Follicular Carcinoma - Alternatives to RAI after surgery
My wife (age 29) had total thyroidectomy last month once follicular carcinoma was confirmed after first surgery. It's been a month now and she is doing fine. She has little weakness but otherwise she has gained everything back. She is taking Synthroid daily.
We have been recommended to go for RAI and we are scheduled to see radiologist next month. Now, we are having second thought whether to go for RAI or not. These are some high level clinical facts:
Left Lobe (post surgery pathology report)
Tumor Size: Unifocal 5.4cm (greatest dimension) - it was 4.2cm as per ultrasound about 45 days before surgery.
Capsular and Vascular Invasion identified
No Extradthyroidal extension
(6) Lymph node negative for metastatic
pTNM: pT3, pN0, (pM- Not Applicable).
Right Lobe: Everything came out normal. No sign of any cancer or lymph node involvement. Right lobe was removed once Follicular Carcinoma was confirmed after first surgery. Second surgery was done exactly after 10days of first surgery.
Background tests: two biopsies (with a gap of 6months) prior to surgery came clean and it was confirmed as benign nodule. Two US confirmed the left side two nodules with about 4.2cm size. Surgery was highly recommended due to nodule size. We also wanted to get it over with just because of life -long burden of follow-up and fear of turning into cancer.
Now, surgery is over and she is doing fine. We got first blood work report few days ago:
TSH: 7.65 (Synthroid dose has been adjusted since it's high)
T4: 1.46ng/dl (within range)
Anti Thyroglobulin Ab(E): Negative
Thyroglobulin TGI (ICMA): 4.1ng/ml (ref range is 1.3- 37) but I understand this should be less than 1 ng/ml after total thyroidectomy.
I want to know if there is a way to manage without RAI at this point? Can we safely monitor Tg in order to manage the cancer since total thyroidectomy has already been performed? We are more concerned with the RAI side effects as well as need of multiple scans over time. I know RAI is kind of standard procedure but it looks it doesn't add much value if distant metastasis is not confirmed. This is what able to learn from various literature. Her cancer has been termed as angioinvasive which is kind of moderately risky. Based on her profile, everything points to the low risk cancer except the size of tumor as it's noted as 5.4 cm in it's greatest dimension.
One of the reason we are hesitating to go for RAI is to plan for baby. We have been planning for our first baby but RAI can shift everything for an year even though female should hold off pregnancy only for 6months after RAI. There can be follow-up, etc. and that can easily delay things. That's why we are thinking if can we safely monitor Thyroglobulin (Tg) at this point and postpone RAI or may be avoid it altogether if looks OK for after few years of management. I know it would be almost impossible to confirm if RAI would really help or cancer could potentially can become more aggressive down the road just because we didn't do RAI within 2 months of surgery. We are seeking second professional opinion and we have even sent her slides for reevaluation as cancer was surprise for us including surgeon too. We will get report hopefully later this week. But, it's always good to learn something from somebody's experience.
Please share your thoughts based on your or your loved ones experiences. I know every case is different but I'm sure we can pick-up something from others experiences.
With the current scenario and test results an RAI may not be absolutely indicated but would be highly recommended especially in view of the thyroglobulin levels. An alternative approach would be to monitor the thyroglobulin levels and proceed to the next step at the slightest suspicion. However if planning a pregnancy and a recurrence suspicion arises during the pregnancy, the RAI would need to be delayed till lactation. Though personally I would advise delaying the pregnancy than the RAI, the decision should be a personal choice. I would suggest discussing the pros and cons well in detail with her treating doctor.
Hope this is helpful.
Thank you Dr. Kaul. We have almost made-up mind to go for RAI. Our endo is recommending the same thing and everything else points to RAI as next logical step. For now, her RAI schedule has been planned mid next month. We have not met Radiologist so don't know about the dosage strength. We will seeing him a 4 days before the current treatment schedule. She has been told start LID early next month. She doesn't need to go hypo as she will be given thyrogen.
We have also got the second pathology report and they have classified her tumor as "Follicular Variant of Papillary Carcinoma". I don't think it really changes any treatments steps since it still differentiated carcinoma and treatment remains same.
I'll update on a new progress. Thanks again for sharing your thoughts.
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