantly safer, honestly, in patients who are high risk.

to avoid these complications. So it leads to the same outcome, which is regulated cell death and eventually the mass will keep shrinking and at the same time we avoid any possible related complications. It's just exciting time. It's very exciting technology to utilize in patients with significant safety.

So I'm excited that we're to do this. We're looking for the outcome. And I guess we can continue to talk about the advantage that we found from this approach compared to others. But definitely, we had very good outcomes with the thermal ablations. But there were possible complications. And no one can claim that they had zero complications. You can have close to zero. But also, when you try to treat difficult cases,

Its Me Jen Again (11:13)
Mm-hmm.

Emad Kandil (11:16)
you are prone to have possible complication. Now this can be eliminated with this novel technology.

Its Me Jen Again (11:23)
for the physicians who may be watching,

who may be familiar with the use of thermal ablation and how it feels, what their experience is like as an operator, how does impulse feel different for the physician? What are you looking for on ultrasound? know, with RFA, microwave, we're looking for changes on ultrasound.

so how is this different in your perception?

Emad Kandil (11:46)
It's a very important question. So I maybe trained over 100 physicians, maybe over 200. I don't keep track of the numbers, but I trained many physicians over the years. They come to the clinic or to the OR, and they come in groups. In some cases, they were seven per time.

I mean, I need maybe to go back and look at the numbers, but I'm thinking right now it could be really over 200 physicians. The problem is the following. Many of these physicians are actually surgeons. Surgeons are very aggressive, but many of these surgeons have no ultrasound experience. I literally had one famous surgeon showed up to my...

Procedure room and I was trying to teach him later on a model how to use this and Realize that he has no ultrasound experience and I said you do biopsies. It's like no I'm like why you're here like you don't even do biopsies and now you're gonna use this like Great technology, but it's kind of a dangerous weapon if you're not really have the perfection and the precise technique

to try to do this and I said, well, I have to say this, like you really need to get an ultrasound experience first. I participated in many training courses with the American session with the consurgents and NASA and all this. But the issue is sometimes for us, the setup was that you have and the ablation course first with hands on experience and then the ultrasound course.

Its Me Jen Again (12:57)
Mm-hmm.

Emad Kandil (13:15)
And I've seen many physicians shows up to the ablation, trying to learn how to do ablation with no ultrasound experience with the plan that they're going to learn the ultrasound in the afternoon session. I'm like, my god. So I think really, patients should really understand who is offering them the procedure, first of all. But when you start to do these procedures, as much as they're helpful, they can have side effects. So my opinion, if you are a

Its Me Jen Again (13:23)
Thanks.

Emad Kandil (13:38)
and you a beginner and trying to offer this to your patients, then maybe nanopulse is the safest thing because the risk of complication is going to be significantly lower. So I'm a data-driven person, but I can tell you now we do not have a published data yet, head-to-head comparison between non-thermal, but scientifically the risk is low because there is no thermal injury here. The risk to injure the nerves is not there. It's electrical pulse.

I want to highlight this. When we do thyroid surgery, we do something called nerve monitoring during the thyroid surgery. We monitor for the nerve function. And what we do, we use electricity to examine the circuit from the vagus and the recurrent laryngeal nerve to make sure everything is perfect and continuous and all this. And we do a continuous monitoring for that using electricity. So electricity is not supposed to really hurt the nerve.

And studies actually been done to this, unless maybe you go crazy on the voltage and stuff like that. But that's not the case here. So I think for physician, this can be a safer approach to incorporate in practice compared to thermal. I believe the risk of complication will be significantly lower. From the technical standpoint, though,

When you do thermal ablation, you actually can see easily the effect while you are doing that. But there is a trick with the nanopulse. A lot of times you do not see a significant difference or significant effect. And you need to have a significant experience with the ultrasound to imagine the three-dimension view of the nodule. I basically plan to divide it into zones, and I make sure I finish that zone, and then the other zone, I'm completely focused.

So I train physicians and fellows and stuff like this, but when it comes to nanopulse, I really kind of take over because I want to make sure I don't miss anything from that nodule The technology, the company is working on trying to figure out certain imaging technology to make sure that you are not missing any part of the nodule And I feel here experienced matters to make sure that you get every single bit of the nodule and not miss it because you do not see.

the significance changes that we see with the thermal ablation, we call this bubbling. You can see the effect like you zap thing and you can see it with the radio frequency or the microwave right away. But that's not the case with the nanopulse. Nanopulse is an electrical pulse and you do like a cycles of treatment that there is a default cycle and there's a shorter cycle. The default cycle is eight seconds. And they actually modifying the technology and it's getting better and better.

