Follow up for patients Follow up for patients with thyroid cancerwith thyroid cancer

TNM definitionTNM definition

TX: Primary tumor cannot be assessed TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T0: No evidence of primary tumor T1: Tumor 1 cm or less in greatest dimension limited T1: Tumor 1 cm or less in greatest dimension limited

to the thyroid to the thyroid T2: Tumor more than 1 cm but not more than 4 cm in T2: Tumor more than 1 cm but not more than 4 cm in

greatest dimension limited to the thyroid greatest dimension limited to the thyroid T3: Tumor more than 4 cm in greatest dimension T3: Tumor more than 4 cm in greatest dimension

limited to the thyroid limited to the thyroid T4: Tumor of any size extending beyond the thyroid T4: Tumor of any size extending beyond the thyroid

capsule capsule

Regional lymph nodes (N)Regional lymph nodes (N) Regional lymph nodes are the cervical and upper medRegional lymph nodes are the cervical and upper med

iastinal lymph nodes. iastinal lymph nodes. NX: Regional lymph nodes cannot be assessed NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N0: No regional lymph node metastasis N1: Regional lymph node metastasis N1: Regional lymph node metastasis

N1a: Metastasis in ipsilateral cervical lymph node(s) N1a: Metastasis in ipsilateral cervical lymph node(s) N1b: Metastasis in bilateral, midline, or contralateral cervicN1b: Metastasis in bilateral, midline, or contralateral cervic

al or mediastinal lymph node(s) al or mediastinal lymph node(s)

Distant metastases (M) Distant metastases (M) MX: Distant metastasis cannot be assessed MX: Distant metastasis cannot be assessed M0: No distant metastasis M0: No distant metastasis M1: Distant metastasis M1: Distant metastasis

Stage groupingStage grouping

Papillary or follicularPapillary or follicular Under 45 years Under 45 years

Stage I Stage I Any T, any N, M0 Any T, any N, M0

Stage II Stage II Any T, any N, M1 Any T, any N, M1

45 years and older 45 years and older Stage I Stage I

T1, N0, M0T1, N0, M0

Stage II Stage II T2, N0, M0 T2, N0, M0 T3, N0, M0T3, N0, M0

Stage III Stage III T4, N0, M0 T4, N0, M0 Any T, N1, M0Any T, N1, M0

Stage IV Stage IV Any T, any N, M1Any T, any N, M1

Stage I papillaryStage I papillary

Cancer is only in the thyroid and may be found Cancer is only in the thyroid and may be found in one or both lobes.in one or both lobes.

Stage II papillaryStage II papillary

In patients younger than 45 years of age: In patients younger than 45 years of age: Cancer has spread beyond the thyroid.Cancer has spread beyond the thyroid.

In patients older than 45 years of age: In patients older than 45 years of age: Cancer is only in the thyroid and larger than 1 centCancer is only in the thyroid and larger than 1 cent

imeter (about 1/2 inch).imeter (about 1/2 inch).

Stage III papillaryStage III papillary

Cancer is found in patients older than 45 years Cancer is found in patients older than 45 years of age and has spread outside the thyroid (but of age and has spread outside the thyroid (but not outside of the neck) or has spread to the not outside of the neck) or has spread to the lymph nodes.lymph nodes.

Stage IV papillaryStage IV papillary

Cancer is found in patients older than 45 years Cancer is found in patients older than 45 years of age and has spread to other parts of the of age and has spread to other parts of the body, such as the lungs and bones body, such as the lungs and bones

STAGE I PAPILLARY THYROID STAGE I PAPILLARY THYROID CANCERCANCER

Treatment may be one of the following:Treatment may be one of the following:

1.1. Surgery to remove one lobe of the thyroid (lobe Surgery to remove one lobe of the thyroid (lobectomy), followed by hormone therapy. Radioactive ctomy), followed by hormone therapy. Radioactive iodine also may be given following surgery.iodine also may be given following surgery.2.2. Surgery to remove the thyroid (total thyroidecto Surgery to remove the thyroid (total thyroidectomy).my).

STAGE II PAPILLARY THYROID STAGE II PAPILLARY THYROID CANCERCANCER

Treatment may be one of the following:Treatment may be one of the following:

1.1. Surgery to remove one lobe of the thyroid (lobe Surgery to remove one lobe of the thyroid (lobectomy) and lymph nodes that contain cancer, folloctomy) and lymph nodes that contain cancer, followed by hormone therapy. Radioactive iodine also wed by hormone therapy. Radioactive iodine also may be given following surgery.may be given following surgery.2.2. Surgery to remove the thyroid (total thyroidecto Surgery to remove the thyroid (total thyroidectomy).my).

