Follow up for patients with thyroid cancer

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Follow up for patients with thyroid cancer

  1. 1. Follow up for patients with thyroid cancer
  2. 2. TNM definition <ul><li>TX: Primary tumor cannot be assessed </li></ul><ul><li>T0: No evidence of primary tumor </li></ul><ul><li>T1: Tumor 1 cm or less in greatest dimension limited to the thyroid </li></ul><ul><li>T2: Tumor more than 1 cm but not more than 4 cm in greatest dimension limited to the thyroid </li></ul><ul><li>T3: Tumor more than 4 cm in greatest dimension limited to the thyroid </li></ul><ul><li>T4: Tumor of any size extending beyond the thyroid capsule </li></ul>
  3. 3. <ul><li>Regional lymph nodes (N) </li></ul><ul><li>Regional lymph nodes are the cervical and upper mediastinal lymph nodes. </li></ul><ul><li>NX: Regional lymph nodes cannot be assessed </li></ul><ul><li>N0: No regional lymph node metastasis </li></ul><ul><li>N1: Regional lymph node metastasis </li></ul><ul><ul><li>N1a: Metastasis in ipsilateral cervical lymph node(s) </li></ul></ul><ul><ul><li>N1b: Metastasis in bilateral, midline, or contralateral cervical or mediastinal lymph node(s) </li></ul></ul>
  4. 4. <ul><li>Distant metastases (M) </li></ul><ul><li>MX: Distant metastasis cannot be assessed </li></ul><ul><li>M0: No distant metastasis </li></ul><ul><li>M1: Distant metastasis </li></ul>
  5. 5. Stage grouping <ul><li>Papillary or follicular </li></ul><ul><ul><li>Under 45 years </li></ul></ul><ul><ul><ul><ul><li>Stage I </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Any T, any N, M0 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Stage II </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Any T, any N, M1 </li></ul></ul></ul></ul></ul>
  6. 6. <ul><ul><li>45 years and older </li></ul></ul><ul><ul><ul><li>Stage I </li></ul></ul></ul><ul><ul><ul><ul><li>T1, N0, M0 </li></ul></ul></ul></ul><ul><ul><ul><li>Stage II </li></ul></ul></ul><ul><ul><ul><ul><li>T2, N0, M0 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>T3, N0, M0 </li></ul></ul></ul></ul><ul><ul><ul><li>Stage III </li></ul></ul></ul><ul><ul><ul><ul><li>T4, N0, M0 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Any T, N1, M0 </li></ul></ul></ul></ul><ul><ul><ul><li>Stage IV </li></ul></ul></ul><ul><ul><ul><ul><li>Any T, any N, M1 </li></ul></ul></ul></ul>
  7. 7. Stage I papillary <ul><li>Cancer is only in the thyroid and may be found in one or both lobes. </li></ul>
  8. 8. Stage II papillary <ul><li>In patients younger than 45 years of age: </li></ul><ul><ul><li>Cancer has spread beyond the thyroid. </li></ul></ul><ul><li>In patients older than 45 years of age: </li></ul><ul><ul><li>Cancer is only in the thyroid and larger than 1 centimeter (about 1/2 inch). </li></ul></ul>
  9. 9. Stage III papillary <ul><li>Cancer is found in patients older than 45 years of age and has spread outside the thyroid (but not outside of the neck) or has spread to the lymph nodes. </li></ul>
  10. 10. Stage IV papillary <ul><li>Cancer is found in patients older than 45 years of age and has spread to other parts of the body, such as the lungs and bones </li></ul>
  11. 11. STAGE I PAPILLARY THYROID CANCER <ul><li>Treatment may be one of the following: </li></ul><ul><ul><li>1. Surgery to remove one lobe of the thyroid (lobectomy), followed by hormone therapy. Radioactive iodine also may be given following surgery. 2. Surgery to remove the thyroid (total thyroidectomy). </li></ul></ul>
  12. 12. STAGE II PAPILLARY THYROID CANCER <ul><li>Treatment may be one of the following: </li></ul><ul><ul><li>1. Surgery to remove one lobe of the thyroid (lobectomy) and lymph nodes that contain cancer, followed by hormone therapy. Radioactive iodine also may be given following surgery. 2. Surgery to remove the thyroid (total thyroidectomy). </li></ul></ul>
  13. 13. STAGE III PAPILLARY THYROID CANCER <ul><li>Treatment may be one of the following: </li></ul><ul><ul><li>1. Surgery to remove the entire thyroid (total thyroidectomy) and lymph nodes where cancer has spread. 2. Total thyroidectomy followed by radiation therapy with radioactive iodine or external beam radiation therapy. </li></ul></ul>
  14. 14. STAGE IV PAPILLARY THYROID CANCER <ul><li>Treatment may be one of the following: </li></ul><ul><ul><li>1. Radioactive iodine. 2. External beam radiation therapy. 3. Hormone therapy. 4. A clinical trial of chemotherapy. </li></ul></ul>
  15. 15. <ul><li>The protocol for follow-up of patients with well differentiated thyroid cancer will differ from center to center </li></ul><ul><li>initially seen at 6 month intervals </li></ul><ul><li>thyroid cancer has been successfully treated, with no evidence for residual disease on physical examination, scanning, or thyroglobulin testing, follow-up may be scheduled at yearly intervals </li></ul>