Its Me Jen Again (15:48)
Mm-hmm.

Emad Kandil (16:11)
But it can be definitely safer for beginners who are trying to learn this. And it needs really those significant experience with the ultrasound. The other thing also for patients that they need to understand that experience matter like everything else in the world, like in surgery, tons of research showed that if you do certain number of cases, you have better outcome, less complications, et cetera. Same thing here. So I get invited to go all over.

Its Me Jen Again (16:35)
Hmm

Emad Kandil (16:37)
And I witnessed many colleagues, not mentioning any names, in well-known prestigious institutions. And I watched them doing this. And they really like literally getting less than 50 % of the nodule They are afraid to cause complications, which I understand. But they don't understand the zones that can be safe or not. And they just do a little bit just to get something.

but experience.

matter is not just to make sure you avoid complication but to provide the best treatment completion to this patient while you are also preventing complication. And nanopulse here significantly increases that zone of safety.

Its Me Jen Again (17:13)
Wow. So for these patients that are undergoing this procedure, one thing that's different about this than with radiofrequency and microwave is that these patients are now being sedated for impulse treatment. Can you talk about how that is a different experience for the patient, how it can enhance the situation, enhance the patient's comfort, and how are the patients feeling when they wake up from the sedation?

Emad Kandil (17:37)
That's a very good question. So we talked about this a while ago for thermal ablation, when people were saying, why do sedation? You do not need to do sedation for thermal ablation for the vast majority of patients. But some patients ask for it, require it. You have to respect the patient's wishes. If the patient say, I can't do this, I'm stressed out. Some patients require sedation for MRI. Most patients do not need it. why we are like, if the patient say, I can't, I have an anxiety, I want to be

Its Me Jen Again (17:57)
Right.

Emad Kandil (18:04)
asleep. We don't, by the way, when we say sedation, this does not mean general anesthesia, does not mean intubation You just put an IV and give a little, some medications to keep the patient comfortable and do not remember what happened and just, you can do the procedure safely. So I started doing the nanopulses. Everyone else was just a local and it's a pulse treatment. So it's kind of electrical shock in the thyroid and it can be

Its Me Jen Again (18:09)
Right.

Emad Kandil (18:30)
⁓ very uncomfortable for many patients. And some physician actually decided not to use the technology earlier when this was getting tried by ⁓ North American, US physicians and decided this is too much for patients. So I started to offer this sedation and...

I invited, you know, the people come from the company and watch and say, wow, this is awesome. So first, the sedation will allow me to give a complete treatment. I'm not worried about the patient getting stressed out. I do a faster treatment like you need to respect the patient wishes. Like if the patient get an anxiety or get pain or get discomfort, you can stop and you might stop for a very long time. But

Its Me Jen Again (19:08)
Mm-hmm.

Emad Kandil (19:08)
You can continue to do the treatment, do a complete treatment, not a partial treatment. Use the default setting and not a shorter setting or incomplete treatment. So you basically provide the best complete treatment for these patients while they are sedated and they wake up and they just leave. not unusual that I can do over a dozen cases and

few hours of hours in morning session. yesterday I just was doing, I did actually in one hospital, the open case, and then I went to do the little ablations and I couldn't even see the patient. Like I, I've done maybe six ablations. I just finished a couple. I went to see the patients like, the patient left. for the patients so that I couldn't, so they, they just literally, they don't even stay for after the procedure.

maybe even 30 minutes, they just recovered them, were on their way out. I had a patient coming out of state yesterday and I did her first and after a of cases I went to look for her and she's gone. And I just called her and say everything's okay and she's like, ⁓ I'm eating now, she's in the restaurant. Okay, I'll talk to you later. But it's not like an operation or anything, we don't put

Its Me Jen Again (20:02)
Wow.

You

Emad Kandil (20:24)
patient to sleep, it's not general anesthesia, but it's a much better approach to get the best outcome in patients, for sure.

I present the data on the American Thyroid Association last meeting in Arizona where I showed the time, OR time, I showed wheel in, wheel out, and the procedure time and everything, and it was not significant at all ⁓ compared to other, this is very similar, comparable to other ablation, like 20 minutes on average, and I showed what really matters is the size of the tumor, so few.

have a larger tumor, you need more cycles, and this will add to the time. But otherwise, sedation by itself does not add much. It actually can help to make the procedure shorter because the patient is comfortable and you're doing the maximum treatment.

Its Me Jen Again (21:10)
I would imagine

you're as a physician, you're probably more comfortable because you know, the patient's comfortable.

