Why RFA Sometimes Fails on Toxic Thyroid Nodules — And What Works Instead | Dr. Salem Noureldine

Jen (00:00)
You're listening to Save Your Thyroid with Jennifer Holkem the podcast where we explore the science and the decisions behind modern thyroid care.

Today we're talking about toxic nodules, the ones that don't just sit there, but actively pump out excess thyroid hormone and cause real symptoms, a racing heart, weight loss, anxiety, and trouble sleeping. For a long time, patients with toxic nodules only had two real options, radioactive iodine or surgery. More recently, thyroid ablation has entered that conversation.

But not every non-surgical technology performs the same way against a hyperfunctioning nodule. So while toxic nodules will be our anchor today, we're also going to zoom out and discuss microwave ablation, what makes it different from RFA at a physics level, and why that difference shows up not just in toxic nodules, but in larger or more vascular nodules. We'll also discuss how this procedure may be helpful for

To patients with pacemakers or patients who simply can't tolerate lying still for very long. To guide us today, I'm excited to welcome my guest, Dr. Salem Noureldine a fellowship trained endocrine surgeon

assistant professor of surgery at George Washington University School of Medicine

and Health Sciences, where he founded the university's minimally invasive center.

And multidisciplinary thyroid tumor board. He's one of a small number of surgeons nationally with a focused practice designation in thyroid and parathyroid surgery from the American Board of Surgery, and he currently serves as vice chair of NASIT's Guidelines and Statement Committee. Dr. Noureldine welcome to the show.

Salem Noureldine (01:47)
Thank you for that kind introduction and and for having me. It's truly an honor to be here and have the opportunity to speak with you and your audience. I look forward to our conversation.

Jen (01:59)
Absolutely. And let's just start off by kind of getting into your background a little bit, and tell us about what drew you to endocrine surgery and ablation specifically.

Salem Noureldine (02:12)
I'm gonna date myself here and a lot of the people that I've worked with because this actually goes all the way back to when I was a medical student. around 2008, I did an away rotation at Tulane University, and I remember being told go to OR-15, and there was a surgeon who turned out to be Emad Kandil doing an adrenalectomy, and then he performed a thyroidectomy afterwards.

and I still remember that day because I just fell in love with the anatomy, the finesse of endocrine surgery. These operations are where like millimeters really matter and there's

something about the precision that really drew me in. It made me want to learn everything I could about the field.

as much as I can. So after medical school, I dedicated time and I spent time in Dr. Kandil's research lab. And that later led me to Dr. Ralph Tufano's lab

Jen (03:10)
Mm-hmm.

Salem Noureldine (03:10)
at Johns Hopkins. And that's where my interest in ablation started. It was around 2013-14. one of the projects we were working on involved using high-intensity focused ultrasound to ablate thyroid tissues in pigs.

at that time it felt very futuristic, but we genuinely believed that some sort of or some form of ablation was going to become part of the future of thyroid care. At that time there was already growing data showing that selected small cancers could safely be monitored rather than removed. but we also knew that simply telling somebody you have cancer.

But we're gonna watch it isn't psychologically easy for everyone. And we were seeing that in the breast cancer literature where some women were choosing much more aggressive extensive surgery than was oncologically necessary. So we felt that ablation offered a viable kind of middle ground option.

I went through general surgery residency and throughout training, nothing gave me the same sense of satisfaction as endocrine surgery. I went to Cleveland Clinic to do my endocrine surgery fellowship. And by then the technology had really evolved. Dr. Eren Berber was one of my mentors there when I was doing training, and he was beginning to perform radio frequency ablation of thyroid nodules. So it was kind of an almost full circle for me.

I had gone from working on experimental thyroid ablations in the lab years earlier, and now I'm seeing it actually being done to treat patients. when I was recruited to GW in Washington, DC, to build the endocrine surgery program, incorporating thermal ablation into my practice felt like a natural progression.

