Recurrent Thyroid Cancer in Neck Lymph nodes 101: Ethanol Ablation PEI a safe alternative to Surgery.
DR.Guttler’s Comments on PEI that he has been using for over 15 years for treating recurrent lateral neck lymph node disease after neck dissection.
- A surgeon at UCLA has recommended PEI as an alternative to more surgery in this study.
- Recurrence in a previously dissected field is more challenging to treat owing to scarring and the increased risk of reoperation.
- Percutaneous techniques of ethanol PEI or radiofrequency ablation RFA have been safe alternatives.
- However the medical community is slow to embrace these inexpensive safe alternatives for thyroid cancer patients.
- Potential recurrences were confirmed with fine-needle aspiration biopsy or thyroglobulin washings. Outcomes were compared between patients who underwent reoperation and those who had PEI.
- 370 initial operations for PTC that included a therapeutic lateral lymph node dissection,
- 67/370 (18 %) had recurrence after neck dissections.
- 25 had another neck dissection, and 32 had PEI.
- PEI of lymph nodes with 200 proof ethanol injected directly into the node under US guidance.
- Also RFA seen below in this study from Korea is also a safe alternative to more surgery.
- The overall recurrence rate was the same after surgery and PEI (28%).
- PEI may be equivalent to reoperation for lateral neck recurrence of PTC.
- PEI is more effective for smaller lymph nodes.
- Get an opinion on this safe easy procedure to replace the intended recommended second neck surgery.
- Call me at 310-393-8860 or email to firstname.lastname@example.org.
Papillary Thyroid Cancer Recurrence in the Lateral Neck Can Be Treated with Surgery or Ethanol Ablation
Approximately 20% of patients with papillary thyroid cancer (PTC) present with lateral lymph node metastases (1). Compartment-oriented lymph node dissection should be performed at the initial operation to reduce the risk of recurrence (2). Recurrence in a previously dissected field is more challenging to treat owing to scarring and the increased risk of reoperation. Management strategies for lateral neck recurrence include observation, reoperation, and percutaneous techniques of ethanol or radiofrequency ablation. The current study compared outcomes between reoperation and ethanol ablation for lateral neck recurrence following an initial lateral neck dissection (3).
This retrospective single-institution study included patients who underwent lateral neck dissection for PTC between 2000 and 2015 at the Mayo Clinic in Rochester, Minnesota. Lateral neck dissection was performed selectively for patients with clinically evident lymph node metastases in the lateral neck. Patients were included if they underwent follow-up with a neck ultrasound. Potential recurrences were confirmed with fine-needle aspiration biopsy or thyroglobulin washings. Outcomes were compared between patients who underwent reoperation and those who had percutaneous ethanol ablation.
The primary end point was disease control in the lateral neck. Following reoperation, disease control was defined by the absence of suspicious lymph nodes on ultrasound. Following ethanol ablation, disease control was defined by the disappearance, volume reduction, or conversion to normal appearance of the treated lymph node. Recurrence after either treatment method was defined by the appearance of suspicious lymph nodes on follow-up ultrasound.
Of 370 initial operations for PTC that included a therapeutic lateral lymph node dissection, 64 patients were treated for 67 (18.1%) lateral neck recurrences. Follow-up data were available for 57 lateral neck recurrences at a median of 57 months. The average patient age was 52 years and 63% of patients were female. Lateral neck recurrence was treated by reoperation in 25 cases and by ethanol ablation in 32.
There was no difference in initial tumor characteristics between patients who underwent surgery versus those who underwent ethanol ablation for lateral neck recurrence. However, patients who underwent ethanol ablation were older (58 vs. 45 years) and had less disease burden (mean largest lymph node diameter, 13 mm vs. 18 mm; mean number of metastatic lymph nodes, 1.3 vs. 1.9; mean preprocedure thyroglobulin, 4 ng/ml vs. 26 ng/ml) at the time of recurrence as compared with patients who underwent reoperation. The ethanol ablation group was also less likely to receive radioactive iodine ablation following initial surgery than the reoperation group (72% vs. 96%).
Outcomes were similar between the two treatment groups. Of 43 lymph nodes treated with ethanol ablation, 20 were not visible on follow-up ultrasound (mean initial diameter, 9.6 mm), 16 had persistently decreased volume (mean initial diameter, 12.3 mm), and 7 grew (mean initial diameter, 14.9 mm). The overall recurrence rate after these therapies was 28%. Of 25 redo lateral neck dissections (including focused excision in 10 cases and redo neck dissection in 15), 28% of patients had a recurrence. Postoperative complications developed in two patients (one had Horner’s syndrome and one a wound infection). There was no difference in the recurrence-free interval or thyroglobulin reduction between the ethanol ablation and reoperation groups. Four patients underwent reoperation following ethanol ablation with no reported complications.
Ethanol ablation may be equivalent to reoperation for lateral neck recurrence of PTC. Ethanol ablation is more effective for smaller lymph nodes.
Ultrasound Image below of a recurrent thyroid cancer lymph node that was successfully ablated by PEI.