STAGE III PAPILLARY THYROID STAGE III PAPILLARY THYROID CANCERCANCER

Treatment may be one of the following:Treatment may be one of the following:

1.1. Surgery to remove the entire thyroid (total thyro Surgery to remove the entire thyroid (total thyroidectomy) and lymph nodes where cancer has spreidectomy) and lymph nodes where cancer has spread.ad.2.2. Total thyroidectomy followed by radiation thera Total thyroidectomy followed by radiation therapy with radioactive iodine or external beam radiatipy with radioactive iodine or external beam radiation therapy.on therapy.

STAGE IV PAPILLARY THYROID STAGE IV PAPILLARY THYROID CANCERCANCER

Treatment may be one of the following:Treatment may be one of the following:

1.1. Radioactive iodine. Radioactive iodine.2.2. External beam radiation therapy. External beam radiation therapy.3.3. Hormone therapy. Hormone therapy.4.4. A clinical trial of chemotherapy. A clinical trial of chemotherapy.

The protocol for The protocol for follow-upfollow-up of patients with we of patients with well differentiated thyroid cancer will differ from ll differentiated thyroid cancer will differ from center to center center to center

initially seen at 6 month intervals initially seen at 6 month intervals thyroid cancer has been successfully treated, wthyroid cancer has been successfully treated, w

ith no evidence for residual disease on physicaith no evidence for residual disease on physical examination, scanning, or l examination, scanning, or thyroglobulinthyroglobulin testi testing, follow-up may be scheduled at yearly interng, follow-up may be scheduled at yearly intervals vals

Routine follow-up assessment will include phyRoutine follow-up assessment will include physical examination focused on the  and neck, ansical examination focused on the  and neck, and blood tests, including d blood tests, including TSHTSH and and thyroglobulithyroglobulinn. .

Periodic chest X rays may also be indicated Periodic chest X rays may also be indicated

outpatient radioactive iodine scans outpatient radioactive iodine scans need for regular thyroid hormone withdrawal aneed for regular thyroid hormone withdrawal a

nd iodine scanning nd iodine scanning recombinant recombinant TSH-stimulated  (Thyrogen) thTSH-stimulated  (Thyrogen) th

yroglobulinyroglobulin testing be the primary test for foll testing be the primary test for follow-up of patients ow-up of patients

(Thyrogen)(Thyrogen) for TSH-stimulated thyroglobulin for TSH-stimulated thyroglobulin blood tests eliminates the need for withdrawal blood tests eliminates the need for withdrawal of thyroid hormone and the development of hyof thyroid hormone and the development of hypothyroidism. pothyroidism.

In patients who have thyroid cancer confined tIn patients who have thyroid cancer confined to the thyroid, with no evidence of extra-thyroio the thyroid, with no evidence of extra-thyroidal disease at the time of surgery  or on the firsdal disease at the time of surgery  or on the first total body radioactive iodine scan, with an unt total body radioactive iodine scan, with an undetectable TSH-stimulated thyroglobulin,  it mdetectable TSH-stimulated thyroglobulin,  it may not be necessary to have periodic or regular ay not be necessary to have periodic or regular thyroid scans.thyroid scans.

more extensive thyroid cancer :more extensive thyroid cancer : or evidence for abnormal iodine accumulation or evidence for abnormal iodine accumulation

outside the thyroid bed on the radioactive outside the thyroid bed on the radioactive iodine scan after the initial radioactive iodine iodine scan after the initial radioactive iodine treatment. For these patients, initial periodic treatment. For these patients, initial periodic rescanning with radioactive iodine as an rescanning with radioactive iodine as an outpatient may be considered outpatient may be considered

Nevertheless, the accuracy of routine scanning Nevertheless, the accuracy of routine scanning for follow-up of thyroid cancer has been for follow-up of thyroid cancer has been questioned questioned

Thyroglobulin level is a better predictor of Thyroglobulin level is a better predictor of disease recurrence than a nuclear medicine disease recurrence than a nuclear medicine scan scan

an undetectable thyroglobulin after their first an undetectable thyroglobulin after their first withdrawal of Thyrogen scan, the utility of a swithdrawal of Thyrogen scan, the utility of a subsequent total body iodine scan appears questubsequent total body iodine scan appears questionable ionable