Emad Kandil (21:15)
100 % yeah, you're just comfortable you're giving the maximum treatment safely and you're just focused on treating the patient rather than worrying about the discomfort of the patient. You have to be respectful. Like listen, I've done over a couple of thousands of these ablations and in couple of patients when we do this on the local patients get like I can do this, my heart is going fast, I have to stop. It's not uncommon but it happens. What are you gonna do? You're gonna tell the patient no, you're gonna do like you have to be respectful.

Its Me Jen Again (21:37)
Yeah.

Emad Kandil (21:44)
to how they feel and you need to stop. ⁓ This does not happen when you do the station. It's almost 100 % guaranteed that you complete the treatment.

Its Me Jen Again (21:46)
Mm-hmm.

Excellent. Well, you said the patients are recovering rapidly and leaving and going out to eat even afterwards. So it seems to me that they're having a really easy recovery. Are they needing afterwards anything like ice packs or non-steroidal anti-inflammatories?

Emad Kandil (22:07)
I don't

we don't do steroids for sure. Steroids is not something that we do in these patients as we do in other ablations of much bigger

But it's amazing how the difference and how they feel.

I tell you this from experience, it's just a difference between day and night. Like they don't have any issues with the inflammatory process that happens after the thermal ablations. It's more comfortable. just a very soft treatment. Patients can tolerate this extremely well with this approach. I mean, a lot of patients with the thermal ablation can, many patients, if you ask them about the pain level during the procedure,

on a scale from 1 to 10. In my experience, the average is 3. Some can go up to 4. You always have a scale, people say 9 or 10, too much. And some people very low, like 2 or 1 even. But the average is 3. But I'm talking about post-ablation, specifically in large nodules Small nodules maybe it's not even noticeable too. But with the...

Nanopulse consistently with the large masses, no issues. You don't get someone to call you say I'm having this or having that or we do not need to hold anyone hand afterwards. They're just very comfortable with the procedures. That's a huge difference. The other important issue though.

It's fascinating the history of all this since we've been doing this for over six years now, I believe. But when we started doing the thermal ablation, our first follow-up visit used to be a month after. And what we know is that there is not much changes happen after thermal ablation after a month. And we now routinely, the first

follow up ultrasound after thermal ablation, radio frequency, or microwave is three months after the ablation. What's interesting that nanopulse, you see the results a lot faster. it's amazing. It's actually happening

So here's my routine. This is in my clinic. The routine is number one, if it's...

Thermal ablation radio frequency microwave the follow up visit in three months. Ultrasound in three months and go over the results. We send the patient a table, the calculation with the volume and they can understand very understandable nice table similar to the ATA calculation. But for nanopulse the visit is one month after, not three months because I see the difference. I mean there is no point for me to see a patient after thermal ablation month after. Nobody's happy.

Its Me Jen Again (24:28)
Mm-hmm.

Emad Kandil (24:37)
But for nanopulse, I can see very happy patient just a month after.

Its Me Jen Again (24:41)
What kind of reduction are you seeing at that point in time?

Emad Kandil (24:44)
It's a very good question. So the recommendation is to do one cycle of treatment per cubic ml. So we publish on this. We publish over 600 patients before I think this paper came out in surgery. I combined the data with the Johns Hopkins at that time. But what we showed that if we put more energy in the nodule, we get a better outcome, more reduction.

And I gotta give a shout here to my dear friend, John Russell. He actually, the one who was like, I noticed that and we start looking to this and he was absolutely right. If you put more energy, we get more things. So yeah, shout out to John Russell. It's very impressive

So when it comes here, was like, all right, how about if I use the same idea? The cycle of treatment is basically it's treatment. How about if I treat more? So I started later on to do two cycles per cubic ml. And I noticed a significant improvement. And then now sometimes I go to actually three cycles per ml. And the safety continued to be the same. And much better results.

Its Me Jen Again (25:51)
Mm.

Emad Kandil (25:53)
Yeah, I just had a patient that I treated recently, a young female patient with a very large mass that usually, usually maybe one treatment is not good enough with the thermal ablation, specifically it's very close also to the nerve territory and the size and all this and you want to treat the whole thing.

we know that the large nodule, when it's toxic nodule, the response is not gonna be as good with hemoglobin. And you cannot have like 100 % guarantee rates. patients understand like number of centimeters. And it's actually published per centimeters from the Italian study. They showed that if it's three centimeter or more, the chance for this to be cured is significantly less.

Its Me Jen Again (26:22)
Right.

Mm-hmm.