I've now been performing radio frequency ablation for about three years.

and microwave ablation for about a year and we're continuing to explore newer technologies, including potentially nanopulse therapy. so for me, ablation wasn't just something I suddenly discovered. it was something that I've been working on over the years. It's really been part of my academic and surgical journey for more than a decade.

Jen (05:23)
It's so exciting to hear doctors saying this because, you know, it's been seven years I've been in this space. the vast majority of the doctors that I've met in this world, they came to ablation after many, many years in practice. And it was something they had to kind of reorient their thinking and their perspective, right?

And you are the second doctor that I have interviewed who actually learned about ablation during their training and and and those times before they actually started practicing medicine. So I think that's great. And I think that that's what we're, you know, hopefully gonna be seeing more and more of in the future is that this is gonna become normal. This is not

Salem Noureldine (06:00)
Mm-hmm.

Jen (06:00)
gonna be some, you know, unique or fringe considered type of treatment option. It's gonna be normal and expected and

have more and more of in physician training. And, you know, I think that the fact that you're working with NASIT, the North American Society of Interventional Thyroidology, is just kind of a a testament to that. You know, this is an organization that is solely dedicated to the promoting of these ablative and non-surgical treatments for thyroid nodules.

You're the vice chair of the guideline and statements committee. Tell us just real quickly, what does that mean and and and why are you doing that?

Salem Noureldine (06:38)
Yeah, so that's something that I've been working with my chair, Chelsea Baldwin, who's another physician and endocrinologist who does these technologies. And our goal is to identify areas where there are question, like how should we proceed with nodules that are indeterminate? Are those

for ablation or not? Which ones can we? how can we make the procedure safer?

Coming up with the expertise that we have from NASIT to write statements or help you know a group of physicians to come up with these guidelines, statements, recommendations to guide people who are interested in doing these procedures to learn how to do them and two always come back and improve our techniques, learn how to compare results and go from there.

So it's been an exciting journey over the past year. We're working on multiple projects and we look forward to for them to come to fruition for our patients and and physicians to see.

Jen (07:39)
That's so important. I think one of the hesitancies some doctors who are considering adopting ablation to their practices, they're looking for those kinds of standards, right? those statements and guidelines that you're forming. So I'm really glad that y'all are working on that.

well, now that we've kind of introduced you to the audience, let's move into talking about toxic nodules. These nodules are a different problem. so explain to patients, especially the new viewers who may not even know what in the world is a toxic nodule, how they're different than just a regular nodule that's just sitting there not doing anything.

Salem Noureldine (08:12)
Yeah, a toxic nodule is simply a thyroid nodule that has become overactive. Instead of listening to the normal signals from the brain, to tell the thyroid how much hormone to make, the nodule starts working on its own and producing too much thyroid hormone for a patient. That matters because we're no longer treating just a lump in the thyroid.

We're treating a lump that is actually affecting the whole body. Too much thyroid hormone can cause a racing or a regular heartbeat, sometimes called AFib, tremors, trouble sleeping, weight loss, heat intolerance, and over time can affect the heart and the bones. So when I think about treatment, I kind of have two goals for these toxic nodules.

One is control the excess thyroid hormone and to treat the nodule that is causing it. That's why the conversation is a little bit different from a typical benign thyroid nodule, where we may simply watch it or treat it because its size or the symptoms that it's causing.

Jen (09:17)
aren't toxic nodules nearly always benign too?

Salem Noureldine (09:20)
Yes, they are almost always benign, you are correct.

Jen (09:23)
Mm-hmm.

Which is one advantage that you do have with a toxic nodule in the mix with all of those other terrible side effects that you're dealing with when you have a toxic nodule I've interviewed lots of patients who talk about like their hands were shaky and they were just sweating all the time and they felt anxious and their hair was falling out and they just felt terrible. That's not a way to live. so you know, when you're seeing a lot of patients that have toxic nodules.

