How do doctors assess differentiated thyroid cancer and develop a treatment plan based on disease characteristics? Let’s look at Mr. Lee’s experience.
Mr. Li, 54, had an ultrasound finding of a nodule on the right side of his thyroid with a TI-RADS grade of 4B during a physical exam at a local hospital 1 month ago.
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First visit: consultation, physical examination, neck ultrasound, thyroid function test
Mr. Li came to our hospital for his first visit. After detailed questioning, the doctor performed neck palpation and found a palpable mass in the right thyroid gland, about 1.5 cm in size, hard in texture, moving up and down with swallowing, and no obvious enlarged lymph nodes were palpable in either side of the neck. The doctor carefully asked whether there is neck pain and discomfort, hoarseness, breathing difficulties, swallowing difficulties, sweating and wasting, panic and hand trembling, fever and palpitations and other symptoms, Mr. Li denied them all.
The outpatient doctor prescribed neck ultrasound and thyroid function tests and instructed Mr. Li to see him again after the tests were completed.
Ultrasound suggests a right central dorsal thyroid nodule measuring 17*18 mm with a TI-RADS grade of 4C, which is considered malignant. No significant abnormalities were found in the left thyroid, bilateral neck and supraclavicular.
Thyroid function tests suggest that all indicators are within normal limits.
Re-visit: fine needle aspiration and enhanced CT of the neck
When Mr. Li returned, the doctor prescribed a fine needle aspiration of the thyroid gland and an enhanced CT of the neck based on the history and test results.
The fine needle aspiration suggested a right thyroid nodule, papillary thyroid cancer, and BRAF gene mutation.
Enhanced CT of the neck showed a slightly hypointense nodule in the right lower and middle thyroid gland with a border of 18*14 mm and no obvious enlarged lymph nodes in either side of the neck.
The doctor said:
The clinical diagnosis of thyroid cancer is based on clinical symptoms and signs, laboratory tests, imaging and pathological examination. Mr. Li had no clinical symptoms at his initial visit and only one physical examination ultrasound, so the physician refined the tests at his two visits to our hospital. You can click below to see exactly what each test does.
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Also, you may find it strange why the grading of physical ultrasound and follow-up ultrasound is different. This is due to the fact that the judgment of ultrasound results is somewhat subjective, and doctors with different experience may come up with different results. We recommend that you visit a regular specialist hospital.
Surgery: radical thyroidectomy of the right side
Mr. Li was then admitted to the hospital. After completing preoperative tests, he underwent radical thyroid cancer resection of the right thyroid lobe + isthmus + lymph node dissection in the right central region under general anesthesia.
Intraoperatively, we found a right thyroid nodule of approximately 2 cm in size, with a hard texture, irregular shape, no obvious envelope, and no obvious adhesions to surrounding tissues. There were several enlarged lymph nodes in the central area, approximately 0.8-1 cm in size.
Postoperative paraffin pathology showed a papillary carcinoma of the right thyroid gland, classic, 1.8*1.6 cm in size, without envelope, nerve, or vascular invasion. Metastases were seen in the lymph nodes in the central region (3/6, meaning that 6 lymph nodes were cleared and metastatic cancer was found in all 3 lymph nodes).
On postoperative day 2, Mr. Li could eat normally without discomfort such as hoarseness, dysphagia, choking on water, and numbness in the hands and feet; the neck drainage was clear, small, and light blood-colored.
On postoperative day 3, the neck drain was removed and he was discharged from the hospital.
The doctor said:
The treatment of differentiated thyroid cancer is primarily surgical. According to the latest international staging criteria, anyone under 55 years of age with no distant metastases is stage I, regardless of the size and invasion of the primary thyroid tumor and regardless of the number of lymph node metastases in the neck. This is the case for Mr. Li.
Therefore, stage I can also have multiple surgical options, from unilateral lobectomy + isthmus + lymph node dissection in the central region to total thyroidectomy + bilateral lateral neck lymph node dissection. The exact surgical approach will also be determined by the preoperative workup.
Post-discharge: TSH suppression therapy
Mr. Li took 50 micrograms of eugenol (levothyroxine) orally every morning on an empty stomach.
The doctor said:
Adjuvant therapy after surgery for differentiated thyroid cancer consists of TSH (thyrotropin, thyroid stimulating hormone) suppressive therapy and radioactive iodine (RAI) therapy.
TSH suppression therapy, also called endocrine therapy, is a “must” for all patients with differentiated thyroid cancer and is often maintained for life. The goal is to replenish thyroid hormones and to suppress TSH levels to reduce the risk of recurrence. The most common drug used in China is levothyroxine sodium tablets (trade names: Eugenol, Raltez).
RAI therapy is only indicated for a subset of patients who have had total thyroidectomy. Postoperative RAI therapy is generally recommended for patients with a higher risk of recurrence, and the doctor’s decision will be based on a combination of tumor size, pathologic subtype, presence of BRAF gene mutations, tumor outgrowth, and number of lymph node metastases.
Targeted agents for differentiated thyroid cancer, only one of which is currently available in China, sorafenib (trade name: doxorubicin), is indicated for locally recurrent or metastatic, progressive RAI-refractory thyroid cancer. Patients with stage I differentiated thyroid cancer do not need targeted therapy after surgery.
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Follow-up
Three months after surgery, Mr. Li came to the clinic for follow-up. The B ultrasound showed that the right side of the thyroid gland had been removed, and there were no abnormalities in the left side of the thyroid gland and bilateral neck. The postoperative thyroid function was within the normal range.
The doctor informed Mr. Li that no adjustment of medication or other treatment was needed and that he would be followed up again in 3 months.
The doctor said:
Follow-up is especially important because of the good outcome of differentiated thyroid cancer and the long postoperative survival of patients.
Purposes of follow-up:
1) to maintain stable thyroid hormone levels while undergoing TSH suppression therapy to ensure postoperative quality of life;
2) Early detection of local recurrent metastases in the neck;
3) Early detection of systemic metastases.
Patients are usually required to have neck ultrasound and thyroid function tests every 3 months for the first year after surgery, with the frequency of follow-up determined by the test results. If stable over time, then at least 1 neck ultrasound and thyroid function test per year and a chest radiograph every 2 years are required.
Conclusion
After reading Mr. Lee’s case, you should know how to treat stage I differentiated thyroid cancer and understand your doctor’s thinking, right? The results of early-stage thyroid cancer are good, and with aggressive treatment and close follow-up, you can enjoy a happy life as a normal person.
Disclaimer:
Tumors are extremely complex and treatment options are highly individualized, and this case does not represent a treatment decision for a “similar patient. Please seek professional advice from a competent physician regarding your specific treatment plan.
Co-written by Dr. Jiaqian Hu, Fudan University Cancer Hospital