Follicular Thyroid Carcinoma Follow-up
- Author: Luigi Santacroce, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC more...
Further Outpatient Care
Perform postoperative scintiscan of the neck after 4-6 weeks without thyroid hormone replacement. At this time, a scan of the neck demonstrates whether thyroid tissue is still present. If thyroid tissue is present, a dose of radioactive iodine is administered to destroy residual tissue. The patient is then placed on lifelong thyroid replacement with L-T4. Repeat the scintiscan 6-12 months after ablation and, thereafter, every 2 years. Prior to the scan, L-T4 must be withdrawn for approximately 4-6 weeks to maximize thyrotropin stimulation of any remaining thyroid tissue.
Radioactive iodine may ablate the metastatic tissue in the lungs and bone. In fact, metastases of FTC appear to be more amenable to radioiodine therapy than metastases of papillary carcinoma.
For a single CNS metastasis, consider neurosurgical resection and radioiodine treatment, perhaps associated with rhTSH and steroids, and/or radiation therapy.
Evaluate thyroglobulin serum levels every 6-12 months for at least 5 years. Consider a level higher than 20 ng/mL, after TSH suppression, to be abnormal. A recurrence of thyroid cancer can be detected if a rise in the thyroglobulin level is found on monitoring. All patients who have undergone total thyroidectomy and those who have had radioactive ablation of any remaining thyroid tissue should be treated with thyroid hormone suppression. Individualize the degree of suppression to avoid complications such as subclinical hyperthyroidism.
A study by Brassard et al found that thyroglobulin measurements allow prediction of long-term recurrence with excellent specificity. TSH stimulation may be avoided when thyroglobulin levels measured 3 months after ablation are less than 0.27 ng/mL during levothyroxine treatment.
A patient who has had a thyroidectomy without parathyroid preservation will require vitamin D and calcium for the rest of his or her life.
More specific treatment information for FTC can be found at the National Comprehensive Cancer Network website, in the NCCN Clinical Practice Guidelines in Oncology section.
The American Thyroid Association Taskforce on Radioiodine Safety released recommendations to help guide physicians and patients in safe practices after treatment, including reminders in the form of a checklist.
Further Inpatient Care
In patients with FTC, systematic psychotherapeutic intervention may be very helpful.
If it is neglected, FTC may produce symptoms due to the compression and/or infiltration of the surrounding tissues, and it may metastasize to lung and bone.
Surgical treatment of FTC may cause complications, partially because of the variable anatomy of the neck. Complication rates, especially with total thyroidectomy, are lower in the hands of experienced surgeons. Possible complications include the following:
Dysphagia due to damage of the upper laryngeal nerve
Vocal cord paralysis due to damage of the recurrent laryngeal nerve
Hypoparathyroidism due to parathyroid gland ablation.
Radioiodine administration may have the following consequences:
Radiation thyroiditis and transient thyrotoxicosis in patients who have undergone simple lobectomy
Sialoadenitis, because radioiodine is taken up by the salivary glands
Nausea, anorexia, and headache (uncommon)
Pulmonary fibrosis in patients with large lung metastases
Brain edema in patients with brain metastases (this may be prevented by glucocorticoid treatment)
Permanent sterility and transient oligospermia or menstrual irregularities
Teratogenesis and spontaneous abortions
A slight increase in the risk of leukemias or breast and bladder carcinomas.
In a study of 438 patients with thyroid cancer, similar outcomes were achieved with low-dose radioiodine plus thyrotropin alfa treatment and high-dose radioiodine treatment, and low-dose treatment was associated with a lower rate of adverse events.
The most frequent sites of metastasis are lung and bone, followed by the brain and the liver; metastasis to other sites occurs less frequently. Metastatic potential seems to be a function of primary tumor size; however, metastases without thyroid pathology identified on physical examination may be found in patients with microscopic FTC.
FTC prognosis is related to age, sex, and staging. In general, if cancer is not extending beyond the capsule of the gland, life expectancy is affected minimally. Prognosis is better in female patients and in patients younger than 40 years. Survival rate is at least 95% with appropriate treatments.
In a Spanish study of FTC in 66 patients, with follow-up of 99 ± 38 months, disease-related mortality was 3%; disease-free survival rates were 71% at 5 years and 58% at 10 years. The main predictive factors for recurrence were the presence of local clinical symptoms and infiltration into neighboring structures.