What would you say primarily is the the biggest concern that they have? I know your concerns, which you just mentioned, but what are their concerns that they're most often mentioning?

Salem Noureldine (09:58)
A lot of the patients that I see that have toxic nodules, that have concerns are usually in two age groups. The young patients are worried of having the hyperthyroidism that is caused by these nodules for a long period of time, that it's gonna affect their bone metabolism, their bone health, and they're gonna end up with osteoporosis or old lady bones when they're

Jen (10:22)
Hm.

Salem Noureldine (10:22)
already in their 30s and forties.

And that's their main concern. And then we have the older patients, the 60, 70, 80 year olds that develop these nodules, and then they worry about developing a fib, needing a blood thinner for the rest of their life, causing heart problems, strokes, and whatnot. So it's kind of two groups with two different concerns, but very important

Jen (10:47)
You know, I just thought about something. knowing someone who has AFib, I wonder how frequently when someone presents with AFib, especially an elderly person, how frequently they screen them for these toxic nodules. Do you think that that's that's a common

Salem Noureldine (11:02)
Yeah.

Jen (11:03)
thing that they screen for?

Salem Noureldine (11:04)
I w I wish like it was always. if you look

Jen (11:07)
Mm-hmm.

Salem Noureldine (11:07)
at the textbook, it says that you should check thyroid function. I

Jen (11:12)
Mm-hmm.

Salem Noureldine (11:12)
can tell you I have seen over the years many patients that realize that they're hyperthyroid after they've had complications from having AFib, been on a blood thinner for many years, and getting an ablation of the heart to try to control the afib but it doesn't work because that's not where the problem is.

Jen (11:33)
Mm-hmm.

Salem Noureldine (11:33)
And then

a year or two later, they're like,

it's the toxic nodule, the hyperthyroidism. Now you have to backpedal and okay, now we have to treat that and then get them off of the blood thinner, get them off of the beta blocker, and you know, I wish it was done for everybody, but sometimes

Jen (11:49)
Yeah.

Salem Noureldine (11:49)
it's not.

Jen (11:50)
Wow. Yeah. It's important to be an informed patient when you're dealing with these things. Well, so let's talk about microwave ablation then. because you started with RFA and then you added microwave. And so there's a bit of a difference between these procedures. So kind of explain to us how they differ because my understanding is that, you know, from the outside looking in, a procedure wouldn't really look that much different.

Between

RFA and micro.

Salem Noureldine (12:17)
Correct. from the outside it's a similar setup, it's a similar technique, it's a similar needle, it's the similar sound that these machines make. So from

Jen (12:29)
Mm.

Salem Noureldine (12:29)
the outside, it's it's really almost the same. the difference is how heat is generated with these technologies. with radio frequency ablation, the heat is generated by an electrical current.

That passes through the tissue to generate heat. Whereas with microwave ablation, heat is created directly in the tissue as a result of the friction that happens from that antenna in that tissue. So it's direct heat in that area rather than a current traveling through the body. So that's why with microwave ablation, heat gets generated faster.

it gets generated to higher temperature and that allows ablation of larger zones and makes it you know easy to use and preferable for large nodules or nodules with certain specifics.

Jen (13:19)
Yeah. My nodule when I had RFA back in 2019, you know, microwave ablation wasn't yet available. And my nodule was quite large, actually. It was between 65 and 75 mls. And now that I've learned so much over the years about these different procedures, I think probably microwave would have been a faster procedure for me because my procedure took about two to three hours. now, granted, it was in an academic setting, my doctor was presenting to

people who were observing, you know, it wasn't your standard just run-of-the-mill RFA procedure, but definitely let's talk about faster procedure times when you're treating with microwave in in comparison to RFA.

Salem Noureldine (13:57)
Yeah, because the antenna generates heat directly in the tissue that you're ablating, it overcomes a lot of the specifics that the nodule has, mainly the vascularity of the nodule. if you think of the vascularity of the nodule, it's just like a cooling system. So it's really trying to counter the effects that we're trying to do, which is generate enough heat in the thyroid nodule.

