Nanosecond Pulsed Field Ablation: Expanding the Toolbox

This transcript has been edited for clarity.

Kaniksha Desai, MD: Welcome to the Thyroid Simulating Podcast. This podcast was created in partnership with the American Thyroid Association to discuss up-to-date diagnosis and management of a wide array of thyroid diseases. I'm your host, Dr Kaniksha Desai.

Today we're diving into one of the most exciting and rapidly evolving innovations in thyroid nodule management, nanosecond pulsed field ablation technique, also known as nsPFA. This cutting-edge, nonthermal technology is transforming how we think about thyroid ablation by selectively targeting tissue and preserving surrounding structures, especially the recurrent laryngeal nerve.

For clinicians accustomed to thermal techniques, such as radiofrequency ablation or microwave ablation, nsPFA represents a fundamentally different mechanism and it's generating significant interest for its precision, safety profile, and broader applications.

In this episode, we'll break down for clinicians how nsPFA works without heat; how it reliably performs across solid and cystic nodules; and what the early clinical evidence shows in terms of volume reduction, symptom relief, durability, and the cosmetic benefits. We'll explore differences in procedural workflow compared to radiofrequency ablation and which patients may or may not be the ideal candidates for this technique. We'll also touch briefly on complications, regulatory progress, and ongoing clinical trials.

I am thrilled to welcome today's guest, Dr Ralph Tufano, an internationally recognized leader in thyroid and parathyroid surgery. Dr Tufano served as the Charles W. Cummings, MD, Endowed Professor in the Department of Otolaryngology-Head and Neck Surgery at the Johns Hopkins University School of Medicine from 2012 to 2021, and he was the inaugural director of the Division of Head and Neck Endocrine Surgery from 2011 to 2021, where he helped build one of the nation's premier thyroid and parathyroid surgery programs.

He has held major leadership roles at the American Thyroid Association, helped shape national guidelines on ablation techniques, and now is clinical professor of surgery at the Florida State University College of Medicine. He directs the Multidisciplinary Thyroid and Parathyroid Center at Sarasota Memorial Health Care System. He is currently the president-elect of the North American Society for Interventional Thyroidology (NASIT) and is a senior consultant and chair of the Scientific Advisory Board of Pulse Biosciences, where he continues to influence the evolving landscape of image-guided and ablative therapies.

With over 280 publications, his expertise and vision make him the perfect guest to help us understand where emerging new treatment of nsPFA fits into the future of thyroid nodule management. Dr Tufano, we're so honored to have you on the show today. Welcome.

Ralph P. Tufano, MD, MBA: Thank you, Dr Desai. It's my pleasure to be here with you.

Desai: Dr Tufano, for clinicians who may not be familiar, can you start us off with the basics of nsPFA? How is it fundamentally different from other thermal ablation techniques like radiofrequency or microwave ablation?

Tufano: Yes. It's distinctly different because there's no heat involved, and this is electrical energy. By introducing the electrical energy in a nanosecond modality, you're creating tiny pores in the cell membrane, the mitochondrial membrane, and also in the organelles. You're disrupting them such that there is a very natural programmed cell death, apoptosis. That is a very non-collateral-damage sort of treatment, which is really very nice when you have something that's a natural process, as opposed to thermal ablation, which is a coagulative necrosis. Then you have some collateral damage beyond where the heap continues to spread. This is very specific.

Desai: It sounds like it's really precise — that you can tell exactly where it's going to end for the treatment zone vs the thermal ablation, as you were mentioning; it goes outside the initial treatment zone and can kind of expand beyond it.

Tufano: That's right. What we can see is that there is a very defined zone at a certain energy level, and so you would have a nano-zone of 1 x 1.5 cm, and that is very specific to that area where the electrical energy is administered. You can even dial down the energy from there and make it a smaller nano-zone if you are worried about being near a structure where you would maybe not want to have too much electrical energy. Overall, this is an incredibly safe technology.

Desai: The question in everybody's mind is, how does it perform? Thyroid tissue is highly vascular and can be very heterogeneous in certain areas. How does nsPFA behave across solid nodules vs cystic nodules?

