Thyroid Cancer No More Surgery 101: Treatment #1 Ethanol Ablation of Recurrent Cancer Lymph Nodes.
Ethanol injection Percutaneous ethanol Injection Method ( PEI )
- Percutaneous ethanol injection for patients with metastatic lymph nodes is gaining interest as a nonsurgical directed therapy for patients with recurrent DTC.
- Most of the studies limited PEI to patients who had undergone previous neck dissections and RAI treatment, those who had FNA-proven DTC in the lymph node, by cytology or thyroglobulin needle washout.
- Not used with known distant metastases.
- One of the first studies examining the effectiveness of local metastatic lymph node control by PEI treated 14 patients with 29 lymph nodes. Lewis BD, Hay ID, Charboneau JW, McIver B, Reading CC, Goellner JR. 2002. Percutaneous ethanol injection for treatment of cervical lymph node metastases in patients with papillary thyroid carcinoma. AJR Am J Roentgenol 178:699–704
- Twelve of the 14 patients had good loco-regional control in this study with short-term follow-up (mean 18 months).
- The largest study to date treated 63 patients with 109 metastatic lymph nodes between the years 2004 and 2009. Ninety-two lymph nodes (84%) were successfully ablated in this retrospective study with a mean follow-up of 38 months, and most required one to three treatment sessions.Hay ID, Lee RA, Davidge-Pitts C, Reading CC, Charboneau JW. 2013. Long-term outcome of ultrasound-guided percutaneous ethanol ablation of selected “recurrent” neck nodal metastases in 25 patients with TNM stages III or IVA papillary thyroid carcinoma previously treated by surgery and 131I therapy. Surgery 154:1448–1454
- Minor complications included brief discomfort at the PEI site, and there were no major complications.
- A study retrospectively reviewed 25 patients who had 37 lymph nodes ablated between the years 1994 and 2012, with a relatively long follow-up of a mean of 65 months.All lymph nodes were successfully ablated in one to five treatment sessions by lack of flow on US. Most of the lymph nodes decreased in size and 46% completely disappeared. Serum Tg levels were reduced in most patients and brought into an acceptable range (<2.4 ng/mL) in 82% of patients with negative anti-Tg antibodies.
- There were no serious or long-term complications. Another recent study also demonstrated safety and efficacy of PEI in 21 patients with 41 metastatic lymph nodes. These investigators treated patients with only one session, and 24% of patients had a recurrence at the site of the injection.
A general consensus from studies and reviews is that PEI should be considered in patients who are poor surgical candidates. Many patients will likely need more than one treatment session and lymph nodes >2 cm may be difficult to treat with PEI. Focal PEI treatment does represent a nonsurgical form of berry picking. Formal neck compartmental dissection is still the first-line therapy in DTC patients with clinically apparent or progressive lymph node metastases. When deciding for the optimal strategy of care for a patient’s lymph node metastases, previous treatment modalities should also be taken into consideration.
[C21] Radiofrequency or laser ablation
The use of radiofrequency ablation (RFA) with local anesthesia in the treatment of recurrent thyroid cancer has been associated with a mean volume reduction that ranges between approximately 55% and 95% ) and complete disappearance of the metastatic foci in 40%–60% of the cases As with alcohol ablation, multiple treatment sessions are often required. Complications include discomfort, pain, skin burn, and changes in the voice . Similar to alcohol ablation techniques, it appears that RFA may be most useful in high-risk surgical patients or in patients refusing additional surgery, rather than as a standard alternative to surgical resection of metastatic disease. More recently, preliminary findings using US-guided laser ablation for treatment of cervical lymph node metastases have been reported.