So that we get irreversible damage. And irreversible damage happens when we're able to raise the temperature in that tissue to a certain degree where we don't cause some damage that the body can heal, irreversible damage to allow the cells to essentially die.

with microwave ablation, because the way that this technology works, it overcomes that

Cooling system that some nodules have, vascular nodules, where we call it the heat sink effect, where that blood flowing through the nodule is always taking away that heat from the nodule. So it allows us to generate the desired effect in that nodule. It allows us to treat the nodule, take away the blood supply faster in a larger zone.

So we're tend to move in ablating that nodule faster. And if you look at studies, it's shown that we can achieve that twenty to fifty percent faster than traditional radio frequency ablation.

Jen (15:23)
Hmm. And can you explain the treatment zone size difference between RFA? I know RFA probes have different treatment tips that will treat different size zones, but can you kind of give us a sense of the difference in the treatment zone? and just for the viewers who may not understand what I'm talking about, let me get out my little my little visual aid. So this is this is a thyroid.

And this is a my pretend probe, right? And so the tip of this probe right here is going to get hot, whether it's microwave or RFA. And I stick it in through the center, which is the Isthmus, and it goes into the lobe inside the thyroid. I'm not sticking it inside the thyroid. And then there's a zone of ablation around the tip, and it varies in size. So tell us about that zone of ablation.

Salem Noureldine (16:11)
Yeah, so with RFA

radio frequency ablation, that zone, whether you use a smaller needle size or a larger needle size, really is about two millimeters away from the tip of that needle. So if you have a smaller one, it's just two millimeters away, it's very close to that tip of the needle. the part that's lateral wider.

from that tip gets ablated with passive ablation what we call meaning that after you ablate that area the effects can spread around the tip of the needle to a wider zone about five or eight millimeters but the main ablation that we're getting is about two millimeters three millimeters around the tip so you have two components the active ablation

And then with time, you have the passive ablation. and usually the temperature is higher in the active area, and then

Jen (17:06)
Mm-hmm.

Salem Noureldine (17:06)
it's lower in the passive area. With

Jen (17:08)
Okay.

Salem Noureldine (17:09)
microwave ablation, that area where it's generating the ablation zone is wider, it's about five to eight millimeters. So you're

Jen (17:17)
Wow.

Salem Noureldine (17:18)
covering a larger area around the tip of the needle.

And you're generating higher temperatures for a wider circumference.

Jen (17:26)
Okay. Yeah. So I kind of envision that being sort of like if you were to compare a like a marker, you know, marker with a with a small tip versus a marker with a wide tip, and you're coloring in this area that you're treating, you're gonna be able to color in your your circle a lot faster if it's a big circle with that larger tip. So and we talked a little already about the heat sink effect.

And these toxic nodules, don't they tend to be more vascular and have more of this problem with the heat sink effect?

Salem Noureldine (18:00)
Yeah, toxic nodules are inherently vascular. they draw a lot of the blood supply, and that's what causes them to grow, and that's what causes them to secrete a lot of these hormones that affect patients. So they are very difficult to treat because of that. And that's why if you look at the data, yes, RFA and traditional ablation has been effective in those patients, but

We tend to need to treat it multiple times to really treat those areas because we realize that sometimes we're not able to achieve that irreversible damage. yes, we do ablate, but we still see some viable portions of that nodule on follow-up of those patients. And their blood work kind of correlates. They have some improvement, but they're still hyperthyroid.

Jen (19:23)
the viable tissue component is really important. we have a lot of patients who ask, why did my nodule grow back after a treatment? And you know, one of the things that was really explained to me by my doctor when I had RFA was that he was very diligent to make sure he got as much of the viable tissue as he possibly could because any remaining viable tissue can grow. And so,

That's definitely important when you're looking for that complete ablation, as much of an ablation as is possibly attainable. Tell us now about we were talking about the difference between RFA and microwave and the energy, but specifically about the grounding pads that are needed with RFA, why those are there, and then maybe why you don't need those with microwave ablation.