Tufano: As you mentioned, thyroid nodules are very heterogeneous, and so for the densely solid nodules, this works very, very well. We typically see about a 40%-50% volume reduction in the first 2 weeks to a month, which is really very impressive, with patients remarking very quickly about how much symptomatic improvement they have. That's really very wonderful.

Also in the elastography analysis, these nodules, unlike with thermal, remain soft and compressible as opposed to with thermal; sometimes you get a firmer, more of a scar ball there in that area. The patient still feels it. It's a very nice, immediate symptomatic relief.

We tend to see the volume reduction go through about 3 months, and for those solid nodules, we have on average about a 60%-70% volume reduction, akin to what we see with thermal ablation. Now, when we have nodules that are more complex and if there's a significant cystic component, we advise that the cystic component should be aspirated if possible. Unlike with thermal ablation, where that can be used very dutifully along the cystic wall, and you may or may not have to drain it, for this, you kind of have to do that because it's, again, more impactful for the solid component than the cystic component.

I would not advise to use it with a purely cystic process or even something that's more than 50%-60% cystic unless you could really adequately drain that cyst. Most of the volume reduction is seen very early. It’s really wonderful for solid nodules, and it remains a soft process. It's not a firm process, so the elastography indices show that this nodule remains really compressible and soft. It's very nice.

Desai: How does it perform with spongiform? I know you said maybe not so well with fully cystic nodules or over 50% or 60% cystic, but how does it do with the spongiform?

Tufano: It does very well with spongiform nodules too. We see the same sort of robust, early volume reduction with the spongiform nodules as well. Even though there may be some very small cystic components to that, those seem to not be a problem with the nsPFA.

Desai: You mentioned that the volume reduction is almost immediate in the first couple of weeks. How does this compare to RFA and microwave ablation?

Tufano: With thermal ablation, in particular RFA and microwave, we do see in some circumstances where there's a nice, robust response. Maybe you will see that in the first 3 months or so, a 50%-60% volume reduction, but usually it takes a little more time and it evolves over the course of 6 months to even a year, giving the body time to resorb some of that area of the coagulative necrosis and remodel it.

This is, I think, a much more rapid effect. Again, patients remark very quickly about this symptomatic relief, and it's really remarkable how early they say that — in the first 2 weeks to a month — that there's just been a significant change.

Desai: Is it sustained?

Tufano: Great question. We've only been using nsPFA for benign thyroid nodules since May 2024. Those were the first cases that were done. I did those cases in May 2024, and we were doing those in the office. Some limitations were at hand.

When the patients are awake, even if we give them some mild sedation or if we go ahead and give them some muscle relaxant, they still experience a little bit of muscle contraction and a little bit of an uncomfortable feeling, some more so than others. It was very idiosyncratic about their response.

Since we moved it into a scenario where we're doing it with sedation and the patient completely amnestic to our intervention, we're able to more thoroughly treat the nodule. We're actually starting to see even more volume reduction. We don't have durability for that. In those where we've had in the clinic a really robust volume reduction, at least 50%-60%, it usually is maintained.

You know why? In these nodules, we're able to more thoroughly treat the entire nodule and not worry about a danger zone, per se, and leaving unablated thyroid tissue for regrowth. Maybe with the programmed cell death, we see a more complete killing off of the cells. We know that these thyroid nodules are not just simply all cellular, that there are noncellular components to it. There maybe is not going to be a complete ablation of the nodule, but we don't see that regrowth that we tend to get concerned about in thermal ablation because, as you know, there is an area that we just won't treat, and we shouldn't treat, if we're really trying to get the patient the best overall result with the thermal ablation, and that's that danger triangle area. That concept really goes out the window with nsPFA.

Desai: You can treat right up to that capsule and you don't need that nice chunk of tissue around it?

Tufano: That's correct. I'll tell you what's really been impressive is treating toxic nodules. As you may know, with thermal ablation, we usually have a cutoff of about 15 cc, and we wouldn't want to go above that because it's really less likely to be successful, and because we can't really treat a certain segment of that nodule.

Well, with nsPFA, you're able to more completely treat the nodule, and even though you may only see a 60%-70% reduction, I have, in even up to 30-cc nodules, reliably had a euthyroid state at about a month or 2 months, and durable. This is really exciting to me. It's a game changer for me to be able to completely treat that nodule.

