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Endocrine Surgery

Long-term Follow-up of Thyroid Cancer

For appointments and information, please call (212) 746-5130

Well Differentiated Thyroid Cancer

Papillary thyroid cancer will recur or persist in about 25% of patients, and 80% of these recurrences will be in the neck. Recurrence occurs most commonly in the first 2 years after thyroidectomy. In papillary thyroid cancer, however, recurrence can occur up to 45 years after surgery, whereas virtually all patients with follicular and Hürthle cell cancer recur before 12 years after surgery.

The current recommendations for postoperative follow-up of well-differentiated thyroid cancer, except for very low-risk patients, are thyroid remnant ablation and thyroid stimulating hormone (TSH) suppression. Radioiodine ablation is recommended for patients with papillary thyroid cancers larger than 1.5cm, multifocal tumors, and for those with lymph node metastases. Invasive follicular and Hürthle cell cancer also warrant radioiodine therapy. We routinely use 30 to 50 mCi of radioiodine in low risk and 100 to 200 mCi of radioiodine in high-risk patients. The initial radioiodine treatment should be performed under hormone withdrawal, or with recombinant TSH stimulation 6-8 weeks postoperatively in an iodine deficient patient. Patients should have a TSH, thyroglobulin, and if could become pregnant, a pregnancy test prior to 131-Iodine scanning and ablation therapy, and also post-treatment imaging. TSH is known to stimulate tumor growth, invasion, angiogenesis, and thyroglobulin secretion. Therefore postoperatively patients are placed on thyroid hormone, approximately 1 mg/pound dose. In low-risk patients we maintain the serum TSH level just below the lower limit of the normal range between 0.1 and 0.4 mU/ mL. In high-risk patients the dosage is adjusted to maintain a serum TSH level less than 0.1 mU/ mL, as this has been reported to improve tumor free survival. Adverse effects of TSH suppression may include the known consequences of subclinical thyrotoxicosis, including exacerbation of angina, atrial fibrillation, and osteoporosis in postmenopausal women.

External beam radiation and chemotherapy have a limited role in the postoperative management of thyroid cancer patients. External beam radiation is used infrequently in the management of thyroid cancer except as a palliative treatment for locally advanced unresectable disease, positive tumor margins, or recurrent disease after re-resection. Chemotherapy has shown only minimal benefit in the treatment of well-differentiated thyroid cancer. New clinical trials have recently become available.

Follow-up is different for patients at low, intermediate, and high risk of having persistent or recurrent disease. Low risk patients are defined as patients with no local or distant metastases, complete resection of tumor contained within the thyroid with no locoregional invasion, tumor without aggressive histology, and if radioiodine was given there was no uptake outside of the thyroid bed. Intermediate risk patients have microscopic invasion of tumor into the peri-thyroidal soft tissue at initial surgery or tumor with aggressive histology or vascular invasion. High-risk patients have macroscopic tumor invasion, incomplete tumor resection, distant metastases, or radioiodine uptake outside the thyroid bed on the post-treatment scan after thyroid remnant ablation.

The absence of persistent disease in patients that have undergone at least a total thyroidectomy and thyroid remnant ablation comprises of no clinical evidence of tumor, no imaging evidence of tumor, and undetectable serum thyroglobulin levels during TSH suppression and stimulation in the absence of interfering antibodies.

All patients with a history of well-differentiated thyroid cancer should have yearly cervical ultrasound scanning, thyroglobulin and thyroglobulin antibodies. Approximately 20% of patients who are clinically disease free with serum thyroglobulin levels less than 2 ng/mL during thyroid hormone suppression will have a thyroglobulin level greater than 5 ng/mL after rhTSH or thyroid hormone withdrawal. One third of this group will have persistent disease identified on imaging studies. Therefore, a serum thyroglobulin level above 5 ng/mL after rhTSH stimulation is highly sensitive in identifying patients with persistent disease. Furthermore, the clinical significance of minimally detectable thyroglobulin levels is unclear, especially if only detected after TSH stimulation. Twenty-five percent of patients with thyroid cancer have antithyroglobulin antibodies making follow-up with thyroglobulin insensitive. In this group serial serum antithyroglobulin antibody measurements may serve as an imprecise surrogate marker to detect recurrence among these patients. Accurate surveillance for possible recurrence and treatment in patients thought to be free of disease is a major goal of long-term follow-up.

Medullary Thyroid Cancer

Blood calcitonin monitoring is the most sensitive test to identify persistent recurrent tumor in patients with MTC. Patients can have locoregional or distant metastasis as their primary site of recurrence. Ultrasound of the neck by an experienced ultrasonographer is the most sensitive method for identifying residual disease. If the plasma calcitonin is not elevated, patients should continue to undergo basal and provocative testing annually for 5 years. Calcitonin levels in the normal range after total thyroidectomy suggest persistent disease. Calcitonin levels greater than 1000 pg/ mL indicate distant metastasis. Chemotherapy plays a limited role in advanced surgically unamenable MTC in clinical trials. Radioiodine may play a role for destroying and residual normal thyroid tissue, and for patients with mixed tumors of follicular and parafollicular cell origin. Its role, however, is still controversial. New clinical trials are currently available.

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