Beat a Large Goiter Without Surgery

In June 2022, Peter Miller began having trouble breathing.

The symptoms arrived in a cluster: sleep apnea severe enough to alarm his wife, heavy snoring, and then episodes of dizziness that frightened him into seeing a doctor. Miller, who splits his time between Ireland and a senior dog hospice he runs outside Atlanta, knew nothing about the thyroid. He would soon learn more than he ever wanted to.

A referral led to a specialist, then another, then another. Over six months, Miller consulted three private specialists in Northern Ireland and a fourth through the National Health Service. The diagnosis was consistent: a massive goiter, an enlargement of the thyroid gland, measuring 13.2 centimeters on the left lobe and 11.7 centimeters on the right. So was the recommendation. Five separate medical opinions, and all of them called for the same thing. Urgent surgery to remove the gland.

No one mentioned an alternative. Because, as far as the system that was treating him was concerned, there wasn’t one.

The Question No One Could Answer

Miller is not, by his own account, someone who questions doctors. “All my life I’ve been like that,” he said. “I’ve never questioned up until this point.”

But as the consultations piled up, one question kept nagging at him, and he began asking it in every appointment: What, exactly, does the thyroid do? Not partially. Completely.

None of his specialists could give him a full answer. Each acknowledged, in one form or another, that there are things about the gland medicine does not yet fully understand.

For Miller, the logic broke down right there. “It didn’t really make sense that I would remove it if I didn’t actually know what it did,” he said.

One consultation ended his patience for good. When Miller raised the possibility of radiofrequency ablation, a nonsurgical technique he had begun reading about, the specialist refused to continue the appointment. “Why would someone close their mind to something like that and not even be open to it?” Miller said. “And if they didn’t know about it, why wouldn’t they go away and just professionally check that out?”

An Article, a Search, and a Flight to Italy

Like most patients backed into a corner, Miller turned to the internet. His searches were vague. He did not know the terminology. Something like “alternatives to surgery for a goiter.”

In the first week of January 2023, one of those searches surfaced an article titled “10 Things Your Thyroid Surgeon Isn’t Telling You,” written by Philip James, a patient advocate who underwent a thyroidectomy in 2013 that he says should never have happened, and who later founded RFAMD, a global directory of physicians trained in thyroid ablation. Miller read the article three times in one sitting.

It introduced him to radiofrequency ablation, or RFA, a procedure in which a physician uses ultrasound guidance to insert a thin electrode into thyroid tissue and heat it, shrinking nodules over time without removing the gland. The technique has been used for years in South Korea, Italy, and elsewhere, and has been expanding in the United States. In the United Kingdom, it was effectively unavailable. One London specialist had stopped performing the procedure. An NHS program in Reading had lost its funding.

Through the RFAMD directory, Miller was connected with Dr. Roberto Valcavi, an endocrinologist in Italy and one of the most experienced ablation physicians in the world. Miller went in with a clear mandate: reduce the goiter by 35 to 40 percent, keep the thyroid, and preserve his quality of life without a lifetime of medication.

Valcavi reviewed his scans and blood work and accepted the case. He would later tell Miller it was the largest goiter he had treated in his career.

The timeline says something about how quickly a motivated patient can move. Miller spent all of 2022 inside a system that offered him one option. He found the article in the first week of January 2023. By the end of that month he had made his decision. By February he was in Italy for his first ablation. A second followed the next year.

The Results

Today, Miller’s sleep apnea is gone. The dizziness is gone. The breathing tightness is gone. His T3 and T4 levels are normal, his TSH slightly low but steadily improving, and his most recent blood work, done weeks before this interview, came back strong. He has lost roughly 30 pounds and can exercise again. He still has his thyroid. He takes no thyroid medication.

He has since referred three other patients from a UK forum to Valcavi, one of whom recently emailed to thank him after a successful procedure.

Miller is careful not to oversell. “RFA is not for everyone,” he said. “Some things work for some people and don’t work for other people. It doesn’t mean they’re bad. It just means it’s not the right fit.”

His complaint is narrower, and harder to dismiss: he was never told the option existed. “I’m quite happy if a specialist says to me, my opinion is you should go this way, but there are other options,” he said. “But not to be given that option is wrong.”

What Patients Should Take From This

Two lessons run through Miller’s story, and they apply well beyond the thyroid.

The first is about asking questions. Miller’s simple question, what does the thyroid actually do, reframed every conversation that followed. A doctor recommending removal of an organ should be able to explain what the patient is giving up. When the answer includes “there are things we don’t yet know,” the calculus of an irreversible surgery changes.

The second is about expertise. Not all ablation providers are equal. A physician offering the procedure in a country where it is new will not have the case volume of specialists in Italy, South Korea, Brazil, or the leading US practices, some of whom now have more than a thousand procedures behind them. For large goiters and complex cases, experience is not a luxury. It is the treatment.

Miller found something else in Italy that he had not encountered in a year of UK consultations: a doctor who would not move to the next topic until his patient understood the current one. “My experience in the UK was, this is what’s going to be done, don’t ask questions, I know best,” he said. “Dr. Valcavi understood that I was scared.”

His message to physicians is the one he wishes someone had heard in 2022. “Remember that the person sitting in front of you doesn’t know what you know, and they’re probably scared,” he said. “Just because you know what you know doesn’t mean you can’t be open to other options. It’s your duty, morally, professionally, and ethically, to offer those options to your patients.”