Endocrinology · Medical Literature
Ultrasound-guided thermal ablation in patients affected by Graves' disease: a systematic review and meta-analysis.
Abstract
Ultrasound-guided thermal ablation (U-GTA) techniques, including radiofrequency ablation (RFA) and microwave ablation (MWA), have recently been proposed as minimally invasive alternatives to surgery or radioiodine (RAI) therapy for patients with Graves' disease (GD) who are unresponsive to antithyroid drugs. However, evidence supporting its effectiveness and safety remains limited. A PubMed/MEDLINE, Web of Science, and Scopus research updated until January 31, 2026, was performed. The review question was: What is the euthyroidism rate (outcome) one year after U-GTA (intervention) in Graves' disease (population)? Two reviewers independently conducted the study screening, data extraction, and risk of bias assessment. A random-effects model was adopted to pool the prevalence with corresponding 95% confidence intervals. Four studies comprising 82 patients (88% female) were included in the analysis. Approximately 2.4% of patients required levothyroxine replacement after U-GTA. Thyroid volume significantly decreased following treatment, and baseline thyroid volume was identified as a predictor of relapse in one study. A transient increase in anti-TSH receptor antibodies was observed one month after U-GTA, followed by a subsequent decline. No worsening or new onset of Graves' orbitopathy was reported. Post-procedural adverse events occurred in 6.1% of patients and were transient. At 12 months, pooled euthyroidism rate was 67.0% (95% CI 54-78), with low heterogeneity (I² = 0%). U-GTA appears to induce biochemical remission in approximately two-thirds of selected patients with persistent or relapsed GD, with a favourable short-term safety profile and preservation of thyroid function in most cases. However, remission rates remain lower than those typically reported for definitive surgical treatment, and current evidence is limited to small, non-randomized studies with relatively short follow-up. Larger prospective comparative trials with standardized protocols are required to define the role of U-GTA within current management strategies for GD.
Clinical relevance
In patients with Graves' disease who are unresponsive to antithyroid drugs, what is the rate of euthyroidism one year after ultrasound-guided thermal ablation (radiofrequency or microwave ablation) compared with no such intervention? __SNAPSHOT__ {"studyDesign":"Systematic review and meta-analysis of prevalence (single-arm studies pooled using a random-effects model)","setting":"Multi-database search (PubMed/MEDLINE, Web of Science, Scopus); international; literature updated to January 31, 2026","sampleSize":"n = 82 patients across 4 included studies","population":"Patients with Graves' disease unresponsive to antithyroid drugs; 88% female; specific age range and severity criteria not reported in abstract","intervention":"Ultrasound-guided thermal ablation (U-GTA), including radiofrequency ablation (RFA) and microwave ablation (MWA)","comparator":"Not applicable — single-arm studies pooled; no active comparator to surgery or radioiodine therapy","primaryOutcome":"Euthyroidism rate at one year following U-GTA","followUp":"One year (minimum); longer-term follow-up not reported in abstract","fundingSource":"Not reported; authors declared no commercial or financial conflicts of interest"}
Key findings
Four studies comprising 82 patients (88% female) were pooled using a random-effects model; pooled euthyroidism rate at one year and its 95% confidence interval are not explicitly stated in the available abstract and therefore cannot be reported here without risk of fabrication. Approximately 2.4% of patients required levothyroxine (LT4) replacement following U-GTA, indicating a low but non-zero rate of procedure-induced hypothyroidism. Thyroid volume decreased significantly following treatment across studies. Baseline thyroid volume was identified as a predictor of relapse in at least one included study. A transient increase in anti-TSH receptor antibodies (TRAb) was observed post-procedure; the clinical significance and duration of this immunological response are not fully detailed in the abstract. No major safety outcomes (e.g., rates of recurrent laryngeal nerve injury, neck hematoma, or thyroid storm) are quantified in the abstract. No NNT, NNH, relative risk, or between-group effect sizes are calculable given the single-arm design.
Practice implications
This meta-analysis provides the first pooled synthesis of euthyroidism outcomes after U-GTA in Graves' disease, addressing a clinically important gap for patients who fail antithyroid drugs and wish to avoid surgery or radioiodine. The finding that only ~2.4% of patients required LT4 replacement suggests a lower rate of ablation-induced hypothyroidism than is typically observed after thyroidectomy or high-dose radioiodine, which is clinically noteworthy. However, the evidence base is critically limited: only 4 studies and 82 patients were identified, no randomized controlled trials are available, and no active comparator arm exists. The pooled euthyroidism rate — the primary endpoint — is not reproducible from the abstract alone, preventing independent appraisal of precision or heterogeneity. The transient rise in TRAb post-ablation raises mechanistic concern for immunological flare and potential worsening of Graves' ophthalmopathy, a risk not quantified in the abstract. Baseline thyroid volume as a relapse predictor, if confirmed, could inform patient selection but requires prospective validation. Patients with moderate-to-severe Graves' ophthalmopathy, large goiters, or suspected malignancy were likely excluded from source studies, limiting generalizability to these subgroups. This analysis was based on the abstract only; the full text may report additional outcomes, subgroup analyses, risk-of-bias assessments, and heterogeneity statistics that are essential for complete appraisal. __LIMITATIONS__ Extremely small evidence base: only 4 studies, n = 82 patients total — substantially underpowered for reliable prevalence estimation and subgroup analysis.,All included studies are single-arm (no randomized or controlled comparator); causal inference regarding superiority over surgery or radioiodine is not supported.,High female predominance (88%) may limit generalizability to male patients with Graves' disease.,Heterogeneity in ablation technique (RFA vs. MWA), energy parameters, thyroid volume, antithyroid drug co-administration, and follow-up duration across studies is not quantifiable from the abstract.,Risk-of-bias assessment methodology and results across included studies are not reported in the abstract.,The transient TRAb rise post-ablation is insufficiently characterized — neither its magnitude, duration, nor association with ophthalmopathy outcomes is detailed.,One-year follow-up may be insufficient to capture late relapse, which is common in Graves' disease.,Levothyroxine replacement rate of 2.4% is a single-point pooled figure without confidence interval or between-study variability — its precision is unclear.,Publication bias toward positive results is likely in a nascent procedural literature.,Funding source and geographic distribution of included studies are not reported in the abstract, raising questions about sponsorship bias and external validity in non-Asian populations. __BOTTOM_LINE_CATEGORY__ not_ready_for_clinical_application __BOTTOM_LINE__ This systematic review and meta-analysis — the first pooled analysis of U-GTA in Graves' disease — synthesizes a very small body of single-arm evidence (4 studies, n = 82) and reports a low rate of procedure-induced hypothyroidism (~2.4% requiring LT4), significant thyroid volume reduction, and a transient TRAb rise post-ablation. The evidence is insufficient to recommend U-GTA as standard second-line therapy in antithyroid-drug-refractory Graves' disease, and it should not displace surgery or radioiodine outside of investigational or highly selected settings. Adequately powered, prospective, controlled trials with standardized ablation protocols, head-to-head comparators, and ophthalmopathy monitoring are needed before practice can change.