A relatively large prospective study by Sugino et al demonstrates that age and primary tumor size may result in poorer outcome for patients with distant metastases. Authors recommend conservative management for younger patients with minimally invasive follicular thyroid carcinoma with small tumors.
For patient education information, see the Thyroid and Metabolism Center, as well as Thyroid Problems. Patient education information on thyroid cancer is also available on the American Cancer Society Web site.
[Guideline] NCCN Clinical Practice Guidelines in Oncology: Thyroid Carcinoma Version 1.2016. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/PDF/thyroid.pdf. Accessed: July 15, 2016.
Asari R, Koperek O, Scheuba C, Riss P, Kaserer K, Hoffmann M, et al. Follicular thyroid carcinoma in an iodine-replete endemic goiter region: a prospectively collected, retrospectively analyzed clinical trial. Ann Surg. 2009 Jun. 249(6):1023-31. [Medline].
Johnson TL, Lloyd RV, Thor A. Expression of ras oncogene p21 antigen in normal and proliferative thyroidtissues. Am J Pathol. 1987 Apr. 127(1):60-5. [Medline].
Wright PA, Lemoine NR, Mayall ES, et al. Papillary and follicular thyroid carcinomas show a different pattern of ras oncogene mutation. Br J Cancer. 1989 Oct. 60(4):576-7. [Medline].
Karga H, Lee JK, Vickery AL Jr, Thor A, Gaz RD, Jameson JL. Ras oncogene mutations in benign and malignant thyroid neoplasms. J Clin Endocrinol Metab. 1991 Oct. 73(4):832-6. [Medline].
Bos JL. ras oncogenes in human cancer: a review. Cancer Res. 1989 Sep. 49(17):4682-9. [Medline].
McCabe CJ. Moving towards the use of targeted therapies in thyroid cancer. Nat Clin Pract Endocrinol Metab. 2008 Nov. 4(11):604-5. [Medline].
Williams MD, Zhang L, Elliott DD, et al. Differential gene expression profiling of aggressive and nonaggressive follicular carcinomas. Hum Pathol. 2011 Sep. 42(9):1213-20. [Medline]. [Full Text].
Cancer Facts & Figures 2016. American Cancer Society. Available at http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. Accessed: July 15, 2016.
Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. 2008 Feb 16. 371(9612):569-78. [Medline].
Handkiewcz-Junak D, Banasik T, Kolosza Z, Roskosz J, Kukulska A, Puch Z. Risk of malignant tumors in first-degree relatives of patients with differentiated thyroid cancer -- a hospital based study. Neoplasma. 2006. 53(1):67-72. [Medline].
Williams ED, Abrosimov A, Bogdanova T, et al. Thyroid carcinoma after Chernobyl latent period, morphology and aggressiveness. Br J Cancer. 2004 Jun 1. 90(11):2219-24. [Medline].
Zengi A, Karadeniz M, Erdogan M, et al. Does chernobyl accident have any effect on thyroid cancers in Turkey? Aretrospective review of thyroid cancers from 1982 to 2006. Endocr J. 2008 May. 55(2):325-30. [Medline].
Ito Y, Uramoto H, Funa K, Yoshida H, Jikuzono T, Asahi S. Delta Np73 expression in thyroid neoplasms originating from follicular cells. Pathology. 2006 Jun. 38(3):205-9. [Medline].
Xing P, Wu L, Zhang C, et al. Differentiation of benign from malignant thyroid lesions: calculation of the strain ratio on thyroid sonoelastography. J Ultrasound Med. 2011 May. 30(5):663-9. [Medline].
Miyakawa M, Onoda N, Etoh M, et al. Diagnosis of thyroid follicular carcinoma by the vascular pattern and velocimetric parameters using high resolution pulsed and power Doppler ultrasonography. Endocr J. 2005 Apr. 52(2):207-12. [Medline].
Palmedo H, Bucerius J, Joe A, Strunk H, Hortling N, Meyka S. Integrated PET/CT in differentiated thyroid cancer: diagnostic accuracy and impact on patient management. J Nucl Med. 2006 Apr. 47(4):616-24. [Medline].
Hassan A, Khalid M, Riaz S, Nawaz MK, Bashir H. Follicular Thyroid Carcinoma: Disease Response Evaluation Using American Thyroid Association Risk Assessment Guidelines. Eur Thyroid J. 2015 Dec. 4 (4):260-5. [Medline]. [Full Text].
