Recurrent Thyroid Cancer

[amela321]

I am a 23 year Papillary Thyroid Cancer survivor having had a near total thyroidectomy and 2 rounds of RAI in 1985.  Recently, I had labs drawn and my Tg came back at 23.0 after hormone withdrawal.  I was then sent for an ultrasound where there is what is described as an abnormal appearing lymph node 6 x 6mm, poorly differentiated with calcium deposits.  Having done a ton of research, I'm pretty sure this means (along with the high Tg) that the cancer has returned.  I am going tomorrow for a TSH stimulated whole body scan.

What I'd like to know is the following:  no matter what the results of the whole body scan, what would be the next step.  Would you recommend surgery and RAI or just one of those or neither?  I'm sure the field of thyroid cancer study has changed considerably in the 23 years since I first had cancer, so I'd like to know what the standard of care for recurrent papillary thyroid cancer is these days.

Thanks in advance!!!!!  

[dawn364]

A related discussion, Aletrnate treatments for thyroid prior to surgery? was started.

[Mark Lupo, M.D.]

Options -- high dose I-131 and hope the LN takes it up OR neck dissection by a skilled surgeon.  IMRT (XRT) is not needed at this point.  The neg PET suggests it is not very aggressive, but still it is tumor and should be dealt with -- or watched closely (if you are comfortable with that).

The other option would be ethanol ablation - like an FNA, only they inject alcohol.

[amela321]

So to recap, I have FNA positive recurrent thyroid cancer.  The WBS was negative and I just got the results of my PET scan and they were negative as well.  What could this mean?  I see in a previous post you've seen cases of PET negative FNA positive cancer.  I'm just wondering how it could not show up on either the WBS or the PET.

Also, with this information, what would be the course of treatment.  Can we maybe assume now that it IS still RAI avid and that my WBS didn't pick it up for some reason so would the course of treatment be a neck dissection followed by RAI?

I am so confused about all of this.  I'd really appreciate your input.

Thank you!!!

[amela321]

What do you think about doing another round of RAI?  In my research, I've seen differing opinions on this since the nodule I have didn't take up any iodine during my whole body scan.  Do you think, even in this scenario, I should have another RAI treatment?  If you don't think another RAI treatment will do any good, after the surgery, is IMRT called for or is that only to treat what they can't remove surgically?  

I'm asking the above questions assuming the cancer hasn't spread beyond my neck.  I'm sure your answer would be different if it has.

Your advice has really been appreciated.  Thank you.  

[Mark Lupo, M.D.]

The PET will be interesting, but not likely to show anything outside the neck - and don't be surprised if it does not even pick up the FNA positive node - it likely will, but I have seen PET neg, USFNA positive cancer.

In terms of surgery -- for this type of recurrence, there should be a dissection of the entire compartment and adjacent compartments, and usually a central (around the trachea) dissection - if this was not done at the time of the intial surgery (which it probably wasn't 23 years ago).  

The key here is a good pre-op ultrasound mapping of the neck for the surgeon. This is not readily available so a thin-cut neck CT-scan may be the best option.  It is important that the surgeon know exactly where the positive node is and what other possible abnormalities might be in the area.

[amela321]

I wish you luck too and hope everything works itself out for you.  My insurance did approved the PET scan today, so that's scheduled in 2 weeks, then the appt. with the surgeon the week after that.  I hate having to wait, but no choice, I guess.

[Hokiehoo]

I am so sorry to hear your news.  Your insurance company should easily approve the expense and I hope you're in an area where you have access to good treatment. Because I haven't had anything definitive show up on any tests yet, I have decided to wait 3 months and see what happens with my thyroglobulin level.  We will know what my mass is eventually.  In the meantime, I will keep you in my prayers.  

[amela321]

Per post below, the FNA came back positive for papillary thyroid cancer (after 23 years!!) so my question is what kind of surgery should be done?  Just taking out the node or taking out surrounding lymph nodes as well?  Even though this didn't show up with the dx dose of radioactive iodine, do you think they will treat with an rx dose anyway?

