Ethanol Ablation of Metastatic Papillary Thyroid Cancer in Neck Lymph Nodes - HD

Introduction

Hello, and thank you for the invitation.

As mentioned, my topic is ethanol ablation of metastatic cervical lymph nodes in the neck.

And for the most part, we're talking about papillary cancer.

I have nothing to disclose.

Goals of the Session

The goals of this session are to go over the very important points of patient selection for ethanol ablation, the technique of ethanol ablation for cervical lymph nodes, the potential complications from the procedure, and the importance of following up patients that have been ablated to be sure that it's adequate treatment.

And some numerical data on the how effective ethanol ablation is for cervical lymph nodes, particularly in papillary thyroid cancer.

History of Ethanol Ablation at Mayo Clinic

Ethanol ablation has a long history at Mayo and Rochester.

The first thyroid cancer patient that was ablated was in 1991.

It was a medullary cancer that was resistant to any other therapy in the neck and was treated successfully with long-term survival with ethanol.

The first papillary cancer was treated in 1993, with ethanol, and the first public series came from a Mayo and a small series of 14 patients with 29 lymph nodes.

These patients were not surgical candidates or declined surgery and were unresponsive to other therapies.

All the ablated lymph nodes decreased in size with even nine or 31% disappearing, all decreased in volume, 85% at one year and 96% at two years.

Fortunately in this group, there were no complications, no significant complications.

Of note, two patients that where the lymph nodes were, all the lymph nodes were treated, with ethanol responded.

They had additional disease occurred that did require surgery, but the lymph nodes, the particular lymph node that was treated, was treated successfully.

Key Studies on Effectiveness

One follow-up study and a larger study Norwegian and more recent from 2011 had 69 patients, which 63 could be followed in 109 lymph nodes.

They had 84% with a complete response with they defined as absence of the lymph node of follow up, or it becoming a small hypovascular scar like area four millimeters or less in diameter, 8% of theirs were considered failures with a mean observation time of about three years.

Once again, it's encouraging.

This larger series had no significant complications.

Patient Selection

So much of alcohol ablation to do it well revolves around relationships with the other doctors and patients, selecting the correct patients to treat, the patient.

A typical patient that comes to us for treatment has had two or more surgeries and has another recurrence or has had a recent surgery and has residual disease, basically potentially a missed lymph node or one that became apparent soon after surgery.

For our services that is ethanol ablation, we want limited metastatic disease in the neck.

Probably less than 10 millimeters is ideal, although we do do larger ones, and likely we'd like it less than five, but of course, patients sometimes would still want ablation with more.

So we do tread into higher numbers, especially if you consider the number of ablations we do over time.

That is patient comes on day one and we do three or four lymph nodes, and they come a year later and those are well treated, but there's three or four new ones and they still don't want surgery, and the surgeon still doesn't wanna do surgery.

And often in this age of the internet and education, these thyroid cancer patients that, particularly ones that have several surgeries, are on the internet looking for sites that have alternative treatments that are less invasive than surgery or radioactive iodine or neck radiation.

So we'll be contacted, of course.

What I would do if in all instances refer to endocrine, because we always have a team approach this, we don't do anything in isolation.

As stated, there is a close collaboration with our Department of Endocrine surgeons, oncologists and radiologists make sure we're doing the appropriate treatment, and they, the endocrine doctors really need to pull in all the data to make sure that ablation right for this patient.

For ethanol ablation, what we do, small lesions are best, which is nice because it compliments what surgeons do, in that they often treat the larger or do treat the larger lesions.

Recent TA guidelines from 2015 recommend surgery for central lesions with a short axis diameter of eight millimeters or greater, or lateral lesions greater than 10.

So this obviously is the larger side of things greater than, so the smaller lesions are have other options including ablation with thermal ablation techniques, ethanol, or even observation Treatment option.

As mentioned with small recurrences, our observation is still an option.

And many of these don't grow over time, particularly when the TSH is well suppressed.

We're in the business of might what might be termed berry picking, which to endocrine doctors and surgeons may mean go pick.

Identifying one lymph node that has macroscopic disease detected by ultrasound that we treat with ablation or RFA, also can be treated in a very picking type fashion by surgeons, but hopefully we can treat more of the smaller ones with less invasive things in surgery.

I, of course, the other options that we leave to the endocrine doctors, the TSA suppression, radioactive iodine, external beam, decide when that's appropriate.

Comparison of Treatment Options

Complicated slide, but I'd just like to sort of point out in this table that I made, the pluses are a good thing, and as we go from ethanol ablation to thermal ablation techniques to surgery, ethanol definitely wins here in the less eva side of things, shorter recovery and repeatability.

These are gonna be potentially our patients or my patient or your patient if you go down this route for years.

So as new occur, recurrences occur, at some point, the surgeon or the patient or somebody else will say no more surgery.

And as they switch to small lesions with ethanol ablation, we can repeat this.

There's no limit how much we repeat it.

Basically, we've had patients with more than 20 recurrences over many, many years that we've treated and controlled.

So the repeatability aspect of ethanol is one of the gold star things.

The build cost is less, that's a good thing.

But the bad part about cost is you, I would suggest pre-approval since it's more likely to be turned down as possibly experimental or unproven by an insurance provider.

It's getting better over time.

And as we write letters back to the insurance company and people that make decisions about whether things will be paid, it is getting fairly well reimbursed routinely, but there's still, it's not universal.

So I would suggest pre-approval for any patient, that's a to get a bill after three or four weeks for a big number is shocking to the patient, then obviously sets some in motion, a lot of letters back and forth.