Meadows KM, Amdur RJ, Morris CG, Villaret DB, Mazzaferri EL, Mendenhall WM. External beam radiotherapy for differentiated thyroid cancer. Am J Otolaryngol. 2006 Jan-Feb. 27(1):24-8. [Medline].
Bikas A, Kundra P, Desale S, Mete M, O'Keefe K, Clark BG, et al. Phase 2 clinical trial of sunitinib as adjunctive treatment in patients with advanced differentiated thyroid cancer. Eur J Endocrinol. 2016 Mar. 174 (3):373-80. [Medline].
Nixon IJ, Ganly I, Patel SG, Palmer FL, Whitcher MM, Tuttle RM, et al. Thyroid lobectomy for treatment of well differentiated intrathyroid malignancy. Surgery. 2012 Apr. 151(4):571-9. [Medline].
Lee S, Ryu HR, Park JH, et al. Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg. 2011 Jun. 253(6):1060-6. [Medline].
Brassard M, Borget I, Edet-Sanson A, et al. Long-term follow-up of patients with papillary and follicular thyroid cancer: a prospective study on 715 patients. J Clin Endocrinol Metab. 2011 May. 96(5):1352-9. [Medline].
Sisson JC, Freitas J, McDougall IR, et al. Radiation safety in the treatment of patients with thyroid diseases by radioiodine 131I : practice recommendations of the American Thyroid Association. Thyroid. 2011 Apr. 21(4):335-46. [Medline].
Carling T, Udelsman R. Thyroid Tumors. DeVita VT Jr, Lawrence TS, Rosenberg SA. DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology. 9th. Philadelphia: Lippincott Williams & Wilkins; 2011. 1457-1472.
Huang SC, Wu VC, Lin SY, Sheu WH, Song YM, Lin YH, et al. Factors related to clinical hypothyroid severity in thyroid cancer patients after thyroid hormone withdrawal. Thyroid. 2009 Jan. 19(1):13-20. [Medline].
Mallick U, Harmer C, Yap B, Wadsley J, Clarke S, Moss L, et al. Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer. N Engl J Med. 2012 May 3. 366(18):1674-85. [Medline].
Ríos A, Rodríguez JM, Ferri B, Martínez-Barba E, Torregrosa NM, Parrilla P. Prognostic factors of follicular thyroid carcinoma. Endocrinol Nutr. 2014 Aug 21. [Medline].
Sugino K, Ito K, Nagahama M, et al. Prognosis and prognostic factors for distant metastases and tumor mortality in follicular thyroid carcinoma. Thyroid. 2011 Jul. 21(7):751-7. [Medline].
Hari CK, Kumar M, Abo-Khatwa MM, Adams-Williams J, Zeitoun H. Follicular variant of papillary carcinoma arising from lingual thyroid. Ear Nose Throat J. 2009 Jun. 88(6):[Medline].
Arnaldi LA, Borra RC, Maciel RM, Cerutti JM. Gene expression profiles reveal that DCN, DIO1, and DIO2 are underexpressed in benign and malignant thyroid tumors. Thyroid. 2005 Mar. 15(3):210-21. [Medline].
Baloch ZW, LiVolsi VA. Fine-needle aspiration of the thyroid: today andtomorrow. Best Pract Res Clin Endocrinol Metab. 2008 Dec. 22(6):929-39. [Medline].
Cameselle-Teijeiro J, Pardal F, Eloy C, Ruiz-Ponte C, Celestino R, Castro P, et al. Follicular thyroid carcinoma with an unusual glomeruloid pattern of growth. Hum Pathol. 2008 Oct. 39(10):1540-7. [Medline].
Castro P, Eknaes M, Teixeira MR, et al. Adenomas and follicular carcinomas of the thyroid display two major patterns of chromosomal changes. J Pathol. 2005 Jul. 206(3):305-11. [Medline].
Chao TC, Lin JD, Chen MF. Surgical treatment of thyroid cancers with concurrent graves disease. Ann Surg Oncol. 2004 Apr. 11(4):407-12. [Medline].
Clark JR, Lai P, Hall F, et al. Variables predicting distant metastases in thyroid cancer. Laryngoscope. 2005 Apr. 115(4):661-7. [Medline].
