Management of Recurrent Thyroid Cancer

R. Michael Tuttle, MD
Assistant Professor of Medicine, Cornell School of Medicine
Memorial Sloan Kettering Cancer Center
New York, NY

Complaint:
Follow-up visit: history of thyroid cancer

Medical History:
The patient is a 26-year-old female who recently graduated from college and is engaged to be married in 6 months. Her last visit to your office was over 2 years ago. She currently is clinically euthyroid with no problems with her voice and no difficulty swallowing or breathing. She is unaware of any new lumps or bumps in her neck. She comes in today for a checkup before getting married and beginning her new job.

At 23 years of age, she was noted to have an asymptomatic 3-cm mass in the right lobe of her thyroid during a routine office visit. Ultrasound of the neck confirmed a 3 cm solitary thyroid nodule, and fine needle aspiration demonstrated classic findings for papillary thyroid cancer. Her thyroid function tests were normal.

One month later, she underwent a total thyroidectomy and had 4 "suspicious" lymph nodes removed from the right neck at the time of her initial surgery. All evidence of gross disease was removed, and she did well post operatively with no change in her voice and normal calcium levels. 

Histological evaluation of the thyroid revealed a 3.2-cm, well-differentiated, papillary thyroid cancer. Two of 4 sampled lymph nodes also contained papillary thyroid cancer. There was no direct extrathyroidal extension of the tumor and no evidence of vascular invasion.

Six weeks postoperatively, she received 75 mCi of iodine131 (131I) following standard hypothyroid levothyroxine withdrawal. A radioactive iodine (RAI) scan performed five days later revealed uptake only in the thyroid bed without evidence of cervical or distant RAI avid metastatic lesions.

She was then placed on levothyroxine suppressive therapy. Her most recent blood tests were done 1 year ago (2 years after thyroidectomy and RAI ablation). These blood tests revealed a thyroid-stimulating hormone (TSH) level of 0.1 IU/mL (0.37-4.42,) a free thyroxine (T₄) of 2.1 ng/dL (0.8-2), and a serum thyroglobulin of 1.9 ng/mL (2-70) with no measurable antithyroglobulin antibodies.

Past Medical History:
Her past medical history is otherwise unremarkable. Her only medications are birth control pills and levothyroxine 150 g Qd, although she readily admits to frequently missing levothyroxine doses over the last few months because of her hectic schedule.

Vital Signs:

Height: 5 feet, 2 inches
Weight: 130 pounds
Blood Pressure: 104/68
Respirations: 12 
Heart Rate: 72 bpm
Temperature: 36.2 C

Physical Examination:

She is a well-developed, well-nourished white female, who is alert and oriented to person, place, and time.
HEENT: normal examination including a normal voice.
NECK: Well-healed thyroid surgical scan in the anterior neck. She has no masses palpable in    the thyroid bed. No palpable cervical or supraclavicular lymphadenopathy.
LUNGS: Clear to auscultation
HEART: Regular rate and rhythm without murmurs
ABDOMEN: Soft and nontender
EXTREMITIES: No clubbing, cyanosis or edema
NEURO: nonfocal examination