Wednesday, May 21, 2008

PEI: What is Percutaneous Ethanol Injection, and why do I need to know about it, if I have had multiple surgeries for papillary thyroid cancer?

Case Presentation:

70 Y/O Japanese female with multiple surgeries in the lateral neck after total thyroidectomy for papillary thyroid cancer. Her cancer marker rose again, and she was given another thyroid cancer lymph node mapping. There was a 7 mm tall and 6 mm wide node in level 4 on the right side. The node had abnormal Doppler blood flow suggestive of another recurrence. She was given an USG FNA of the node, and cancer marker was collected from the needle washings. The cytology was negative, but the cancer marker in the washings from the lymph node was 156,000. This was diagnostic of metastatic papillary thyroid cancer. She was told it was too risky to operate again due to scarring and high complication rate. The surgeon recommended she have radio-iodine instead. Her endocrinologist had heard about alternatives to surgery, and knew radio-iodine was not helpful to kill lymph nodes. He referred her to me for evaluation for PEI. I called the surgeon and suggested he might want to do the surgery, if I could mark the cancerous node , by placing a small dot of blue dye on the abnormal node one hour before surgery to reduce the risk of complications. He refused my request. I was left with PEI as the only other treatment. I injected ethanol directly into the cancerous node under ultrasound guidance. She had no complications, but did note a slight tingling along the tract of the needle when I pulled it out. The return visit in 4 weeks was notable for a complete loss of blood flow by Doppler, and a 67% reduction of the node. Also the cancer marker dropped 3 fold to <0.1. 2 more sessions resulted in a small remnant node with no blood flow. The yearly ultrasound follow exams have shown no recurrence of the node in question, and the cancer marker is still non-detectable.

PEI is a new method for treatment of recurrent thyroid cancer in the neck. It is operator dependent and should only be done by expert thyroid interventional ultrasonographers.

Good Luck,


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