Dr.Guttler’s Case was presented at the World Congress of Thyroid Cancer WCTC 4 on 10-17-21.
Case Summary
One year ago patient was diagnosed with hyperparathyroidism. She elected to have a right parathyroidectomy. During the surgery the thyroid surgeon elected to remove the right lobe. There was 2 <1cm micropapillary cancers. There was 1/3 positive level VI lymph nodes. 6 month examination one 1.8 ml ( 1.2×1.4×1.8 ) right level IV was found. There were no nodules in the left lobe. The size suggested it was there at the time of the first surgery 6 months before.PE: Neck scar and no palpable neck masses.
The Surgical Plan And Tumor Board.
The thyroid surgeon’s recommendation was completion thyroidectomy and bilateral Modified Neck dissection. The patient was not against the parathyroid surgery but was unhappy they took the right lobe without justification in her opinion. She refused the extensive treatment. The surgeon was unhappy. “No one ever refused my treatment plan for thyroid cancer before.” A presentation to the university tumor board she refused the treatment plan. The surgeon offered no alternative. Lay member was unhappy with the surgeon for failing to listen to the patients desire not to have extensive surgery, and not offering alternatives.
The patient found there were alternatives on the internet. These included palliative “cherry picking of just the lymph node, Ethanol or radiofrequency ablation RFA. She is presently awaiting RFA in a week. The RFA plan to explore the carotid artery connection to the node. Hydrodissection if successful the node would be ablated. If no space can be formed between node and carotid then the procedure could be aborted. Alternative 3 would be the limited palliative surgery to just remove the node, or the completion thyroidectomy and Modified radical neck dissection.
During a RFA procedure of the lymph node, the hydrodissection failed to move the node away from the lymph node. This suggested the node had infiltrated the outer wall of the carotid. The RFA procedure was halted. She was told to consider the original surgery or have a surgeon just remove the lymph node. A surgeon could do what RFA was unable to do by scraping the lymph node off the carotid. She was told that would not be cure. The big surgery was now her best alternative.
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Dr.G.
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