Emad Kandil (26:39)
And I discussed it when a counseled patient discussed this with them. So I treated this patient with the nanopulse and I did give her a three cycle per cubic ml, cure, normalize, off the thyroid medication, 80 % drop within just one month. She and her mom were just like, unbelievably very happy about the outcome. Like she doesn't need the medicine anymore and the mass is gone. It's impressive.

Its Me Jen Again (26:52)
Wow.

Emad Kandil (27:04)
Really to get this with thermal ablation can be challenging. I need like two sessions to do it with thermal ablation.

Its Me Jen Again (27:11)
So for toxic nodules then this could changer because we've seen less response from toxic nodules once they hit a certain size threshold. And so unfortunately a lot of the time when we see patients with three, four, five centimeter toxic nodules, we kind of have to warn them, it might not be as effective. You might need more than one treatment. I know one patient right now I'm thinking of has had three.

treatments of RFA because her nodule just is very persistent with being toxic. So this is exciting to think about for those patients.

Emad Kandil (27:43)
I have no idea who is this patient, who is the treating physician. treatments is too much. Like something's not right here. I don't know, as I mentioned earlier, did she really get a full treatment? Did she get really the complete treatment or you get a third person? Like for example, if you do surgery, you need to remove the whole thing. You don't remove half and you hope it's gonna be okay. So you treat half of it,

Its Me Jen Again (28:04)
Right.

Emad Kandil (28:06)
the nodule will regrow and continue to grow. So you need to do a full treatment. So basically the failure of treatment in toxic nodule is because the failure of ability to cause a apoptosis on all the cells of the nodule That could happen if the nodule is extremely large or there is a significant part of it close to the dangerous triangle. I think this can be covered by the ⁓

Its Me Jen Again (28:22)
Mm-hmm.

Emad Kandil (28:34)
by the nanopulse, specifically if you're doing with sedation, patient is comfortable, you keep treating and it's amazing. I I feel at some point, know, the average reported success rate of ablation of toxic nodule is around 85%. But now we can do it to 100%. Why you need to undergo surgery and have all the possible complications related to surgery when you can just have a needle treatment and get cured.

Its Me Jen Again (28:49)
Mm-hmm.

So exciting. So we've talked about toxic nodules. Now let's talk about cancer because thyroid cancer patients are coming into the Savior Thyroid community more than ever and they're wanting to save their thyroid. So tell us about treating thyroid cancer or even indeterminate nodules with this technology.

Emad Kandil (29:20)
So people know that I'm a big proponent of treating thyroid cancer with the ablation technology. And I think most of my patients are cancer patients now. And people think I'm a little bit, you know, have those kind of indication for treating this.

But you know what, I really have a passion for this. Listen, I respect cancer. I come from a family that has a significant history of cancer. is a big thing in my family and big. So genetically, I'm something that I'm always concerned about and worried about. So cancer is a big deal thing. But let's talk science here. I'm all about science and research and all that.

Its Me Jen Again (29:49)
Really?

Mm-hmm.

Emad Kandil (30:06)
Thyrocancer, well differentiated, what are we offering here? We're for treating well differentiated thyroid cancer. What are the mortality rates from treating these patients, from this cancer? Now we have in the American Thyroid Association Guidelines, clear guidelines for treating patients with active surveillance.

We're not talking about even what's happening outside North America. There is like now cohorts with over 4,000 patients who are thyroid cancer and progression and maybe less than 3 % of cases. And progression means that the nodule increased three millimeter or something, over three millimeter. But how is that really affect survivor? Nobody died in Japan with Kuma Hospital.

doing active surveillance for these. you know, active surveillance been reported to be effective in cancer up to two centimeters with a very low progression. Mortality rate is extremely low, below 1 % in the well differentiated small cancer. I've been treating thyroid cancer for over 20 years now and...

How many patients die from thyroid cancer? mean, when you look at mortality of thyroid cancer, you need to look specifically at the well-differentiated small cancer. What happens is people look at how many people die from thyroid cancer, but this includes anaplastic thyroid cancer, includes medulary thyroid cancer. We're not treating this with ablation. We're talking about well-differentiated cancer, the small cancer, et cetera. So we have good results from this in ablation. There is strong data on this that there is no progression is

below 1%, close to zero, actually. You have a disappearance rate for less than a centimeter or less in 99 % of the cases. They did actually a very interesting study in China. They had a cohort of patients where they ablated the nodules with cancer, and they decided, you know what, we're just going to take him to the OR.

Its Me Jen Again (31:44)
Wow.