I have had people come see me and they say, "Oh my gosh, that needle is in a place where I would never put thermal." I said, "You're right. Neither would I. In this circumstance, not a problem." We've treated over 70 patients now with benign thyroid nodules, and I have not had one complication — knock on wood. That's just remarkable to say because I can't say the same thing with thermal.

Desai: There are complications with thermal. Can you talk a little bit about why those complications don't necessarily occur, such as nodule rupture? Have you had any nodule ruptures with this particular technique?

Tufano: Because the electrical energy, as you had mentioned before, is very specific and you can create these nano-zones, even in an animal model — and hopefully these data will be presented and also published soon — you can put the energy right next to the nerve within 0.5 mm, and you may get a depolarization of that nerve. It would stop working for maybe 20-30 minutes before it recovers. Simple neurophysiology, really, to understand that, right?

Since you're not putting heat inside the nodule, you're not having the coagulative necrosis, and that material that may be under some pressure to expand and then express through a thin capsule or maybe a capsule that's been transgressed too many times with the needle, so that you have this nodule rupture. That concept doesn't exist with electrical energy and the nsPFA.

This is probably the safest thing I do all week. As a surgeon, and you know this, anything we put into our hands when we are in the OR, if it's delivering energy — whether it's our cautery or a ligation technology — if that heat or electrical energy spreads too much, we can get in trouble. Here, this is the safest thing I do all week. It is really comforting to know that safety is just so paramount here. It's so important for us and it's so important for our patients.

Desai: I know we talked about the recurrent laryngeal nerve and using it similar to those areas, but it's the same for the trachea or the carotid arteries. There's no difference in blood vessels vs nerves.

Tufano: That's correct. Absolutely. It's very, very specific for only cellular tissue. For nerves especially, we have our ganglion way away from our treatment area, so that's important. Then the trachea and the esophagus, there doesn't seem to be any issue with that either. It's very protective of those areas.

Desai: You talked a little bit about the workflow being different in that you move the patient from the outpatient suite to a more like outpatient OR setting with a more active sedation. For thermal ablations, we usually keep the patient awake so that they can have that voice feedback, and then we can use the water-cooling effect to decrease the voice hoarseness. Do you have any of those concerns?

Tufano: Our first 38 patients, we did in the office. They were awake and they did complain about some of this discomfort. There were some idiosyncrasies. Some people fell asleep when we did it, and some people said this was the worst thing that they experienced in quite a while.

With that, we wanted them to have a better experience. What was very obvious was that no matter what we did and how much energy we were putting into the nodule, how many nano-zones we were delivering, and as close to the danger triangle or where we would expect the recurrent laryngeal nerve to be, we just didn't have any problem. Not even a temporary vocal fold weakness or hoarseness.

That gave us the strength to move it into a situation where, go ahead — you want to sedate them? Sedate the patient. You're worried about sleep apnea and that they may obstruct? Put a breathing tube in. You don't have to worry about it. That is just very comforting.

Now, the patient is asleep, they're amnestic to it, they wake up, and that's it. It's done, just like your surgery. It's a different experience. Now, if you wanted to do this in the office? Absolutely. In the office, what I would say is that it does take a little more technical skill because you do have to hydrodissect. With D5W, you want to try to create an aqueous barrier around that nodule so that the electrical energy doesn't propagate.

Not that it's going to harm the patient, but rather you don't get as many muscle contractions and you don't have the patient uncomfortable. The anterior muscles can contract, the posterior neck muscles, and then the arm, even. The brachial plexus sees a little electrical energy as it propagates out. It’s obviously safe and not going to harm it, but it's stimulating. In a way, it's sometimes disconcerting to have your arm moving a little bit as you're getting this treatment. That's why we've moved it to the scenario where we do monitored anesthesia care with sedation, or you can even do general and intubate the patient.

Desai: You talked a little bit about this electrical activity with the muscles. Does it cause any short-term muscle weakness, pain, or soreness after the procedure?

Tufano: I do think for the first, probably, 48 or so hours, the patients complain of a little bit more muscular aching than I see with thermal ablation. It usually remits pretty quickly, and I don't see them needing anything more than Tylenol or ibuprofen in that time period anyway. I do think that they probably do have a little bit more muscle soreness after.

