Management of Patients with Differentiated Thyroid Cancer
Management of Patients with Differentiated Thyroid Cancer
European Endocrine Disease 2007 - Issue I
Published: October 2008
Published: October 2008
The management of patients with differentiated thyroid carcinoma (DTC) has changed dramatically over the last few decades, resulting in a 20% fall in thyroid cancer mortality rates, for example, in the US between 1973 and 1996. The improvement of post-surgical management is mainly due to the introduction of serum thyroglobulin (Tg) measurements as evidence of tumour recurrence. Recently, overall management has been supplemented by the possibility of stimulating any remaining thyroid cells in the body, including metastases, with recombinant human thyrotropin (rhTSH). Therefore, both national and international guidelines are based on these principles.1–5
Questions remain unanswered concerning differentiated-thyroid carcinoma
• What is the role and optimal extent of surgery?
• What is the role of adjuvant therapy?
• What is the role of thyroid hormone therapy?
• What is the optimal monitoring therapy?
There is increasing international recognition of the need for changing and agreeing upon strategies for these patients, and the aim of this review is to look into the evidence relating to some of these matters Topics relate to the choice of method for measuring serum Tg, how to assess nterference of Tg autoantibodies (TgAbs), how to manage patients who have these TgAbs, whether or not to perform whole body scan (wbs), using iodide-131 (131I), routinely and how to suppress serum thyrotropin (TSH).
Types, Epidemiology and Prevalence of Thyroid Cancer
The histological types of thyroid cancer include the most frequent differentiated forms - papillary and follicular cancers (DTC) - as well as the less prevalent types: anaplastic, medullary, lymphomas and other rare types The incidence of thyroid carcinoma is, in most populations, 20-50 per million inhabitants, but the mortality rate in the US, for example, is only five per million inhabitants, and therefore any population has an accumulation of survivors after treatment for DTC. The papillary cancers are usually less aggressive than the follicular ones, the former metastasising to neck lymph nodes, whereas the follicular cancers often develop distant metastases. The ratio between these two types (papillary/follicular) depends on the iodine ntake of the population, with the less aggressive papillary cancers appearing at a higher rate in iodine sufficient areas compared with areas of iodine nsufficiency. The overall cancer prevalence is probably not higher in areas of iodine deficiency, although this is debatable. An increased prevalence is noted after the thyroid glands of children have been exposed to radiation The childhood thyroid carcinomas seen in Chernobyl, for example, have commonly been the papillary type, but with a more aggressive variation Data from large cohorts of patients and long-term follow-up comes mainly from the US, finding 40-year relative survival rates of papillary and follicular cancer at 94 and 84%, respectively. The corresponding recurrence rates were about 35%, two-thirds of which occurred within the first decade. Cancer mortality from DTC with local recurrence was about 12%, and with distant recurrence about 43%
References:
- Mazzaferi EL, Robbins RJ, Spencer CA, et al., A consensus report of the role of serum thyroglobulin as a monitoring method for low-risk patients with papillary thyroid carcinoma, J Clin Endocrinol Metab, 2003;88:1433–41.
- Schlumberger M, Berg G, Cohen O, et al., Follow-up of low risk patients with differentiated thyroid carcinoma: a European perspective, European J Endocrinol, 2004;150:105–12.
- Pacini F, Schlumberger M, Dralle H, et al., European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium, Eur J Endocrinol, 2006;154:787–803.
- NCCN Clinical Practice Guidelines in Oncology, May 2003. www.nccn.org
- British Thyroid Association guidelines: Guidelines for the management of patients with thyroid carcinoma, www.britishthyroid- association.org
- Mazzaferi EL, Kloos RT, Current approaches to primary therapy for papillary and follicular thyroid cancer, J Clin Endocrinol Metab, 2001;86:1447–63.
- Torlontano M, Attard M, Crocetti U, et al., Follow-up of low risk patients with papillary thyroid cancer: role of neck ultrasonography in detecting lymph node metastases, J Clin Endocrinol Metab, 2004;89:3402–7.
- Pacini F, Capezzone M, Elisei R, et al., Diagnostic 131-iodine whole-body scan may be avoided in thyroid cancer patients who have undetectable stimulated serum Tg levels after initial treatment, J Clin Endocrinol Metab, 2002;87:1499–1501.
- Pacini F, Molinaro E, Castagna MG, et al., Recombinant human thyrotropin-stimulated serum thyroglobulin in combination with neck ultrasonography has the highest sensitivity in monitoring differentiated thyroid carcinoma, J Clin Endocrinol Metab, 2003;88:3668–73.
- NACB guidelines, Laboratory Support for the diagnosis and monitoring of thyroid diseases, Thyroid, 2003;13:1–126. www.nacb.org
- Pacini F, Molinaro E, Lippi F, et al., Prediction of disease status by recombinant human TSH-stimulated serum thyroglobulin in the postsurgical follow-up of differentiated thyroid carcinoma, J Clin Endocrinol Metab, 2001;86:5686–90.
- Robbins RJ, Tuttle RM, Sharaf RN, et al., Preparation by recombinant human thyrotropin or thyroid hormone withdrawal are comparable for the detection of residual differentiated thyroid carcinoma, J Clin Endocrinol Metab, 2001;86:619–25.
- Robbins RJ, Chon JT, Fleischer M, et al., Is the serum thyroglobulin response to recombinant human thyrotropin sufficient, by itself, to monitor for residual thyroid carcinoma?, J Clin Endocrinol Metab, 2002;87:3242–7.