Emad Kandil (31:56)
and do surgery for them and not just remove their thyroid, but we're going to remove the lymph nodes around the thyroid, the central lymph node dissection and see what happened after the ablation. No cancer in the thyroid. They found in one patient or couple patients like some micro-mets in the lymph nodes, which clinically insignificant. It does not mean anything. So this technology has been used to treat liver cancer, kidney cancer,

not thyroid cancer that you can do active surveillance and monitor. So the idea that every cancer should come out, only most patients, the only reason if you ask him, how did you find out about your cancer? They were looking at something else. They were doing a scan, the spine, they found the nodule. They, somebody thought that they felt something, which is 50 % of the exam is wrong.

Its Me Jen Again (32:32)
Right.

Emad Kandil (32:41)
But if they are not living in US and they are just enjoying their life, they wouldn't even know that the diseases exist. Now, they are prone to lose their thyroid, increase the risk of osteoporosis if they are young female patient, the thyroidectomy triple the risk of osteoporosis. Triple the risk of osteoporosis. If you actually...

Its Me Jen Again (33:01)
Wow.

Man.

Emad Kandil (33:05)
If you don't die from cancer or heart attack or stroke, you get older osteoporosis can cause bone fracture and you fracture bone in your 70 or something, the mortality rate is 50%. 50 % will die from something related to the possible operation. So to have weak bones is something that if you can do everything, you can avoid.

And we talked about this also, even if you are the most compliant patient, take your medication on time, have normal thyroid function test. Easily, 20 % will never feel normal again. Nothing like your own hormones that comes from your own gland. For all these reasons, we're not talking about thyroid surgery and possible issues related to dysphagia and all this. You can do a perfect operation.

No complication. Everything is good. Nothing can be documented for possible complication. But look at the surveys for patients after very good successful surgery. About 50 % will have dysphagia I will tell you, I'm having problems swallowing. I'm having discomfort in my neck. So the operation is 100 % success, zero complication rate. But let's talk about surveys afterwards. There's a lot of issues with this. So now you're losing the thyroid, affecting your longevity, the quality of your life.

survival in general to remove something that is not good enough. You know, I have to mention the story. I had this discussion just yesterday with one of our esteemed transplant surgeons, a patient with liver cancer who they're planning to do a liver transplant for.

they found to have a small cancer in the thyroid. So I was planning to ablate But guess what? They said, no, it needs to come out because it needs to be cancer free. I said, I promise you it's going to be cancer free with the ablation. So well, in our guidelines, we don't have the thyroid to be monitored or to do this. We have it for prostate. Well, the thyroid cancer is literally over a decade behind prostate cancer. So now we know if you have small prostate cancer, you can monitor. It's not a contraindication to do a transplant. No issues.

So this person is going to lose his thyroid just because it does not include in the guidelines. I this thyroid cancer, bet everything is not going to cause a thing to him. Now we know we're just going to make him lose his thyroid, have really a worse recovery from eventually his liver transplant just because we are just going with guidelines.

Sometimes it's baffling to see how we are just thinking about thyroid cancer, that we need to take it out. you can talk to me, I'm sure you know, you talk to any of my patients, the cancer will disappear. They cannot find it in the ultrasound. And sometimes you find the rim of a small thing, the biopsied, cancer. So what else you want? There is no cancer, it's cancer free. Or if it's shrinking, what's wrong? And sometimes I had...

I had a physician that had been decided on their own to monitor a large cancer that's not according to the guidelines of following active surveillance. But the cancer has been stable for 15 years. Nobody's going to take my thyroid out. It's been stable for 15 years. So why not update this? We updated over 80 % shrinkage. The patient's happy. It's like, oh, it's not growing. There's nothing happening. It doesn't follow the guidelines for active surveillance.

Its Me Jen Again (35:58)
Wow.

Emad Kandil (36:13)
So why not? If the patient, we need to stop this paternalistic approach about it needs to come out because cancer and stuff. I think there is a significant change in the field of the active surveillance. Memorial Sloan Kettering is leading the field with active surveillance. But then we have another better option, which is, well, instead of just watching it, let's just try to make it disappear or shrink.

My approach for this is this, I tell my patients this, like listen, if it doesn't work, this actually means that this could be a bad cancer and instead of doing hemithyrodectomy and removing half, you should remove the whole thing because otherwise if it's not that bad, it should respond. If it's not responding, it's an aggressive one. And in my experience, this is the case usually. If it's not responding, that's a bad one that needs to come.