Desai: Since you've done both of these techniques, what is the treatment time like? Is it faster to do the thermal ablation or faster to do this new technique?

Tufano: When we have the patients under sedation, it's really very fast to do the nsPFA. As you know, when we're doing thermal, we have to see that needle tip at all points in time before we turn that energy on. We have to really be very diligent about working posteriorly to anteriorly, to always reconciling that needle tip.

Sometimes, with a bigger nodule, you may not be exactly sure where that needle tip is, and you're trying to reconcile it, especially in a big nodule that may be more inferior or close to going underneath a clavicle. You're challenged by the patient anatomy. Here, because it is so safe — and I'm not saying just turn it on any point in time; no, not at all; you want to be inside the thyroid nodule — you don't have those same concerns.

With the patient, again, asleep and not moving, you're not having to manage their issues that they're experiencing. With many patients, when they're awake, we need to encourage them and say, "This is okay. This is what you should be expecting. Don't get too worked up." If you're not having to manage that, it's very quick.

Let's say, for example, I had three of these cases yesterday. The largest nodule I had was 35 cc, and it took me less than 40 minutes from the time I started to the time I finished to make sure I delivered all the energy completely to the nodule. That was a very thorough delivery of that energy throughout the entire nodule.

Desai: Do you ever have to re-treat patients? You said that most of the response is in the first 3 months. Do you come back and re-treat them after 3 months or a year if, say, you get a 50% reduction, but you start out with a 35-cc nodule and it’s still decently big even with that reduction?

Tufano: I had two patients very early in the treatment phase where, when we first started, we started on some very big nodules — 60 cc, 50 cc. We were able to reduce those nodules. When we had the opportunity, though, because they were still feeling it a little bit and they could see it a little bit, and we moved it under sedation and put it in the monitored setting, with the opportunity to do it more completely and with less discomfort, we did elect to take those patients.

Unlike with thermal, there's really no challenge in trying to get that needle back through those areas or to migrate it to different areas because you don't have that stiffness and scar that develops with thermal. As you know, regardless of what ablation technology we're going to use with these big nodules, we tell patients plan for at least two ablation sessions to try to get the desired result.

For this, the timing really doesn't matter. You can go back at 3 months, 6 months, or 12 months. Whereas with thermal, we tend to want to wait a year and let things settle out before we go back. There is really no issue with going back whenever you need to, if you needed to, with these patients.

Desai: I know we've been kind of skirting the topic, but who's the ideal patient for this?

Tufano: I think anybody who has a benign thyroid nodule, as we tend to analyze these and feel very confident that by sonography they look benign and we do our due diligence with a dedicated sonogram of the thyroid and neck to make sure the lymph nodes are okay as well, and then fine-needle aspiration biopsy cytologically is benign. That's the most confident, right? Especially two times where we can feel 99.7% confident that it's benign and that the nodule is realistically related to symptoms.

We don't want to treat benign nodules just because they exist or for an academic pursuit, right? That's not good. We want to know that whatever we're doing, there is a value to the patient. If it's a nodule that is bothersome to the patient, they feel it. And if it's realistically related to a little dysphagia or a little globus, or some unsightly view of their neck or how they feel about their neck, well, that volume reduction is going to benefit them. I think that's the ideal patient.

I do think for the toxic nodules, though, this has really opened my eyes, as I explained to you before. For anybody with a toxic nodule, I'm so convinced about this technology and its effect for these toxic nodules that I hope others will start to see this too as they start to use it.

It may be the first-line technology to treat toxic nodules. That's another really great patient population, and that's what we really know right now in November 2025. It works very well for toxic nodules, and it works well for benign thyroid nodules related to compressive symptoms as well.

Desai: For our listeners, is there any other imaging besides ultrasound that you use when evaluating these patients or do you just rely entirely on ultrasound?

Tufano: I've been doing my own ultrasound on patients since 2003. I've implored people elsewhere in the world to do their own because I knew that these technologies would evolve and we would need to be able to use them ourselves.

My ultrasound usually is all that I'll need in these circumstances to treat these nodules. Ultrasound, I think, tells you everything. As we start to think about what other disease processes we would treat, you're going to use your ultrasound to help localize the needle. You want to make sure you can see that nodule very well, you can access it, and it's in an area that's favorable.

