Keeping thyroid cancer in perspective

An excellent question was raised on a previous post about percutaneous ethanol injection (PEI) of thyroid cysts.

Can a small thyroid nodule that is less than 0.5 cm and suspicious for papillary cancer be treated with PEI?

I am not yet using PEI for anything other than benign thyroid cysts which have cosmetic or anatomical concerns. There is a higher risk for complications when using PEI to treat solid nodules compared with thyroid cysts.

Some are now using PEI as a palliative treatment for metastatic cervical lymph nodes in those with recurrent thyroid cancer who are not surgical candidates and/or in whom radioactive iodine (RAI) ablation has been ineffective. I am not aware if anyone is also using PEI to treat thyroid cancer still within the thyroid gland.

Without doing surgery, there is no way to know for sure if other thyroid nodules are also cancer and if the patient cannot receive RAI ablation. We need to remember that even papillary microcarcinoma can metastasize. Thus, in an otherwise healthy person who does not have other health problems and who is expected to have years or decades of life left, usually I would advocate surgery.

However, what if the patient has other comorbidities that prevent them from being a good surgical candidate?

I currently have an 86-year-old patient with severe cardiac disease who also has residual thyroid cancer with slowly rising thyroglobulin. Her last non-stimulated thyroglobulin was 148 ng/mL. I know exactly where the residual thyroid cancer is, I can see it on ultrasound.

However, my patient had sudden cardiac arrest during her first surgery and almost died. Therefore, no one wants to repeat surgery. Unfortunately, she is also on amiodarone which means that RAI ablation would not be effective either. I have had extended conversations with her and her other physicians about her options. More than likely she will succumb from her cardiac disease long before she suffers complications from her thyroid cancer.

I had another patient with biopsy-proven papillary thyroid cancer who came to me for recommendations prior to thyroidectomy. He was in his 50s but also had advanced amyotrophic lateral sclerosis (ALS). I strongly advised against surgery because his prognosis from the ALS was poor. He would die with thyroid cancer but not from it. Indeed that is exactly what happened several months later.

I wonder why someone had recommended fine-needle aspiration of a thyroid nodule in a patient with a terminal disease. Sometimes, and in some situations, choosing to not do something is the correct decision. If a patient is already so ill or has other medical problems that are serious enough to prevent them from undergoing surgery, we must ask: Why are we treating thyroid cancer at all?

Perhaps someday there may be a place for PEI for thyroid cancer in patients who are not surgical candidates. However, at the present time I would not advise using PEI to treat thyroid cancer within the thyroid gland without data on safety and outcomes. If anyone who reads this has used PEI in this situation, I would be very interested in hearing about your experience.