Salem Noureldine (20:10)
That's a great question. so the way that the technology works with RFA, as I said, it's a current that travels through the body. It starts where the probe is, and then that current needs to exit the body. So that's why patients have grounding pads on their thighs usually when we're doing these procedures, so that that current can then exit the the body, and then you know it's kind of a circle happening. So that's why patients who undergo

radio frequency ablation, we one need them to be wearing shorts or have them change out of their pants to put those grounding pads. But more importantly, not to have any metal piercings, jewelry that they're wearing because that is a source where that energy can escape and it can cause burns. So that's why we tell patients when you come in for these procedures, keep your jewelry at home, don't wear any

earrings, if your bra has a metal wire or metal clips, try to avoid that. Wear a sports bra, is because we don't want that current to travel in not through the the the grounding pads and through the jewelry that would cause burns. Luckily, that rarely happens, but we do see it a lot of times in surgery when we use something similar called a bove, which is a pencil that generates.

Heat to cut tissue. If patients have that, they can cause burns and and we we do sometimes see that in the hospital. Whereas with microwave

Jen (21:40)
Hm, interesting.

Salem Noureldine (21:42)
ablation, it's an antenna, it's a different type of system, and it just directly generates heat. there's no current traveling through the body. so that's why my patients, you know, just come in with their dress clothes, they don't have to change. We do the procedure and then they walk out. So

From an efficiency standpoint, it's you know it's good. And then the other thing, patients don't have to be vulnerable in taking their clothes off or having those very freezing cold pads on their thighs.

Jen (22:12)
I

do remember those were very cold going. I don't remember them coming off, but I imagine they're kind of sticky.

Salem Noureldine (22:17)
Yeah.

Jen (22:18)
So well, okay, so let's walk the physics into the exam room. We've talked about this slightly already, but let's kind of reinforce how this looks day to day when you're treating patients. So because this energy is greater in microwave ablation and you're treating a large nodule, that procedure time would then be shorter, right? Because

you're not gonna have to spend as much time coloring in with little tiny tip.

Salem Noureldine (22:44)
Yeah, absolutely. The the the physics is interesting, right? But what really matters is whether it changes what I can offer the patient or make the procedure better for them. one of the most notable differences, as you mentioned, is speed. Microwave heats the tissue very efficiently, so procedures can be shorter. And I think this is a really a big deal. Cause when you ask patients who undergo these procedures, what was the worst part? It's not the needles.

It's not the pain, it's not the popping sound, it's the extended period of laying flat or the neck tightness from extending the neck. That's always there's like, yeah, I, you know, I that was the worst part of it. So that advantage can be very meaningful for someone who has difficulty lying flat for an extended period of time because of back pain, neck discomfort, anxiety, or other physical limitations. I also

Jen (23:35)
Mm-hmm.

Salem Noureldine (23:36)
think about

microwave when i'm treating larger, particularly vascular nodules, because I'm able to generate higher, more consistent temperatures that are less affected by that heatsink effect that we talked about. And toxic nodules are probably the clearest example of that where that benefit is because how vascular they are and with RFA achieving enough destruction of the functioning tissue can sometimes require

As we said, more than one treatment. In my practice, I just found that with microwave, I can achieve normal thyroid function after a single treatment. And

Jen (24:11)
Wow.

Salem Noureldine (24:12)
that's been the most compelling difference in my own practice. And of course, I'm still building and comparative data. And I wouldn't say that every toxic nodule should be treated with microwave or that one session is guaranteed. There

Jen (24:25)
Mm-hmm.

Salem Noureldine (24:26)
are some very simple kind of practical differences.