Ultrasound is really all we need at this point in time for benign thyroid nodules, whether they're toxic or not, to plan our treatment and feel confident about going forward with our ablative therapy.

Desai: You mentioned seeing the entire nodule, so this would not be a good technique for substernal nodules or goiters? How do you feel about that?

Tufano: I don't think that any ablative technique in and of itself is going to be ideal for a substantive substernal goiter because it's very hard for you with your ultrasound to angle your ultrasound probe and see your needle tip, especially for thermal energy, as to where you're going to deliver that energy.

There's more safety with the nsPFA. As long as you see your needle, there is the opportunity to see that you can render that energy and give it to that area. There has been some discussion about substernal goiter and thermal ablation — I haven't practiced this, though, with nsPFA — we treat the obvious component in the neck and then maybe that helps to pull up the substernal compartment so it's available for treatment in the next go-around.

I would say that if you have a large substernal component and then you look at your armamentarium for other treatment options, especially if the patient's experiencing symptoms, that may still be the candidate for good, old-fashioned surgery or even another alternative, which would be inferior thyroid artery embolization, which may help in that circumstance.

It's really nice to know about all of these options, even if you don't do them yourself, so that you can let the patient know of their options and they can make a value-based decision as to what's best for them. If you don't know about them, you’re restricted to just maybe surgery, and that's not necessarily ideal for the patient or what the patient wants. When we have options, we should be able to present them, even if we don't do them, with some equipoise to the patient so that they can make the best decision for themselves.

I don't like the fact that I sometimes hear, "Oh, that ablation doesn't work. You just need surgery." That's very paternalistic and dismissive, and it's not fair to the patients because that's not necessarily true.

Desai: I'm glad we have you on here today to talk about some alternative techniques to surgery. Can you talk a little bit about size? I know you mentioned symptoms, but is there a smaller end of size or larger end of size, assuming you can see it all in your ultrasound?

Tufano: So far, we haven't said that there are any size limitations. Again, we just have to make sure the patient has realistic expectations. You and I spoke before about how, if we have somebody who has a softball in their neck and they think we're going to get it to the point of where they're going to be happy and look great after one treatment, that's not the case. We tell them to plan probably for at least two treatments so they're not disappointed.

If that's the path you want to go down, great — we're on this with you. If it's not, we have alternatives. The size for us really doesn't matter. It's a non-issue as we select the patients, really, as long as they have realistic expectations of what we can accomplish and are willing to go down the path to try to achieve the desired result that they want.

Desai: Are there any other restrictions, like neck surgeries, expanding the neck area, or patients whose body habitus limits you from doing this procedure?

Tufano: That's a great point. If a patient has had multiple cervical fusion surgeries and they can't really extend their neck, and you're having a hard time even looking at the extent of the nodule and you're thinking, How am I going to get a needle into this area and put the energy into the nodule? Yes, I think you're absolutely right. That is a problem.

I'm worried about a thick neck and a patient who can’t extend their neck, and I have a chin-to-chest ratio of about 2 cm. I don't know how I'm going to get in there. Obviously, I would prefer a patient who can nicely extend their neck and afford me the space and the real estate that I need to work very easily in that area. That is a good point. We have to be cognizant of that and look into that.

Desai: Evaluation is clearly needed. We have to consider many things when we're evaluating these patients. We talked a little bit about the complications. You talked about some musculoskeletal pain or soreness after the procedure. Is there any edema, vasovagal response, or other things that are side effects or complications of this procedure?

Tufano: I have not had any patients with a vasovagal process during or after the procedure. Patients do complain of anterior neck swelling and some tightness in their neck. Much like with thermal, we advocate for ice over the first 24 hours in the area, and then also Tylenol and ibuprofen to help relieve some of that.

Fortunately, we haven't had any problems, whether it's been thermal ablation or nsPFA, and I know some people are concerned that, with nsPFA, you may not have the ability because it's not heat to coagulate vessels, for example. We haven't had any problem with hematoma or bleeding inside a thyroid nodule that would be causing a problem.

I've been very happy with that, and that it's pretty much the same that I've experienced with thermal ablation and that nsPFA has been the same. I was a little worried about that initially, but it hasn't been a concern. No, not much more than that.