We try to make sure that we do genetic mutation for all these patients with cancers to make sure that we are not treating a genetically aggressive tumor. So we are very selective on treating these and very careful, and we follow up closely. But the patient has to have understanding of all this and the understanding that it takes time also for thyroid cancer. So it's amazing, and I published that. We looked at all the databases and the published data.

I'm not sure if we discussed this before, but do you know that the effect on thyroid cancer is completely different if you ablate benign nodules? So for benign nodules, you see the shrink as we discussed, three months. Most patients will, at six months, that's the maximum response. Some will continue up to a year, but it's completely different than thyroid cancer. In thyroid cancer, you can see the best results in a year. It actually...

Its Me Jen Again (37:44)
Okay.

Emad Kandil (37:45)
It's completely different from benign nodules. Benign nodules, it can happen quicker and start to plateau and that's it. Thyroid cancer, takes longer time. So patient needs to understand this and be willing. So for example, in my practice, I wait approximately nine months before repeating the biopsy to see where we are with the treatment. The other thing I tell patient which is important, this is actually goes for benign and for thyroid cancer.

I tell them this, listen, if a patient has diabetes or hypertension, they don't expect to go to the doctor and have just one pill and this disease is gone. I tell them, for example, if you have a benign thyroid mass, you're not born with it. And if you don't do anything, it will just continue to grow because there's an intrinsic thing inside that makes it grow. So here's the thing, if I'm able to control the growth and shrink it now, but still the intrinsic

Its Me Jen Again (38:19)
Sure.

Emad Kandil (38:37)
factor is inside and it will make it grow. So if it starts to regrow, what's wrong with considering another ablation to keep it down? don't see any reason not to do that.

Its Me Jen Again (38:48)
It's like cutting

your lawn. You have to maintain it.

Emad Kandil (38:51)
Exactly.

We don't go to the barber and say I want just one nice haircut. Don't touch we do have good long term data on thermal ablation. We wait for the nanopulse, but even I think for either one, it's not a bad thing to try to do a safe approach to maintain things.

The other thing what we know about thermal ablation radio frequency and micro but mostly about radio frequency that more than one treatment can have an additive or maybe even synergetic effect. Additive effect meaning if you get for example 40 % and 40 % you get 80%. But synergetic meaning that you can get maybe 30 and 30 but like an effect is like 80. It's actually can be significant if you treat the patient one second time.

So some patients might not have the best results of the first treatment. That's why they undergo a second treatment. Yeah, but they need to make sure that they are treated by the person with experience that the outcome and not just more. It's not. I really think I love this. It's not about the technology as much as the operator. For example, like

When you do thyroid surgery, it's not about using the certain technology, the harmonic scalpel, the ligature, the robot, whoever. It's about who's doing this. You can use the same, any great invention can be a great weapon too, a dangerous weapon that can have significant complications.

Its Me Jen Again (40:19)
Well, and you mentioned your technique too earlier about treating an area, you know, maybe three times instead of just once. And so I'm curious if that, ⁓ yeah. So that's really incredible that you were able to observe that in your use of the technology. And have you done any repeat treatments, like how to patient come and do impulse a second time?

Emad Kandil (40:29)
Yeah, not three times three cycles. Yes. Correct.

So what I've done, the patient did not respond well to thermal ablation, whatever technology, and we did the nanopulse, and we had a significant better outcome. I did not have yet to treat a second nanopulse. But we shall see. mean, it's amazing. I mean, I'm looking forward to more studies, comparison between different technologies and...

Its Me Jen Again (41:02)
Okay.

Emad Kandil (41:11)
adding more and all that kind of things. But it's just an exciting time.

Its Me Jen Again (41:15)
Well, talking about studies, let's talk about the clinical trial that's going on at MD Anderson. Dr. Vicky Benucci is leading that up on the use of impulse for papillary thyroid cancer. Talk about, you having any involvement with that and talk about how this could be really important. mean, we've already touched on how this could be really important for patients with thyroid cancer because most of these cancers are indolent, they're not causing death.

So why is that such an important thing for us to study?

Emad Kandil (41:44)
It is important because a lot of, many of these cancers can be small and everything, but can be close to the nerve. So that can be a contraindication to treat, specifically if the operator is not very experienced of doing hydrodynamic section, getting the nerve away with a significant hydro dissection. And by the way, hydro dissection is something that I do not use often with nanopulse because there is no thermal injuries and this can be done very safely too. So.

