Treatment of Thyroid Cancer on Lymph Nodes Without Surgery

We have numerous lymph nodes all over our bodies. Most of us feel them in our necks as small round structures the size of jelly beans. Their functions are to help us fight infection and foreign elements to our body like cancer cells. In Papillary thyroid cancer, one of its main methods of spreading is by lymph nodes dissemination.  

When the cancer cells travel outside the thyroid cancer nodule, the nearby neck lymph nodes capture them to prevent them from spreading further to the rest of the body. At this point, this lymph node will be called a metastatic lymph node.

In patients with thyroid cancers, lymph node spread (metastases)within the neck lymph nodes may occur in up to 75 percent of cases. The presence of lymph node metastasis in the neck may be associated with a higher stage of the disease and a higher chance that cancer comes back months or years later (a higher recurrence rate). 

This recurrence could happen in months or years, Papillary thyroid cancer spread with metastatic lymph nodes does not necessarily mean that there is a higher mortality rate. 

In fact, among patients less than 45 years of age, even with spread to neck lymph nodes, survival rates of papillary thyroid cancer exceed 97%If lymph nodes are proven positive by FNA biopsy or in Imaging scans they look worrisome for malignancy, they will be surgically removed.

Papillary thyroid carcinoma is a very indolent cancer, and it can take long years before it becomes apparent, therefore metastatic to the lymph nodes can occur very frequently. Spreading to the lymph node is not correlated with the size of the primary thyroid cancer size as it has been reported in microscopic thyroid cancer. On rare occasions, the patient sometimes feels the enlarged lymph nodes first.

Lymph nodes can be detected by diagnostic scans during various stages during the course of thyroid cancer therapy. On rare occasions, the patient initially feels the metastatic lymph nodes as hard lumps in the neck or tight neck feeling prior to the cancer discovery. 

If you or your provider suspect thyroid nodule, enlarged lymph nodes or feel a neck nodule during a physical exam, your provider will recommend an ultrasound scan. This step is important as it determines if you have any suspicious nodules along the neck 

After an ultrasound scan, your provider may recommend a fine needle aspiration (FNA) biopsy. FNA is a common procedure used to diagnose cancer within the lymph nodes.

In the majority of the patients, the suspicious lymph nodes are identified during the thyroid ultrasound scan or on other scans such as CT Neck scan.  However, for early detection of these metastatic cancer cells,  Cervical lymph node mapping is highly recommended. 

Lymph Node mapping is a dedicated detailed neck ultrasound scan. It is a sensitive method for detecting metastatic cervical lymph nodes and is recommended as a part of the standard workup by the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) on the in when patients get a new diagnosis of thyroid carcinoma.

Removing lymph nodes in the neck (lymph node dissection) can be part of the thyroid surgery if preoperatively your FNA biopsy showed cancer cells in the lymph nodes.

Also, if your surgeon detects any abnormal lymph nodes during your thyroid surgery, they will be dissected and tested.

After your thyroidectomy, your provider will recommend a Postoperative Cervical Lymph Node Mapping scan to aid for detecting cancer changes within the neck lymph nodes.

The prevalent initial treatment for recurrent/ residual thyroid cancer within the thyroid bed or local lymph nodes consists of repeat operation, followed by radioactive iodine and or thyroid suppression hormone therapy. However, any repeat neck surgery carries a higher risk of complications due to postoperative neck scarring and fibrosis.

In case repeat surgery or re-exploration neck of lymph nodes cannot be safely performed due to the risk of injuring vital neck structures,  A need for an effective alternative treatment option has led to the evolution of US-guided percutaneous ablative techniques. 

These options include Ultrasound (US)-guided Ablation techniques, such as Radiofrequency Thyroid Ablation (RFA) or Ethanol Ablation (EA).  Any of these ablative techniques complement surgery and other treatment modalities to achieve the best outcomes for the patient.

RFA ablation therapy is a safe and effective option in the eradication of papillary thyroid carcinoma either in thyroid bed or lymph nodes. The RFA probe induces irreversible heat damage to induce cancer cell death. RFA can be curative and/or palliative in recurrent thyroid cancer at the thyroid bed site or for metastatic cervical lymph nodes.

RFA tended to result in a greater volume reduction and a greater complete disappearance rate than Ethanol ablation 

Ethanol ablation(EA) is also a safe effective way of eradicating positive lymph nodes. This type of ablation is caused by the ethanol chemical reaction which induces irreversible damage to cancer cells. 

Ethanol ablation may require several sessions till the cancerous lymph nodes or focus is completely fibrosed. The larger the recurrent/ residual cancer size, the more treatment sessions are required. 

Even with multiple sessions, it is a considerably less expensive alternative to operative management.  Some reported complications are discomfort and pain in the neck; however, they are usually self-limited

RFA and EA are safe procedures that are easy to repeat, are relatively inexpensive, can be performed easily on an outpatient basis,  no general anesthesia, no more scarring, no more suture and have only minimal side effects.

Thyroid cancer patients  with residual or metastatic biopsy proven lymph nodes with:

Choosing between the options depends on the size of cancer, its location in relation to vital neck structures, history of prior treatments, the patient’s medical condition, and provider recommendations. 

EA or RFA  may be recommended for complete ablation in patients with residual thyroid bed carcinoma or with few local /neck metastatic lymph nodes without known distant metastasis, or for palliative purposes in patients with known distant metastases and progressive thyroid cancer.