Desai: To transition out a little bit, this is an FDA-approved technique, but can you talk a little bit more about the regulatory process? Is there anything left that needs to be done regarding this new technique?

Tufano: No. The technology is FDA-approved for soft tissue ablation. There's not a specific indication for this disease process or that specific disease process. Electroporation has been used by our interventional radiology colleagues for quite some time. From that standpoint, there are some other things that we do need to better understand as far as how the technology fares with different disease processes that we face.

For example, I'm very interested in seeing how this technology fares with small papillary thyroid cancers, or recurrent or persistent nodal metastases, differentiated thyroid cancer nodal metastases. Probably the next step for us is we're hopefully going to have a trial open pretty soon, where we will take some of these small papillary thyroid cancers, low-risk cancers, and see how the technology works for patients as we enroll them in a trial to see the efficacy and safety in that situation.

Desai: You're openly taking patients for a clinical trial for low-risk papillary thyroid carcinoma currently?

Tufano: Not just yet, but sometime — hopefully soon.

Desai: We'll be on the lookout for that. Have you ever used this for parathyroid disease? It works really well for that toxic adenoma, so I was just curious how it would work in the setting of hypercalcemia.

Tufano: I love the way you're thinking because that's what I thought. If it works for something that is densely cellular, making a large amount of hormone and revved up, wouldn't that work for parathyroid? I mean, we hypothesize that it should work.

Let's remember, though, when we have a toxic nodule, we've done everything that we can to make sure that we're impugning that toxic nodule as the cause of the problem. We rule out a diffuse process and we do an uptake scan, and we do antibodies and thyroid function testing. We're pretty specific about that.

You and I know we can pick a parathyroid gland and it looks like it's going to be the correct parathyroid gland, we treat it, and maybe the PTH doesn't drop. We can't impugn the technology if it doesn't drop because what if there's multigland disease? This has to be a carefully crafted study, but I like the way you're thinking.

I'd love to try it where maybe an ideal candidate would have primary hyperparathyroidism, two scans, colocalizing maybe an inferior parathyroid gland, very accessible, and seeing what happens in that situation. I think that would be an ideal candidate, and I'm as excited as you are to try to do that and maybe start thinking about a trial for that one as well.

Desai: I'm going to put an even more interesting clinical scenario out there. Nobody's a fan of surgery during pregnancy. Can this technique be used in pregnancy, if needed? In extreme situations, of course.

Tufano: Right now, as you know, for our thermal ablation, we're not supposed to use it while a patient is pregnant. The company, again, indicates that this technology should not be used while a patient is pregnant. We could debate whether this technology is actually unsafe, but what happens, obviously, in our society is that it's better to take the safest path, and so to say just don't do it when the patient is pregnant.

We haven't found, luckily in our field, many situations where we really had to dive in to do something while the patient is pregnant. For now, the line from the company is to say, we don't want this to be done when the patient is pregnant.

Desai: Talk to me about training or credentialing. What kind of training do you need for this?

Tufano: First and foremost, for any ablative therapy, you have to be excellent in ultrasound. As you and I know, you can go to your medical professional societies, such as the American College of Surgeons or American Academy of Otolaryngology-Head and Neck Surgery, and go through an ultrasound training course.

That is really essential because, from the ultrasound, all the appropriate decision-making for the intervention or what type of intervention you're going to make comes from that. Certainly, as you are manipulating your needle through the neck, you want to have a high-level acumen of surgical and neck anatomy. You want to be able to be really excellent at ultrasound.

From there, there are opportunities to see people who practice ablation, and you certainly have opportunities to go to courses that have ablation at hand for using it on phantoms or possibly cadaver. There are many opportunities there to get experience.

I also think that performing fine-needle aspiration biopsies helps you to really get dexterity with both hands and be able to work seamlessly in the neck in this way. Right now, we don't have any official credentialing. I don't know where we are going to go with that, but I think many of us are very responsible.

We do our due diligence, becoming excellent in what we try to do. Ultrasound training, phantoms, cadavers, having a few dry runs, and then maybe starting to introduce this to your patients and your practice. I think that's just very prudent and we should continue as we've done probably with other things that we've done, other technologies, other surgical interventions that we're doing, to try to become expert at them as well. Just make sure we practice, practice, practice as much as possible.