It's definitely exciting time. There is no data yet. So this is a clinical trauma. We were supposed to be part of this for sure, but I announced that I'm leaving Tulane. And so I'm not going to be able to do it through my current employment right now, but I'm here until March. Eventually, plan is to get started with the...

my new ⁓ position and we'll talk from there. But I'm excited about hopefully making an effect with this and we can see it. This is a clinical trial. We don't have data yet, but I think honestly, it's, I mean, patients can do it off-label if it's an option, specifically in cases where maybe thermal ablation is not the best option.

because of the location of the nodule close to the dangerous triangle or close to vital structures.

Its Me Jen Again (43:05)
It seems like most of the patients that I encounter with thyroid cancer have nodules that are in an unfavorable location, unfortunately.

Emad Kandil (43:14)
Well,

we talked about this. I've done them a lot of these cancers, but it needs a really significant precision. And patients been told that many times. I look at the scans, it's not. And I think they've been told that you are not a candidate because you need an operation. And they've been pushed for surgery.

Its Me Jen Again (43:25)
Mm-hmm.

You

Emad Kandil (43:35)
So I think patients need to do little bit due diligence and understand their options. I mean, why in the world do you think it's always like, I mean, I hear this all the time. Most of my patients were told that, which is not the case. We told all kinds of things like, it's close to the carotid, it's close to the carotid. You can, what's the meaning of close to the carotid? I literally can make a significant hydro dissection

Its Me Jen Again (43:42)
Definitely.

Okay.

Right. It's always good to get multiple opinions.

Emad Kandil (44:04)
that you can put two thyroid between the thyroid and the quad. In a second, you can put good D5W in a very short time. You literally see a huge expansion. Maybe I can get you a video, but it's just like you literally can put two thyroid there. So.

Its Me Jen Again (44:08)
my goodness.

Amazing.

Emad Kandil (44:23)
I have say it's close to the fact, to the carotid. I mean, are you serious? This means there's no experience here, not enough experience. I have to say though, I have extreme respect to my colleagues who are not pushing to do these. Like if someone just did a couple of cases or a certain number and they are trying to shy away from this, I have huge respect to my colleagues who are not pushing for that. That's in their experience. But also, you need to be careful when...

someone telling you it's very close and they don't even do the ablation, they did not do enough and they're just saying, you need surgery because of that. So you need this kind of a red flag a little bit, but I think one should just do a little due diligence and learn more about their options.

Its Me Jen Again (45:04)
Absolutely. I always tell patients, a second opinion, get a third opinion, even if it's necessary. It's always good to have multiple doctors' opinions, but they must be doctors who are aware of and performing these procedures and not just, know, have you ever heard of it? No, don't do that. That's terrible because if they're not aware of it, how can they adequately advise and counsel you on that topic?

Emad Kandil (45:29)
So I have a funny scenario here that happens. I will have patients that have cathartic cancer and they're consulting about their options. And for whatever reason, sometimes certain insurance do not cover it, et cetera. And they cannot afford it. I will, it depends on the location, will refer them for active surveillance. They just go for active surveillance. And I think it's appropriate. So they were trying to seek

ablation, but maybe at this point, they're insurance is not proving it, and they just go and I refer patients to Memorial Sloan-Kathleen for active surveillance. It's amazing. So I get patients from Memorial too that been on active surveillance, but they decided that they want to do something for it instead of just watching it. yeah, but I think it's important that patients understand that they have options.

between active surveillance, between ablation, between maybe remote access surgery where, you know, we've done over like a thousand of robotic approach with a head and incision and all the kind of things, if that's something that they are concerned about. But that's another thing. mean, I know my dear friend John Russell talk a lot about surgery for this, but he's a good friend. talk a lot about this, but in my opinion,

You know, used to do a ton of robotic surgery and at some point I used to do at least five robot cases in a day. Yeah, it was a very big thing and patients also flew from all over the country for this procedure. I'll tell you, the ablation actually is a great option for most of these patients. So I don't do...

Its Me Jen Again (46:49)
Wow.

Emad Kandil (47:04)
as much as I used to because now we have a significantly more minimally invasive approach that can just avoid everything. Avoid the general anesthesia, avoid the surgery, avoid removing your gland. mean, you remove the gland.

Its Me Jen Again (47:20)
Right?

Emad Kandil (47:23)
So it's amazing. I I miss doing as much robot as I used to do to work, one of my favorite things, but I'm excited about this. Neutron is much better for patients for sure.

Its Me Jen Again (47:35)
You mentioned a second ago insurance. Are you having any insurance coverage come through for N-Pulse procedures?

Emad Kandil (47:42)
So the company does help with getting pre-authorization for this, but it can be an issue in some insurances or many. They do have a special code, and I really cannot tell anymore. We just tried to submit and figure it out. But it's definitely not a guarantee approval. But we...