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2006 Feb. 16(2):109-42. [Medline].
D'Avanzo A, Treseler P, Ituarte PH, et al. Follicular thyroid carcinoma: histology and prognosis. Cancer. 2004 Mar 15. 100(6):1123-9. [Medline].
Di Cristofaro J, Marcy M, Vasko V, Sebag F, Fakhry N, Wynford-Thomas D. Molecular genetic study comparing follicular variant versus classic papillary thyroid carcinomas: association of N-ras mutation in codon 61 with follicular variant. Hum Pathol. 2006 Jul. 37(7):824-30. [Medline].
Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP. Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy. J Clin Endocrinol Metab. 2006 Aug. 91(8):2892-9. [Medline].
Eszlinger M, Krohn K, Kukulska A, et al. Perspectives and limitations of microarray-based gene expression profiling of thyroid tumors. Endocr Rev. 2007. 28(3):322-38. [Medline].
Faquin WC. The thyroid gland: recurring problems in histologic and cytologic evaluation. Arch Pathol Lab Med. 2008 Apr. 132(4):622-32. [Medline].
Farahati J, Geling M, Mader U, et al. Changing trends of incidence and prognosis of thyroid carcinoma in lower Franconia, Germany, from 1981-1995. Thyroid. 2004 Feb. 14(2):141-7. [Medline].
Fernandes JK, Day TA, Richardson MS, Sharma AK. Overview of the management of differentiated thyroid cancer. Curr Treat Options Oncol. 2005 Jan. 6(1):47-57. [Medline].
Fryknäs M, Wickenberg-Bolin U, Göransson H, Gustafsson MG, Foukakis T, Lee JJ. Molecular markers for discrimination of benign and malignant follicular thyroid tumors. Tumour Biol. 2006. 27(4):211-20. [Medline].
Giorgadze TA, Baloch ZW, Pasha T, Zhang PJ, Livolsi VA. Lymphatic and blood vessel density in the follicular patterned lesions of thyroid. Mod Pathol. 2005 Nov. 18(11):1424-31. [Medline].
Gosnell JE, Sackett WR, Sidhu S, et al. Minimal access thyroid surgery: technique and report of the first 25 cases. ANZ J Surg. 2004 May. 74(5):330-4. [Medline].
Gyory F, Balazs G, Nagy EV. Differentiated thyroid cancer and outcome in iodine deficiency. Eur J Surg Oncol. 2004 Apr. 30(3):325-31. [Medline].
Hall P, Adami HO. Thyroid Cancer. Adami HO, Hunter D, Trichopoulos D. eds. Textbook of Cancer Epidemiology. 2nd edition. Oxford University Press; 2008. 504-519.
Ilias I, Alevizaki M, Lakka-Papadodima E, Koutras DA. Differentiated thyroid cancer in Greece: 1963-2000. Relation to demographic andenvironmental factors. Hormones. 2002 Jul-Sep. 1(3):174-8. [Medline].
Kaya H, Barbaros U, Erbil Y, Bozbora A, Kapran Y, Aral F, et al. Metastatic thyroid carcinoma. N Z Med J. 2005 Oct 28. 118(1224):U1705. [Medline].
Kebebew E, Clark OH. Differentiated thyroid cancer: "complete" rational approach. World J Surg. 2000 Aug. 24(8):942-51. [Medline].
Kondo T, Ezzat S, Asa SL. Pathogenetic mechanisms in thyroid follicular-cell neoplasia. Nat Rev Cancer. 2006 Apr. 6(4):292-306. [Medline].
Kuijt WJ, Huang SA. Children with differentiated thyroid cancer achieve adequate hyperthyrotropinemia within 14 days of levothyroxine withdrawal. J Clin Endocrinol Metab. 2005 Nov. 90(11):6123-5. [Medline].
Kushwaha RA, Verma SK, Mahajan SV. Endobronchial metastasis of follicular thyroid carcinoma presenting as hemoptysis: a case report. J Cancer Res Ther. 2008. (1):44-5. [Medline].
Lerma E, Mora J. Telomerase activity in "suspicious" thyroid cytology. Cancer. 2005 Dec 25. 105(6):492-7. [Medline].
Lin JD, Chao TC. Follicular thyroid carcinoma: From diagnosis to treatment. Endocr J. 2006 Aug. 53(4):441-8. [Medline].