As we talked about, then you know, no grounding pads with microwave. So it's a little bit of a less of a setup. Patients don't have to change out of their clothes or before uncomfortable in doing so. So I don't think that you know, microwave is really a replacing RFA. I think of it as having another tool in the toolbox, you know, the size, the vascularity, the location, the function of the nodule, as well as the individual patient.

Help me decide which technology will likely give them the best results with the least burden to that patient.

Jen (25:03)
Absolutely.

Yeah. And so as you have different tools in your toolkit, RFA, microwave, and hopefully soon nsPFA, let's kind of talk through your decision making for a particular patient, which procedure would be right for them.

Salem Noureldine (25:21)
Yeah. I actually use an analogy for this that came from my son. I was preparing for a talk on thermal ablation, you know, the different techniques for the American Thyroid Association meeting I think one or two years ago, and a picture popped up on the Alexa screen that I have next to my desk of my son. he was two or two and a half at that time, and he was playing with one of those children's shape sorter toys.

where you have to put the circle through the circular opening, the square through the square, and so on. I ended up using that picture as my summary slide because I thought it captured exactly how I approach thyroid ablation The patient is the shape sorter box, and my job is to find the shape, the technique or the technology that fits that particular patient and that particular nodule.

I don't try to force every shape through the same opening. I started with RFA three years ago and now microwave and as you said, hopefully working towards getting nanopulse technology soon. but in my opinion, having more tools doesn't mean that the newest technology automatically becomes the best one. It means I can be more thoughtful about matching the technology to the problem I'm trying to solve.

And for example, toxic nodules increasingly push me towards microwave because you know they're often very vascular. I want to achieve a complete ablation as possible as I can. And ideally in a single treatment. For benign nodules, RFA remains an excellent option with a long track record and a very robust body of evidence behind it. If it's on the larger side, microwave allows me to treat it faster, and patients like that.

there are also those special considerations. you know, somebody with a pacemaker or another implantable device, for example, microwave is attractive because it does not rely on electrical current traveling through the body, such as RFA. So there's no risk of damaging those electrodes, the wires that go down to the heart, the device itself.

You don't have to do these procedures in the operating room. You don't have to interrogate them, have it an anesthesiologist, because the technology is different. Dr. Kandil and I published that we can do RFA safely and there's an algorithm for it, but I'm still able to do these procedures in the office without needing or worrying about the pacemaker with microwave ablation.

Jen (27:52)
Hmm. And when would you say somebody is completely ruled out for any of these procedures? And what would maybe point them back towards radioactive iodine or surgery?

Salem Noureldine (28:03)
Yeah, if I'm concerned about a cancer, if I ablate a nodule and then over time it grows, I want to make sure that there wasn't a mutation or something that was causing it that we missed. if I think that the nodule can't be safely accessed without putting critical structures at an unacceptable risk, if the whole gland is enlarged and it's not just one nodule is the culprit.

if patients have many toxic nodules, it's not just one. Or don't think that ablation will reliably solve the patient's hyperthyroidism or their symptoms. and I shouldn't force ablation just because I can do it. in those situations, the right answer may still be radioactive iodine or surgery. but having you know RFA, microwave, nanopulse,

Isn't about choosing a favorite technology. It's about having enough you know, different shapes in your toolbox that I can find the one that best fits the patient sitting in front of me.

Jen (28:57)
Very

good. Well, for someone who's considering any of these procedures, what what should they expect walking in? What do you wish more people knew when they come into your clinic to talk with you about this?

Salem Noureldine (29:10)
Yeah, I think most patients are surprised by how straightforward the experience it actually is. You're awake for the procedure, we use local anesthesia to numb the neck we're usually talking through it. most patient feel pressure or movement, but very little to no actual pain. In fact, afterward I frequently find or hear that patients tell me that was much easier than I expected.

Jen (29:36)
Mm-hmm.

Salem Noureldine (29:36)
also a recovery process that I think patients should understand. During the first week, the nodule may actually feel a little swollen

Jen (29:45)
No.

