New Paradigms Emerging in Diagnosis, Management of Thyroid Cancer

An emerging trend that has more and more surgeons being trained and personally performing their patients’ imaging tests is encouraging, he added.

I think there’s no better person to do the neck ultrasound than the surgeon who is about to operate on, or has previously operated on, the patient, Dr. Tuttle said. Surgeons understand three-dimensional anatomy better than anyone on the planet. They understand the risks and benefits, so this trend toward surgeons learning to do ultrasonography, I think, is very good.

Managing Patients

Putting some of these new paradigms into practical terms, Dr. Tuttle offered his insight regarding the management of both low-risk and high-risk patients.

In low-risk patients-and by low risk I mean your 20- and 30-year-olds with papillary thyroid cancer, 2- or 3-cm papillaries, and two to four lymph nodes-the typical bread-and-butter 30-year-old womanwith thyroid cancer-the first thing that we do, down the road at six months or a year, is to measure thyroglobulin, he said. That’s our first test. It’s not a radioactive iodine scan; it’s not a PET scan and it’s not a CT. A physical exam and a serum thyroglobulin is where we start.

If, one year later, that patient still has measurable thyroglobulin, they either still have some normal thyroid tissue left in the neck or they have persistent disease and a surgeon should go in and find that disease, he said.

Unfortunately-and this is my truth in advertising, as much as it kills me to admit it-thyroid cancer is a surgical disease, Dr. Tuttle said. If at all possible, if there are lymph nodes, if there is disease remaining, it should be surgically excised. That’s the best way to treat this.

Ultrasound is the first stop, he said, for the patient with positive thyroglobulin.

It makes sense to do the ultrasound first, see if they have surgically correctable disease; it’s reasonable to also do a chest X-ray and then move toward radioactive iodine, he said. Fortunately for most patients, a year down the road, the thyroglobulin is undetectable or almost undetectable.

That measurement, however, is potentially unreliable, Dr. Tuttle cautioned, because about 20% of these patients who have an undetectable thyroglobulin at one year will still measure positive for thyroglobulin when stimulated, suggesting that some disease is still present.

When a paper on this came out, I started stimulating these patients. I thought I was trying to find these people with low-level thyroid cancer, so that I could cure them with more radioactive iodine or more surgery, he said. It turns out, though, that’s not the reason to do this test. The reason is to find those patients that were low-risk patients who, a year down the road, have an undetectable thyroglobulin and when you stimulate them, they still have an undetectable stimulated thyroglobulin. This is as close to a cure in thyroid cancer as we’re ever going to get.