We have a good number of patients that were able to get

patients, Medicare has great with all the ablation technology recently. Somehow though, like, sometimes they say, well, approve this approach, but not the approaches. I'm trying to get a handle on this. I actually tried to put some kind of a talk. It's very...

Its Me Jen Again (48:16)
Fantastic.

Yeah.

Emad Kandil (48:31)
But it's very changing. And for example, it's crazy. Like, for example, the Blue Cross Blue Shield, they treat patients differently from one state to the other, which is completely unclear. So you live in Alabama, correct? And I'm here in Louisiana. So for example, to my knowledge, Blue Cross Blue Shield in many states will approve 100%, 100%. But

Its Me Jen Again (48:42)
yeah. Yeah.

Yes.

Emad Kandil (48:55)
in Louisiana, in Alabama, zero. It's like wow. It's like, and you just suffer with this. What's the difference? It's like it's same company, but the different things and it's crazy. I live here in New Orleans. I give patients with Blue Cross Blue Shield from other states to come and do it with their insurance. My own people here cannot do it with their insurance. Really? How does that make any sense in the world? But...

Its Me Jen Again (49:05)
Mm-hmm.

doesn't.

There's so many things about insurance.

Emad Kandil (49:21)
And they told

us to stop trying. They even refused, to do, ⁓ appear to be refusing. It's like, I'm not doing it. It's just an experiment.

Its Me Jen Again (49:31)
There's so many things

about insurance that just infuriate me and don't make any logical sense. And to me, it borderlines on practicing medicine without a license because they're dictating patients' outcomes and patients' care without having any knowledge of their situation or what's best for them. So you would really, really get me riled up and on a soapbox. Let's talk about insurance because this is infuriating.

Emad Kandil (49:55)
No, it's too difficult.

No luck, It's mind-blowing, honestly. I just cannot make sense of this. Well, we try our best to help patients. And eventually, with the new practice that I will have, we'll have some options with payment plans, with zero interest rate, and stuff like this. And we'll figure out ways to help as much as possible.

Its Me Jen Again (50:18)
Well, since we're running out of time, we're coming to the end of this episode. Tell us a little more about where you're going to be moving and how patients can reach you.

Emad Kandil (50:26)
All right, I hope you will put on the screen now the contact information. So I'm starting some kind of like an institute with different centers. will have, I'll continue to be here in New Orleans and I will continue to work with the same hospitals that were affiliated with the university here. And I will also have another center in New Jersey, Jersey City, but I will have.

some kind of offices in New York City and in New Jersey. There is some talks about something intermittent in Dubai. I'm not sure where this is going to go, but I'll continue to do surgery for sure. I love that, but I think I'm going to really try to push the envelope here for... ⁓

more ablations and I'm very excited about the new chapter. I'm excited, I'm thrilled. I'm very happy that we can be able to really see more patients, take care of more patients. I've been struggling to get new patients and the wait time was approximately four months to see me in consultation where I am currently now and I have...

constantly over 100 patients on waiting list that I cannot get to. So I'm hoping that this will completely change and I will be more available to see more new patients and take care of this. I'm very excited about the new chapter.

Its Me Jen Again (51:44)
Very exciting indeed and ⁓ congratulations. Thank you so much for joining me today. Any final pieces of advice you want to throw out there? I think I know what you're going to say, Dr. Candeel, to patients who want to save their thyroid.

Emad Kandil (51:57)
What do you say I'm going to say? Tell me what you think I'll say.

Its Me Jen Again (52:00)
⁓

I think you're going to say save your thyroid if you absolutely possibly can't.

Emad Kandil (52:06)
100 % 100 % I

mean I cannot say more I mean really try to save your thyroid as much as you can 100 % we'll just give it like that yeah

Its Me Jen Again (52:18)
That wraps up today's episode. If you found this valuable, please like, subscribe, and share it with someone who might benefit.

you can find links to everything we discussed in the show notes below. Find a physician, discover treatment options, and join our patient community at saviourthyroid.org. To stay up to date on new episodes, resources, and expert insights, be sure to subscribe to my mailing list at saviourthyroidwithjen.com. It's the best way to stay connected and informed. There you can also find all podcast episodes,

and book a one-hour patient navigation consult for personalized guidance on your next steps. As always, please remember this podcast is for informational purposes only and is not a substitute for professional medical advice. No endorsement is given or implied for any specific product, treatment, or physician mentioned. As always, consult with a qualified healthcare professional for your individual needs. Thanks for listening and I'll see you next time.