  16. 16. <ul><li>Routine follow-up assessment will include physical examination focused on the  and neck, and blood tests, including TSH and thyroglobulin . </li></ul><ul><li>Periodic chest X rays may also be indicated </li></ul>
  17. 17. <ul><li>outpatient radioactive iodine scans </li></ul><ul><li>need for regular thyroid hormone withdrawal and iodine scanning </li></ul><ul><li>recombinant TSH-stimulated  (Thyrogen) thyroglobulin testing be the primary test for follow-up of patients </li></ul>
  18. 18. <ul><li>(Thyrogen) for TSH-stimulated thyroglobulin blood tests eliminates the need for withdrawal of thyroid hormone and the development of hypothyroidism. </li></ul>
  19. 19. <ul><li>In patients who have thyroid cancer confined to the thyroid, with no evidence of extra-thyroidal disease at the time of surgery  or on the first total body radioactive iodine scan, with an undetectable TSH-stimulated thyroglobulin,  it may not be necessary to have periodic or regular thyroid scans. </li></ul>
  20. 20. <ul><li>more extensive thyroid cancer : </li></ul><ul><li>or evidence for abnormal iodine accumulation outside the thyroid bed on the radioactive iodine scan after the initial radioactive iodine treatment. For these patients, initial periodic rescanning with radioactive iodine as an outpatient may be considered </li></ul>
  21. 21. <ul><li>Nevertheless, the accuracy of routine scanning for follow-up of thyroid cancer has been questioned </li></ul><ul><li>Thyroglobulin level is a better predictor of disease recurrence than a nuclear medicine scan </li></ul>
  22. 22. <ul><li>an undetectable thyroglobulin after their first withdrawal of Thyrogen scan, the utility of a subsequent total body iodine scan appears questionable </li></ul>
  23. 23. <ul><li>The superior performance and enhanced sensitivity of the TSH-stimulated Tg test alone, compared to the inclusion of the whole body scan plus Tg, for the detection of recurrent or residual thyroid cancer </li></ul>
  24. 24. <ul><li>Repeat diagnostic scanning for thyroid cancer recurrence has traditionally involved withdrawal of thyroid hormone for 4-6 weeks </li></ul><ul><li>to make patients hypothyroid for the scan to be informative </li></ul>
  25. 25. <ul><li>as the pituitary production of TSH maximally stimulates uptake of the diagnostic dose of radioactive iodine (5mci) </li></ul><ul><li>usually done as an outpatient, hence there is no need for isolation or extreme precautions </li></ul>
  26. 26. <ul><li>Common sense dictates that a small amount of radioactive iodine may be present in body fluids for a few days after the scan, so avoiding intimate exchange of body fluids, shared foods, prolonged kissing etc, may be reasonable for a few days after the administration of radioactive iodine </li></ul>
  27. 27. <ul><li>At the same time as the scan is done, a blood test for TSH and the thyroglobulin protein should also be done </li></ul><ul><li>normal values are: </li></ul><ul><li>0 - 34 ug/L for patients who still have their thyroid gland and </li></ul><ul><li>0 - 3 ug/L for patients following surgical removal and thyroid ablation </li></ul>
  28. 28. <ul><li>importance of keeping the TSH suppressed during ongoing management of patients with thyroid cancer. The standard therapy for patients with thyroid cancer is Treatment with L- thyroxine </li></ul>
  29. 30. Q and A <ul><li>Q: thyroglobulin levels are low or undetectable. Does this guarantee that my thyroid cancer has not returned? </li></ul><ul><li>A: it is possible for thyroid cancer to recur, yet the thyroglobulin levels may be low or undetectable. Hence the thyroglobulin alone is not 100% perfect in the follow-up of patients with thyroid cancer </li></ul>
  30. 31. <ul><li>A: Nevertheless, a low thyroglobulin after initial surgery seems to be a useful prognostic sign </li></ul>
  31. 32. <ul><li>A: total body scan is negative but my thyroglobulin is elevated. What should I do? </li></ul><ul><li>Q: First, it is important to make sure that the thyroglobulin is not falsely elevated as a result of antibodies ( 如果不是 ;tumor too small ,scan 不到 or 不能 uptake) </li></ul><ul><li>empiric treatment with high dose radioactive iodine, followed by a repeat total body scan </li></ul>
  32. 33. <ul><li>A: It is not uncommon for a single abnormal thyroglobulin to be elevated, followed by a repeat blood test a few months later where the thyroglobulin may be lower, or even undetectable. In other cases, where the thyroglobulin blood test abnormality persists, additional imaging studies may be requested, such as a neck ultrasound, high resolution CT scan, MRI PETscan . </li></ul>

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