Salem Noureldine (29:45)
rather than smaller. And that's normal. We've intentionally created an inflammatory response inside the nodule. So after that first week, that swelling will start settling down, and then the nodule gradually starts shrinking.

you'll probably start noticing some reduction between one to three months, but it continues to shrink, you know, six months into a year after the procedure. For toxic nodules, there are really kind of two timelines that we're watching: the size of the nodule and then the function of the nodule. We may start seeing some meaningful changes in the thyroid blood work within maybe two or three months after the procedure.

Which would then allow us to begin reducing those antithyroid medications that are trying to stop some of that thyroid hormone overproduction. And over the following six months to a year, many of those patients eventually come off of those medications altogether. And more importantly, because we're preserving normal thyroid function rather than destroying the entire gland or affecting the normal thyroid tissue, it's very uncommon for these patients.

To go on to need thyroid hormone replacement therapy after these procedures. Another thing that I wish patients knew is that the technology is only part of the equation. The experience of the person holding the probe, in my opinion, matters tremendously. Patients often ask me, like, how many ablations have you done? And that's certainly a reasonable question. But I don't think it's the most important question. I would also ask.

How long have you been doing your own ultrasounds? Do you do your own biopsies? Because ablation is really a culmination of all of those skills. Have to understand the anatomy in three dimensions on ultrasound. Know exactly where your needle is at all times. Understand how the nodule relates to the nerve that goes to your voice box, the trachea, the esophagus, blood vessels, know how to protect those structures while you're treating the nodule as complete as possible.

I think an important question to ask are what's your volume reduction rate? Are you closer to that 40 50% or no? Are you closer to that 70 80%? How many times do you need to ablate a thyroid nodule to get to those numbers or to get to somebody to a euthyroid normal thyroid state? And again, whether we're talking about RFA, microwave, or another technology, the machine doesn't perform the procedure. The proceduralist does.

And choosing the right patient, the understanding the anatomy, the experience working inside the thyroid with ultrasound guidance are ultimately, in my opinion, just as important as which technology we use.

Jen (32:23)
Those

are great questions for anyone who's considering one of these procedures. Thank you for going through those. Well, let's close out with a story about an actual patient from your practice. We're not going to reveal any personal details, but tell us about someone who underwent microwave ablation and what was their outcome.

Salem Noureldine (32:41)
Yeah, when you told me that you were gonna ask me this question, I was in clinic and I was seeing a patient that day who came to me for a second opinion. She's had a toxic thyroid nodule and she was on methimazole for approximately a year and it was discovered incidentally when she was having those symptoms of

Palpitations, losing her hair, and she was found to be hyperthyroid. And then the workup showed that she had an isthmus nodule that was causing the hyperthyroidism. That nodule was hot and toxic and lit up on the imaging studies. she was young, very hesitant appropriately about surgery, and she sought consultation with somebody who offered her RFA, which I think is very reasonable, and she underwent the procedure.

Her nodule initially was about three and a half centimeters and it went down to about two and a half centimeters. So, from that standpoint, great. She also noticed that it was going down. But her problem was the thyroid function. And she was still hyperthyroid despite giving it enough time, and her levels were not changing, and she was still requiring the methimazole. So her physician recommended that she undergo repeat ablation.

she learned about me from a friend who I had taken care of and she told her, Why don't you see Salem? So she came and and saw me. And when I did the ultrasound, I can see that yes, the nodule has shrunk compared to before, but there were those viable portions within those nodule, and then when I look at the vascularity of the nodule, it was lighting up like a Christmas tree.

In almost the majority of that nodule. So that tells me that the treatment was complete, right? The nodule shrunk. I can see the changes of ablation throughout the nodule, but it was not irreversible damage. Whereas the nodule was able to still retain that blood flow, and then the thyroid hormone was just going in and out through those

Jen (34:37)
Yeah.