Desai: Talking about practice, is there a certain number of cases that make you proficient? We always like to say high volume for surgeons or high volume for procedures. How do you feel about that?

Tufano: Again, with the nsPFA, because the safety profile is so remarkable, I don't feel as strongly as I do with thermal that you have to be so rigorous. Thermal is really incredibly operator dependent. You have to know where that needle is, you have to get it into the right areas, you have to safely administer the energy, and you have to know when it's on and when it's off.

It's very critical to be exceptional as an operator in that area. That's why I think with nsPFA, if I were going to train my residents or fellow to start this field just to get some initial experience, with the safety, this is probably the best way to go because since the technology is so safe, you have a little leeway.

Not that that's ideal, right? But at least because you know it's protective and not going to hurt those other structures, there's a little more leeway to learn about the process and learn to become adept at maneuvering through these nodules with your needle, finding the area, and localizing with your ultrasound. Then if you needed to advance for a little more precision with thermal, you would have this practice. I think this is an excellent way to get started in ablation. I really do.

Desai: For those who already do RFA or microwave ablation, would this be an easy transition or do you think it's different or difficult?

Tufano: It’s incredibly easy. In fact, what you probably have to overcome is the mindset of, Oh my God, I have to be careful here; I can't go to the danger triangle, I can't be too close to the capsule, or I can get a skin burn if I'm too anterior. None of that happens.

At the beginning, I found myself being a little sheepish and like, Should I really go here? Can I really go to these areas that I would never go to with thermal? You have to change your mindset because it's like, Of course I can because it's so safe and I want a more complete ablation. Especially if I'm dealing with a toxic nodule, that's the advantage, right? It's a mindset change. Once you get past that, conceptually and procedurally, there's not much of a change.

Desai: Do you see this technique eventually replacing RFA? I know it's a projection out there. Do you see a role for both of those in different scenarios?

That's a great question. We have to do the studies, and I think we have to continue to do the studies here in the United States of America to further understand the efficacy and safety of thermal ablation in our hands and for our patients and for nsPFA.

Could this be possible? Yes, of course it could be possible, but until we prove it, that's all speculation. Right now, I do think that both really have a place. I am very comfortable in treating small papillary thyroid cancers in an ideal location, typically where we would consider active surveillance with thermal ablation. Will I be as comfortable using nsPFA? We have to do the trial, right? It remains to be seen.

Desai: What are your top three takeaways for our listeners?

Tufano: One, nsPFA technology is incredibly safe, period. With safety, everything is possible. Two, it's highly effective for volume reduction in symptomatic improvement of benign thyroid nodules, and for the conversion of a hyperthyroid patient to a euthyroid patient with a toxic nodule. Three, as far as the future, I think the possibilities are endless, but we have a responsibility to evaluate the other areas where we have challenges — as you had mentioned before, and we've discussed, thyroid cancer, hyperparathyroidism, parathyroid adenomas, single-gland disease, recurrent and persistent nodal disease, and maybe even, dare I say, Graves disease. Who knows?

It's exciting because the future is in front of us, but we just have to do the work. I know our patients really value this. They are looking for options. They're looking for all of their options. Don't just tell them they need to have their entire thyroid removed.

Unfortunately, that still happens. You even see patients where you say, "Whoa — I don't know why they told you that you need to have your entire thyroid removed." At least we could remove half. I think that would be okay.

I think we can do better for our patients. When we don't have hard evidence to hit us over the head and say, "Of course you must do option number one" — what are you, crazy? When you have option one, two, and three, you should support the patient in the decision-making process so that they can make the decision that's best for them and do it without bias, hopefully.

Desai: Thank you for joining us in this important discussion about this new technique that's out there and for the patient-centered focus for treatments: Discuss all the options. I am honored to have you here to talk about another treatment option for thyroid nodules. This field is expanding exponentially.

For the listeners who are interested in microwave ablation, we have an episode previously on microwave ablation as well as an episode with Dr Hussain on RFA treatments for toxic adenomas that you can listen to. Please stay tuned for upcoming topics in 2026, including aging and the thyroid gland, and GLP-1 use and thyroid diseases.

Thank you so much.

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Cite this: Nanosecond Pulsed Field Ablation: Expanding the Toolbox - Medscape - Jan 12, 2026.