The superior performance and enhanced sensitThe superior performance and enhanced sensitivity of the TSH-stimulated ivity of the TSH-stimulated Tg testTg test alone, com alone, compared to the inclusion of the whole body scan pared to the inclusion of the whole body scan plus Tg, for the detection of recurrent or residuplus Tg, for the detection of recurrent or residual thyroid cancer al thyroid cancer

Repeat diagnostic scanning for thyroid cancer Repeat diagnostic scanning for thyroid cancer recurrence has recurrence has traditionallytraditionally involved involved withdrawal of thyroid hormonewithdrawal of thyroid hormone for 4-6 for 4-6 weeks weeks

to make patients hypothyroid for the scan to be to make patients hypothyroid for the scan to be informative informative

as the pituitary production of as the pituitary production of TSHTSH maximally maximally stimulates uptake of the diagnostic dose of stimulates uptake of the diagnostic dose of radioactive iodine (5mci)radioactive iodine (5mci)

usually done as an outpatient, hence there is usually done as an outpatient, hence there is no need for isolation or extreme precautions no need for isolation or extreme precautions

Common sense dictates that a small amount of Common sense dictates that a small amount of radioactive iodine may be present in body radioactive iodine may be present in body fluids for a few days after the scan, so fluids for a few days after the scan, so avoiding intimate exchange of body fluids, avoiding intimate exchange of body fluids, shared foods, prolonged kissing etc, may be shared foods, prolonged kissing etc, may be reasonable for a few days after the reasonable for a few days after the administration of radioactive iodine administration of radioactive iodine

At the same time as the scan is done, a At the same time as the scan is done, a blood tblood testest for for TSHTSH and the and the thyroglobulinthyroglobulin protein sho protein should also be done uld also be done

normal values are: normal values are: 0 - 34 ug/L for patients who still have their t0 - 34 ug/L for patients who still have their t

hyroid gland andhyroid gland and 0 - 3 ug/L for patients following surgical re0 - 3 ug/L for patients following surgical re

moval and thyroid ablationmoval and thyroid ablation

importance of keeping the importance of keeping the TSHTSH suppressed du suppressed during ongoing management of patients with thyrring ongoing management of patients with thyroid cancer. The standard therapy for patients woid cancer. The standard therapy for patients with thyroid cancer is ith thyroid cancer is Treatment with L-Treatment with L-thyroxinethyroxine

Q and AQ and A

Q: thyroglobulin levels are low or undetectaQ: thyroglobulin levels are low or undetectable. Does this guarantee that my thyroid canble. Does this guarantee that my thyroid cancer has not returned?cer has not returned?

A: it is possible for thyroid cancer to recur, yet A: it is possible for thyroid cancer to recur, yet the the thyroglobulinthyroglobulin levels may be low or undetec levels may be low or undetectable. Hence the thyroglobulin alone is not 100table. Hence the thyroglobulin alone is not 100% perfect in the follow-up of patients with thyr% perfect in the follow-up of patients with thyroid cancer oid cancer

A: Nevertheless, a low thyroglobulin after initiA: Nevertheless, a low thyroglobulin after initial surgery seems to be a useful prognostic sign al surgery seems to be a useful prognostic sign

A: total body scan is negative but my thyrogA: total body scan is negative but my thyroglobulin is elevated. What should I do?lobulin is elevated. What should I do?

Q: First, it is important to make sure that the thQ: First, it is important to make sure that the thyroglobulin is not falsely elevated as a result oyroglobulin is not falsely elevated as a result of antibodies (f antibodies ( 如果不是如果不是 ;tumor too small ,scan ;tumor too small ,scan 不到 不到 or or 不能不能 uptake)uptake)

empiric treatment with high dose radioactive iempiric treatment with high dose radioactive iodine, followed by a repeat total body scan odine, followed by a repeat total body scan

A: It is not uncommon for a single abnormal thA: It is not uncommon for a single abnormal thyroglobulin to be elevated, followed by a repeayroglobulin to be elevated, followed by a repeat blood test a few months later where the thyrot blood test a few months later where the thyroglobulin may be lower, or even undetectable. Iglobulin may be lower, or even undetectable. In other cases, where the thyroglobulin blood ten other cases, where the thyroglobulin blood test abnormality persists, additional imaging stust abnormality persists, additional imaging studies may be requested, such as a neck ultrasoudies may be requested, such as a neck ultrasound, high resolution CT scan, MRI PETscan .nd, high resolution CT scan, MRI PETscan .