Radiofrequency Ablation Case Study: Use of Thyroid RFA for Palliative Treatment for Thyroid Cancers.
What to do with a patient with cystic micro-papillary cancer with the only good recurrent nerve on the side of the cancer after childhood heart surgery .
Patient is clinically euthyroid. She has a palpable nodular goiter.
Left lobe cystic nodule 2.48 x 3.34 x 4.03 cm 16 ml complex cyst. Not hypochoic or taller than wide or irregular margins, but with echogenic foci. A mural solid nodular area was 1.4 cm within the cyst wall. FNA positive with BRAF MUTATION.
1. Ideally she should have at least a lobectomy or total thyroidectomy. 2. But she is complicated by a right recurrent nerve injury. 3. Surgeons could do a lobectomy on the side of good nerve. 4. Nerve Stimulation and an ENT on standby for rapid treatment if the nerve is injured. 5. The right lobe removal without worry as the nerve is already paralyzed.
The left cyst with the mural papillary cancer could be treated with either ethanol PEI or radiofrequency ablation RFA procedures. 7. She is firmly against surgery on the left side of the good nerve. 8. Alternative therapy can be considered. 9. Curative RFA or PEI therapy has been reported for micro-papillary cancers. 10. However this micro-papillary is a mural micro-papillary on the 3 cm cyst wall
What is the place for Radiofrequency Ablation?
Thyroid RF approved for benign thyroid nodules could be used in cases where RFA can help treat thyroid cancer cases with co-morbidity. 2. Recurrent papillary thyroid cancer in neck lymph nodes have been treated by both ethanol and RFA. 3. Primary micro-papillary cancers have been treated with ethanol and RFA.
. She has a serious cardiac condition that requires anticoagulant and cardiac drug therapy. 2. Thyroid surgery can have more heart related complications that RFA or PEI. 3. Thyroid surgery on the lobe with the intact recurrent nerve is also more likely to have nerve injury than PEI or RFA. 4. Thyroid surgery would need a nerve stimulator and ENT on call in the OR for emergency treatment if the nerve is injured.
I suggested she consider thyroid RFA therapy if she continues to refuse surgery. This should be last resort therapy. 2. It could result in ablation of the cancer or just palliative. 3. The right lobe small nodule can be followed with ultrasound yearly. 4. The cystic nodule on the side of her good nerve could be PEI or RFA ablated.
. The anterior located mural micropapilary would be ablated with the protection of the cyst fluid and the use of hydrodissection to protect the nerve. The amount of heat needed would be less than used for solid thyroid nodules. 5-15 watts compared to 20-60 watts. 6. After ablation of the mural cancer the electrode will be placed in the middle of the cyst and ablated until hyperechoic images are seen through the cyst. 7. Follow up cutting needle biopsies can be done to see if the ablation was successful. 8. Only limited studies with PEI make it a second choice, as RFA can ablate the cancer and the cyst.
Because of the anticoagulant with Warfarin she will need a custom protocol. 2. Stop Warfarin 5 days prior. 3. Start Lovenox SubQ 80 mgs bid for 3 days prior to RFA. The last dose 24 hours before the RFA procedure. 4. Restart the Warfarin the day of the procedure in addition to the 80 mgs Lovenox BID until anticoagulant therapy is back in goal range.
What are your thoughts on this complex case?
Thyroid RFA can be used to relieve symptoms in large goiters and advanced thyroid cancers.
It can be an alternative to surgery or active surveillance for micro-papillary cancers as seen in this case study
For RFA therapy evaluation for thyroid cancers, thyroid nodules or parathyroid adenoma please call Alicia at 310-393-8860 or secure email to [email protected]