So pre-approval, I would suggest no, of course, there are obviously advantage of the surgery.

It's complete removal, it comes out and they can see that the whole thing's removed and therefore there's less imaging follow up, less need for re-treatment.

As I will mention later, these lesions have to be filed to see if they need additional treatment and follow up.

But keep in mind that surgery and these more focal things like RFA and ethanol ablation are really complimentary.

Ideally, we get if the patient is gonna have treatment on a small lesion, ethanol or RFA or possibilities and ethanol more at our institution than RFA and larger lesions to go to surgery.

We often worked with the surgeons too.

If they patient has disease at more than one site, they perhaps they would do.

The central compartment that has bulkier disease and not wanting to open or in size, a second compartment laterally will treat the lateral disease with ethanol.

So they're really more complimentary than competitive.

Technique of Ethanol Ablation

The treatment is simple.

We just slowly inject 98% alcohol into the tumor.

Tend to treat the deeper areas first, so the microbubbles from the etol do not obscure the more superficial treatment that comes later.

Of course, you wanna inject slowly so you can watch it disperse in the nodule, and if it's not dispersing, well readjust the needle.

Or if you start seeing leakage from your needle track or elsewhere repositioning your needle, again, the goal, of course, is to treat the whole nodule, cover it at one time, at least one time during the course of your treatment with microbubbles and eliminate the visible blood flow as detectable by color Doppler, we use small needles, 25 and 27 gauge.

Usually use a one cc syringe so we can control the injection rate best and high resolution ultrasound, of course, continuously monitoring it.

Of course, these are simple and now becoming less and less expensive.

And with those combination things has become a more and more common practice in the endocrine world too.

You could see an outpatient visit and treatments happening more based on my conversations with the endocrine doctors from other places.

Just a simple ablation of a small lesion.

The needle's placed in the middle and you light it up with ethanol.

It contains microbubbles so it does brighten up and become white.

This is of course the ones we like.

Nice, small, central or nice small lesions.

It take very little alcohol to whiten up.

And then once they beca have been saturated and ethanol, the blood flow does go away.

It sclerosis arteries and veins.

A larger lesion that takes more repositioning, more ethanol, you'll see the ethanol dispersed at different spots.

As the needles moved around, you'll see there's a little leakage back toward the needle track that that's toward muscle.

So it's not as concerning for as leakage toward deeper structures and nerves.

But that's something that when you see leakage along a needle track or outside the tumor, that's the time to reposition the needle and make sure all the alcohol that you can stays in the tumor.

Potential Complications

In general, it's a very well tolerated procedure.

As mentioned in the prior more older studies, there was no significant complications reported in those series that were around a hundred or around 30.

Most people are have a little focal swelling at the complica or at the treatment site.

And sometimes, or it's actually more than fairly frequently, patients will report referred pain in unusual locations like their teeth and sinuses and the top back of their head, in their chest and arms.

You know, the neck is a nerve rich area, and this referred pain isn't surprising, but fortunately it only lasts minutes.

I've had no patient have prolonged referred pain.

There is a risk of nerve damage.

The first two series reported no significant complications.

But there we have had since then, the rare patients has recurrent laryngeal nerve damage and hoarseness.

It's usually transit, but not always.

There's at least two that are permanently hoarse from ethanol ablation and had to implants to improve their hoarseness, but there is potential damage to any nerve that's in the vicinity.

For a while there, all the significant complications were that we had, that I had were hoarseness temporary usually.

But then as you do more and more at different locations, we've had two horner syndromes from a synthetic ganglion chain injury, one phrenic that was temporary, and there's always a potential for other nerves to be damaged, although I don't know of any vagal damage or bra plexus permanent damage from the procedure to minimize those risks.

We use the minimum amount of alcohol necessary and keep the amount of, keep the alcohol in the tumor as best we can.

One, I would say trick or one way to select patients that may have recurrent laryngeal nerve damage.

Before the, before you inject alcohol, it is injected tumor of local anesthetic.

If the patient becomes low hoarse from the local anesthetic, there's a good likelihood they'll become more permanently hoarse from an alcohol.

So select ones you don't want to in with an injection of a local anesthetic, and that'll wear off in the usual time period.

And I don't treat those with ethanol if they become hoarse with a local anesthetic.

Follow-Up and Management

Follow up is important.

We do it in three to six months intervals.

The goal is to become avascular.

Much smaller serum tumor markers are followed and we repeat the injection if there's persistent vascularity or growth.

Surgeries rarely needed in.

Patients have gone down the ethanol ablation route for the nodule.

Just one of our endocrine doctors probably has the longest follow-up.

In 2012, 19 years, 164 ablated nodules, all 43% disappeared entirely and all have become small, much less vascular, and rarely require surgery.

As you manage, these patients are managed.

We just have to keep in mind, although surgery's great, it takes out all the tumor.

These patients are going to often be recurrent patients, so we have to choose one that's repeatable, perhaps not quite as complete, but for a inland, usually indolent tumor that may recur several times and grow very slowly, these less complete, but less invasive left, less costly and more repeatable procedures such as ethanol ablation and thermal ablation need to be considered.

Conclusions

Finally, of just briefly conclusions, we in our practice, it's ethyl ablation is effective in treating metastatic papillary cancer in the selected patients I discussed, it has a low complication risk.

It eliminates the need for repeat surgery in most of these patients, and does require close collaborations with experts in surgery and endocrine.

Thank you.