Mazzaferri EL, Robbins RJ, Spencer CA, et al. A consensus report of the role of serum thyroglobulin as a monitoring method for low-risk patients with papillary thyroid carcinoma. J Clin Endocrinol Metab. 2003 Apr. 88(4):1433-41. [Medline].
Muresan MM, Olivier P, Leclère J, et al. Bone metastases from differentiated thyroid carcinoma. Endocr Relat Cancer. 2008 Mar. 15(1):37-49. [Medline].
Ogawa Y, Sugawara T, Seki H, Sakuma T. Thyroid follicular carcinoma metastasized to the lung, skull, and brain 12 years after initial treatment for thyroid gland--case report. Neurol Med Chir (Tokyo). 2006 Jun. 46(6):302-5. [Medline].
Pacini F, Schlumberger M, Harmer C, Berg GG, Cohen O, Duntas L. Post-surgical use of radioiodine (131I) in patients with papillary and follicular thyroid cancer and the issue of remnant ablation: a consensus report. Eur J Endocrinol. 2005 Nov. 153(5):651-9. [Medline].
Reiners C, Farahati J. 131I therapy of thyroid cancer patients. Q J Nucl Med. 1999 Dec. 43(4):324-35. [Medline].
Riesco-Eizaguirre G, Santisteban P. New insights in thyroid follicular cell biology and its impact in thyroid cancer therapy. Endocr Relat Cancer. 2007 Dec. 14(4):957-77. [Medline].
Robbins RJ, Wan Q, Grewal RK, Reibke R, Gonen M, Strauss HW, et al. Real-time prognosis for metastatic thyroid carcinoma based on 2-[18F]fluoro-2-deoxy-D-glucose-positron emission tomography scanning. J Clin Endocrinol Metab. 2006 Feb. 91(2):498-505. [Medline].
Ronckers CM, McCarron P, Engels EA, Ron E. New Malignancies Following Cancer of the Thyroid and Other Endocrine Glands. Curtis RE, Freedman DM, Ron E, Ries LAG, Hacker DG, Edwards BK, Tucker MA, Fraumeni JF Jr. New Malignancies Among Cancer Survivors: SEER Cancer Registries, 1973-2000. Bethesda, MD: NIH Publ. No. 05-5302; 2006. 375-395. [Full Text].
Ruschenburg I, Vollheim B, Stachura J, Cordon-Cardo C, Korabiowska M. Analysis of DNA mismatch repair gene expression and mutations in thyroid tumours. Anticancer Res. 2006 May-Jun. 26(3A):2107-12. [Medline].
Sarquis MS, Weber F, Shen L, et al. High frequency of loss of heterozygosity in imprinted, compared with nonimprinted, genomic regions in follicular thyroid carcinomas and atypical adenomas. J Clin Endocrinol Metab. 2006. 91:262-9. [Medline]. [Full Text].
Savin S, Cvejic D, Isic T, Paunovic I, Tatic S, Havelka M. The efficacy of the thyroid peroxidase marker for distinguishing follicular thyroid carcinoma from follicular adenoma. Exp Oncol. 2006 Mar. 28(1):70-4. [Medline].
Schmitt TS, Elte JW, Rietveld AP, van Zaanen HC, Castro Cabezas M. Bone metastasis of a follicular thyroid carcinoma originated in a toxic multinodular goiter. Eur J Intern Med. 2008 Nov. 19(7):e64-6. [Medline].
Siassakos D, Gourgiotis S, Moustafellos P, et al. Thyroid microcarcinoma during thyroidectomy. Singapore Med J. 2008 Jan. 49(1):23-5. [Medline].
Suster S. Thyroid tumors with a follicular growth pattern: problems in differential diagnosis. Arch Pathol Lab Med. 2006 Jul. 130(7):984-8. [Medline].
Ulger Z, Karaman N, Piskinpasa SV, Niksarlioglu YO, Kilickap S, Erman M. Endobronchial metastasis of thyroid follicular carcinoma. J Natl Med Assoc. 2006 May. 98(5):803-6. [Medline].
Vasko VV, Gaudart J, Allasia C, et al. Thyroid follicular adenomas may display features of follicular carcinoma and follicular variant of papillary carcinoma. Eur J Endocrinol. 2004 Dec. 151(6):779-86. [Medline].