eMedicine Specialties > Oncology > Carcinomas of Endocrine Organs

Hurthle Cell Carcinoma: Follow-up

Author: Serhat Aytug, MD, Staff Physician, Division of Endocrinology, Diabetes and Metabolism, CrystalRun Healthcare
Coauthor(s): Lawrence E Shapiro, MD, Chief, Division of Endocrinology and Metabolism, Professor of Medicine, Department of Medicine, Winthrop University Hospital
Contributor Information and Disclosures

Updated: Nov 5, 2009

Follow-up

Further Inpatient Care

  • Standard postsurgical care is usually adequate. Monitor patients for signs of infection or hematoma formation.
  • Clinically monitor patients for hypocalcemic signs and check calcium levels at least every 12-24 hours. If hypocalcemia is present, immediately treat the patient.
  • Monitor patient for signs of laryngeal nerve injury (eg, hoarseness, respiratory compromise).
  • If the patient is hospitalized for131 I treatment, administer antiemetics and adequate hydration.
  • Salivary dysfunction secondary to uptake in salivary glands can be managed with adequate hydration and sucking on candies.
  • Follow effective radiation precautions.

Further Outpatient Care

  • Signs of hypothyroidism should be monitored after surgical treatment.
  • Levothyroxine therapy should usually be started after the treatment dose of131 I is administered.
  • Monitor patient for signs of hypocalcemia.
  • Monitor patient's calcium levels.
  • Before scanning, instruct the patient to avoid iodine-containing medications and iodine-rich foods. Measure urinary iodine in doubtful cases.
  • In women of childbearing age, pregnancy must be ruled out.
  • Patients should be instructed carefully about radiation precautions prior to131 I treatment; patients should follow the instructions meticulously when sent home.
  • Thyroxine treatment
    • The adequacy of therapy is monitored by measuring serum TSH approximately 8-12 weeks after treatment begins, with the initial goal being a serum TSH concentration of 0.1 µU/mL or less and a serum T3 concentration within the reference range.
    • In patients who are at low risk and considered cured, the dose of T4 is decreased to maintain a low, but detectable, serum TSH concentration (0.1-0.5 µU/mL). In higher-risk patients, higher doses are continued, targeting a serum TSH concentration of 0.1 µU/mL or less.
  • Clinical and ultrasonographic examinations
    • Thyroid bed and lymph node areas should be examined routinely. Ultrasonography is recommended in patients at high risk for recurrent disease and in any patient with suspicious clinical findings. Palpable lymph nodes that are small, thin, or reduced in size after an interval of 3 months can be considered benign.
    • Serum thyroglobulin concentrations were undetectable in a group of patients receiving T4 treatment who have isolated lymph node metastases; therefore, undetectable values do not rule out metastatic lymph node disease. If the patient is thought to have metastases, a lymph node biopsy may be performed.
  • Thyroglobulin measurement
    • Thyroglobulin is produced only by normal or neoplastic thyroid follicular cells and should be undetectable in patients who have been treated with surgery and radioablation.
    • In the follow-up care of patients, thyroglobulin is used as a marker of residual disease, of disease recurrence, and as a prognostic factor.
    • Thyroglobulin concentrations as low as 1 ng/mL or even lower can be detected with current assays.
    • Antithyroglobulin antibodies, which are found in approximately 15% of patients with thyroid carcinoma, can alter tests for thyroglobulin artifactually. These antibodies always should be checked when serum thyroglobulin is measured.
  • Chest x-ray films: Most patients with abnormal x-ray findings have detectable serum thyroglobulin concentrations; therefore, this study might not have an additional value in diagnosing metastatic disease, but it still can have a limited diagnostic value in a subgroup of patients.
  • Iodine-131 total body scanning
    • The uptake of131 I and the level of TSH concentration determine the accuracy of total body scanning. In patients whose levothyroxine is held, the serum TSH concentration usually should be higher than 30 µU/mL when the total-body scan is performed. Intramuscular injection of recombinant human thyrotropin is a promising new alternative because T4 treatment does not need to be discontinued and the adverse effects are minimal. Thyroglobulin measurement and obtaining total body scan after Thyrogen administration is currently the standard of care in many institutions. For routine diagnostic scans, 2-5 mCi (74-185 mBq [millibecquerel]) of131 I is administered; higher doses may reduce the uptake of a subsequent therapeutic dose of131 I.
    • Scanning is performed to measure uptake, if any, 3 days after the dose has been administered. In certain situations, uptake cannot be detected with diagnostic scans when 2-5 mCi of131 I is administered but may be detectable after the administration of 100 mCi. This is the rationale for administering 100 mCi (or more) of131 I in patients with elevated serum thyroglobulin concentrations (usually levels >10 ng/mL after T4 has been withdrawn). If this approach is taken, total-body scanning should be performed 4-7 days later.
    • If the serum thyroglobulin concentration becomes detectable in patients receiving T4, thyrotropin alfa (Thyrogen) should be administered or the T4 should be withdrawn, an131 I total-body scan should be obtained, and serum thyroglobulin should be measured. If any uptake is detected or the serum thyroglobulin concentration rises above the previous level,131 I therapy should be administered or PET scan should be considered to localize the metastasis/recurrence.
  • In the absence of131 I uptake, a CT scan of the neck and lungs, bone scintigraphy, and scintigraphy using a less-specific tracer (eg, thallium, tetrofosmin, fluorodeoxyglucose) and particularly PET scan should be considered strongly in patients with Hürthle cell carcinoma who are known to have no or low uptake.

