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Follicular Thyroid Carcinoma Follow-up

  • Author: Luigi Santacroce, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
 
Updated: Jul 15, 2016
 

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 Prior to the scan, L-T4 must be withdrawn for approximately 4-6 weeks to maximize thyrotropin stimulation of any remaining thyroid tissue.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.[23]

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.[24]

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Further Inpatient Care

In patients with FTC, systematic psychotherapeutic intervention may be very helpful.

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Complications

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.[25] Possible complications include the following:

  • Hypothyroidism [26]
  • 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.[27]

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.

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Prognosis

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.[28]

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.[29]

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Patient Education

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.

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Contributor Information and Disclosures
Author

Luigi Santacroce, MD Assistant Professor, Medical School, State University at Bari, Italy

Disclosure: Nothing to disclose.

Coauthor(s)

Lodovico Balducci, MD Professor, Oncology Fellowship Director, Department of Internal Medicine, Division of Adult Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine

Lodovico Balducci, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American College of Physicians, American Geriatrics Society, American Society of Hematology, New York Academy of Sciences, American Society of Clinical Oncology, Southern Society for Clinical Investigation, International Society for Experimental Hematology, American Federation for Clinical Research, American Society of Breast Disease

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Benjamin Movsas, MD 

Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Radiation Oncology

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Philip Schulman, MD Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Acknowledgements

Silvia Gagliardi, MD Consulting Staff, Department of Surgery, Medical Center Vita, Italy

Disclosure: Nothing to disclose.

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Surgical specimen of a large goiter. Total thyroidectomy was performed because of the presence of a solid nodule in the right lobe (note the size of the thyroid lobe at left of the screen).
The right lobe of the thyroid was sectioned and reveals a large solid nodule with necrotic and hemorrhagic areas. Histologic diagnosis is follicular thyroid carcinoma.
Histologic pattern of a mildly differentiated follicular thyroid carcinoma (250 X). Image courtesy of Professor Pantaleo Bufo at University of Foggia, Italy.
Histologic pattern of a rare lymph node metastasis of follicular thyroid carcinoma (140 X). Image courtesy of Professor Pantaleo Bufo at University of Foggia, Italy.
Histologic pattern of a rare lymph node metastasis of follicular thyroid carcinoma (250 X). Image courtesy of Professor Pantaleo Bufo at University of Foggia, Italy.
 
 
 
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