Salem Noureldine (34:38)
blood channels. So I talked to her, you know, I gave her my two cents, which was

doing the same thing, the definition of insanity, doing the same thing twice and expecting a different outcome. And I

Jen (34:50)
Mm-hmm.

Salem Noureldine (34:50)
reasoned with her that I would consider doing microwave ablation. And in me, you know, it's a very sensitive area. It's just anterior to the trachea. The trachea the windpipe is very sensitive. So I thought that yes, that is the right treatment for her because I'm able to achieve

destruction of that blood flow and hopefully achieve euthyroidism or normal thyroid function. But more importantly, I had to do a lot of maneuvers during the procedure, inject cool water like material around the windpipe, around the muscle, so she can tolerate me burning those areas effectively. And when I asked her, she told me like, yeah, the first time she underwent the procedure, like some areas were very sensitive and quote unquote, that proceduralist moved quickly through them.

Jen (35:37)
Mm-hmm.

Salem Noureldine (35:37)
So that told

me like, yeah, those areas next to her windpipe were very sensitive and that's why they were not completely ablated. I was fortunate that she went with me and we did the microwave ablation. It was very successful. I did it in clinic just under local numbing medication. She did great. And then when she came to see me a month after in clinic, I was so happy. I saw that the nodules started shrinking in size and went from two point five centimeters to

Two already, so half a centimeter and just one month from the procedure. But more importantly, I started seeing that there was no vascularity left in that nodule. So

Jen (36:12)
Mm.

Salem Noureldine (36:13)
I knew that that next three months where I'm gonna anticipate that nodule is gonna continue to significantly decrease in size, that it's gonna decrease in size, and then her blood work is gonna start improving. And now we're at a point where her methimazole, she's taking it every other day. She's about two and a half months out from the procedure.

And the levels are looking good where I anticipate in three months we're gonna repeat blood work and try to decrease it even more to hopefully in six months to eight months that she would be able to come off of that medication altogether. So

Jen (36:44)
Wow.

Salem Noureldine (36:45)
again, I maybe I would have done RFA the first time, maybe now that I have more experience, I would do microwave. But again, it allows me to have options for the patient.

I know what the problem is now. It wasn't that that person did the wrong procedure, did not do a complete procedure. They did a great job. It's just that

Jen (37:02)
Mm-hmm.

Salem Noureldine (37:03)
that patient, their disease, their nodule is different and it needs something different. It needs another shape to match that patient.

Jen (37:10)
I love the shape sorter. It's such a great way to put it. wow. Well, that's exciting for her. I know she must be very excited. And, you know, nodules on the isthmus are very easily noticed for women, especially. you know, we don't tend to have a very prominent Adam's apple. And so, especially, you know, I remember when my nodule was shrinking and I started to see this notch again, I was just so thrilled. So I bet that that's

probably happening for her and I know she's probably excited about that. So thank you for sharing her experience.

for patients who want to reach out to you, Where can they find you?

Salem Noureldine (37:47)
I am at George Washington University. it's called the CMG Group. So it's the George Washington University Hospital and then George Washington University I have a practice in Washington, DC, I have two offices in Northern Virginia as well. I have a lot of information on the website. I have some

pictures of outcomes, some educational content. There's an email. Feel free to reach out to me. always happy to listen to your story. And if I can't help you, send you to somebody who will. this is all I do, and I love what I do. my goal is to give as much information to the patient. So

ultimately they can make the best decision for them and that gives them peace of mind.

Jen (38:30)
Excellent. Well, I will just tease this for the viewers. We're hoping that maybe at some point I could make a trip up to your clinic and actually film some procedures. So if you're watching this and you're curious what it looks like to have a microwave ablation procedure, stay tuned.

you so much for being with me today, Dr. Noureldine. It's been a pleasure

Salem Noureldine (38:50)
Thank you so much. I really enjoyed this I hope this information helps your followers and all our patients. Thank you.