Thanks in advance!

[amela321]

Hi and thanks for asking.  I just got the results today.  Unfortunately, it came back positive for recurrent papillary thyroid cancer.  I'm scheduled to see a surgeon in 3 weeks and am waiting to see if my insurance company approves a PET scan to make sure it's not anywhere else.  Have you decided what direction you're going to go?

[Hokiehoo]

Any news on your FNA?

[amela321]

Thanks Hokiehoo.  I answered on your other post.  Just waiting for the results of the FNA now.  

[Hokiehoo]

You and I seem to be going through a similar experience. If you can, read my post re: "Recurrent cancer; RAI resistant; what to do". I have one acquaintance who was diagnosed with thyroid cancer several years ago, but he only had a part of his thyroid removed and his follow-up has been much different than mine.  Because your situation sounds so similar, I hope you continue posting your experiences.  It at least makes me feel a little better knowing I'm not the only one going through this process.  

[amela321]

Interesting development.  It turns out that the thyroglobulin level that came back as 23.0 was not from my most recent lab.  It was drawn in 2006 when I had been off of my synthroid for 6 weeks.  The most recent ones, taken a week ago before Thyrogen and on Synthroid (TSH extremely suppressed at 0.03) came back at 1.6 and after Thyrogen tsh stimulation came back as 6.0. So I have the 6.0 level, the finding (above post) on the ultrasound from 2 weeks ago and the negative WBS.  My doctor was extremely reluctant to pursue it any further and thinks "it's nothing."  I guess I don't understand.  I realize the 6.0 is lower than the 23.0, but wouldn't it be anyway because of the two ways of getting the result?  All of my research has told me that anything over 2.0 after rhTSH stimulation needs to be further investigated.  Anyway, I had to insist something be done and he reluctantly agreed on a FNA which I'm having today.  I guess where I'm confused is this....how can a Tg finding of 6.0 be nothing?  Isn't Tg only made by either normal thyroid tissue (which I shouldn't have after the near total thyroidectomy and 2 rounds of RAI) or by malignant thyroid tissue?  Shouldn't it be treated either way?   Is there any scenario that I haven't mentioned that would cause the Tg to be above .2?  

I've seen posts here about false negatives on FNA.  That seems, though, to be from people who still have their thyroid.  Is there a possibility of a false negative on the FNA they are doing on my lymph node today?  If the FNA comes back negative, should I just let it go or pursue something further with a different physician?    

I'm sorry for the long post, but really would like to understand better why my doctor doesn't seem to be concerned about this when I can't find anything in my research that suggests that he shouldn't be.

Thank you for your time.

[Mark Lupo, M.D.]

Would do PET next, then consider FNA.

[amela321]

Thank you very much for your response.  I received the results of my WBS.  There was no uptake...negative.  My doctor's office called for me to come in Tuesday morning.  I assume we'll be discussing options at that time.  Do you think the PET scan should be next?  Should I ask for them to plan a FNA of the lymph node also or should that wait for the PET scan results?  

Thanks again!

[Mark Lupo, M.D.]

This is an area of great debate -- the most aggressive approach is repeat neck surgery with removal of the cancer node and surrounding lymph nodes, often followed by repeat RAI.  Another option, if there is uptake on the upcoming WBS would be an RAI treatment and follow-up US and Tg levels.  The Tg of 23 is fairly high and treatment should be considered.  Would probably FNA the lymph node to document that it is cancer -- certainly this would need to be done before surgery.  

If the WBS is negative (ie no uptake anywhere) and the Tg high, then a PET scan can sometimes help determine where any other lesions may be and how aggressive (metabolic on PET) the lesions are.  This may help determine the course of treatment.

If it were my neck, and there is uptake on WBS (and perhaps even if there is not) I may be inclined to try a high dose RAI before undergoing a neck dissection for a small (<1cm) lymph node.