Inpatient & Outpatient Medications

Levothyroxine: The dose should be titrated to a subnormal TSH concentration.

Deterrence/Prevention

No specific prevention is available, although avoidance of radioactive exposure and adequate iodide intake can be considered preventive measures.

Complications

Surgical complications include laryngeal nerve injury and transient or permanent hypoparathyroidism manifested as hypocalcemia. Hypothyroidism can occur if replacement therapy is inadequate. Hyperthyroidism can occur if the patient is overtreated with levothyroxine. Surgical scars in the neck also can be cosmetically disturbing in certain individuals.

  • Surgical complications
    • Recurrent laryngeal nerve injury
    • Hypoparathyroidism (transient, permanent)
    • Infection
    • Hematoma
  • Nonsurgical complications
    • Acute adverse effects
      • Nausea or vomiting sialadenitis
      • Radiation-induced
      • Thyroiditis
      • In metastatic cases, radiation-induced fibrosis of the lung when using large doses of131 I (>150 mCi) administered at short intervals
      • Mild pancytopenia observed after repeated131 I therapy, particularly in patients with bone metastases who also have received external radiotherapy
    • Genetic defects and infertility
      • Transient reduction in spermatogenesis
      • Transient ovarian failure
      • Increased frequency of miscarriages
    • Carcinogenesis and leukemogenesis - Risk of secondary carcinoma or leukemia increased only in patients who have received a high cumulative dose of131 I (>500 mCi) and those who also receive external radiation therapy

Prognosis

  • Hürthle cell carcinomas behave in a more aggressive fashion than other well-differentiated thyroid cancers, as evidenced by a higher incidence of metastasis and a lower survival rate. Hürthle cell carcinomas produce thyroglobulin. In addition, most Hürthle cell carcinomas have decreased avidity for131 I; therefore, treatment with radioactive iodide has limited efficacy.
  • In some series, nuclear aneuploidy is present in as many as 90% of patients with Hürthle cell carcinoma; in some studies, this condition is shown to be associated with an adverse prognosis.
  • In a retrospective review of all patients treated with Hürthle cell carcinoma at their institution between 1946 and 2003 (62 patients in all), Mills et al found that independent predictors of disease-free survival were lymph node status (p=0.008), presence of metastases at diagnosis (p=0.005), and tumor stage (p=0.009). These authors suggest that radical surgery may improve outcome; on multivariate analysis, extent of surgery (p<0.001) was the only independent factor that affected cause-specific survival.24

Patient Education

  • Patients should be advised not to become pregnant for at least 1 year after treatment.
  • Radiation precautions should be explained in length and clearly to a patient who will be receiving radioactive iodine treatment.
  • The need for life-long levothyroxine treatment should be explained to the patients.
  • For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.

Miscellaneous

Medicolegal Pitfalls

  • Failure to explain potential surgical complications
  • Failure to explain the need for levothyroxine treatment
  • Pregnancy
    • 131 I should not be administered to pregnant women.
    • Pregnancy should be ruled out prior to treatment.
    • Postponement of pregnancy for 1 year after treatment with131 I is recommended.
 


More on Hurthle Cell Carcinoma

Overview: Hurthle Cell Carcinoma
Differential Diagnoses & Workup: Hurthle Cell Carcinoma
Treatment & Medication: Hurthle Cell Carcinoma
Follow-up: Hurthle Cell Carcinoma
Multimedia: Hurthle Cell Carcinoma
References
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Further Reading

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Keywords

Hürthle cell carcinoma, Hurthle cell carcinoma, thyroid cancer, Ashkenazi cells, oncocytic tumors, oncocytoma, oxyphil tumor, follicular carcinoma oxyphilic type, differentiated thyroid cancer, Hürthle cell neoplasms, follicular carcinoma of the thyroid, follicular cell neoplasms, oncocytic cells, Hashimoto thyroiditis, Hashimoto's thyroiditis, nodular goiter, toxic goiter, thyroid gland, cancer, papillary thyroid carcinoma, PTC

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Contributor Information and Disclosures

Author

Serhat Aytug, MD, Staff Physician, Division of Endocrinology, Diabetes and Metabolism, CrystalRun Healthcare
Serhat Aytug, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, Endocrine Society, and Pituitary Society
Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence E Shapiro, MD, Chief, Division of Endocrinology and Metabolism, Professor of Medicine, Department of Medicine, Winthrop University Hospital
Lawrence E Shapiro, MD is a member of the following medical societies: American Diabetes Association, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Antoni Ribas, MD, Department of Medicine, Division of Hematology-Oncology, Assistant Professor of Medicine, University of California at Los Angeles Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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