Thyroid Cancer - What's Next?
Once thyroid cancer is diagnosed, a patient should be informed of the treatments and educated as to the proper surveillance for recurrence.
During the first year after diagnosis of thyroid cancer there can be many visits with your physicians. How often you will need to see your endocrinologist at Houston Thyroid and Endocrine after the first year will depend on a patient's thyroid cancer staging. Texas endocrinologists Dr. Jogi , Dr. Elhaj, and Dr. Desai are thyroid cancer doctors that will give you detailed information on your treatment options. Your endocrinologist should be the primary physician managing your thyroid cancer. The thyroid glossary and endocrinology conditions review unfamiliar terminology. The basic treatment of thyroid cancer may include some or all of these management strategies listed below.
This section below reviews how the usual chronology of management strategies may be implemented with a general hypothetical timeline for well-differentiated thyroid cancer, specifically papillary and follicular thyroid cancer. Actual chronology depends on a patient's specific circumstances and clinical information. In all circumstances your endocrinologist should be directing your care and answering your questions unless indicated below. The endocrinologists at Houston Thyroid and Endocrine will be happy to give you detailed directions.
1. Accurate Diagnosis
A diagnosis or suspicion of thyroid cancer based on fine needle aspiration biopsy (FNA) of thyroid nodule is made. Endocrinologists are usually the type of physician to mange this condition. The endocrinologists at Houston Thyroid and Endocrine would discuss fully the management of thyroid cancer and perform a pre-operative full neck ultrasound to search for possible metastatic thyroid cancer.
2. Surgery Referral
Completeness of surgical resection is an important determinant of outcome because any metastatic thyroid cancer in lymph nodes represents the most common site of disease recurrence/persistence. The extent of surgery and location of disease both play important roles in determining the risk of surgical complications. Your surgery date will be planned.
Patients are given a surgical date for thyroidectomy by the surgeon. For most patients with thyroid cancer larger than 1cm, the initial surgical procedure should be near total or total thyroidectomy unless there are contraindications to this surgery. Most patients will be able to return home within 1 week after the surgery, but this may vary greatly depending on the type of surgery planned and complications from surgery, if any. Speak to your surgeon in detail about this issues.
Wound and Pathology Evaluation
Patients usually visit their surgeon a few days after return home from surgery to inspect the wound and check blood calcium levels. You will meet with your Houston endocrinologist one to two weeks after the surgery to determine if and when you should start taking thyroid hormone suppression therapy based on the type of surgery, final surgical pathology report, and TNM staging of your thyroid cancer. If your endocrinologist decides that a radioactive iodine treatment is needed, you will be instructed to follow a low iodine diet. You may be asked to remain off thyroid hormone medication until your TSH level rises to greater than 25 mIU/L or receive injections of thyrogen to stimulate elevation of your TSH. A high TSH will make any left over microscopic thyroid cells 'hungry' to take up radioactive iodine which will destroy them . When the visit is done a patient is given a set of detailed orders:
3. Radioactive Iodine Remnant Ablation Treatment and Post-Treatment Scanning
If your endocrinologist has determined that you will benefit from radioactive iodine treatment based on your thyroid cancer staging, and your TSH has risen sufficiently, a patient will meet with the nuclear medicine department to be dosed with radioactive iodine depending on the instructions of your endocrinologist ( PATH 1, PATH 2). The dose of iodine will depend on the stage of thyroid cancer. This is an outpatient procedure. All patients will be allowed to go home with some restrictions after the medication is taken. Read through the radioactive iodine instructions and precautions section to understand what restrictions you will have to follow. Here are some common side effects of iodine therapy. We have a Radioactive Iodine Clinic for our patients.
4. Thyroid Hormone Suppression and lab evaluation
Thyroid hormone will be started in pill form to not just replace the hormone your thyroid is no longer producing but also to prevent regrowth of the tumor. The dose of the medication will be higher than what would usually be given to patients who are hypothyroid from conditions other than thyroid cancer. Generally only an endocrinologist or physicians very familiar with thyroid cancer treatment should manage your thyroid hormone dose. The TSH value will be pushed lower than the "normal" range, making a patient slightly hyperthyroid. If a patient develops symptoms of hyperthyroidism which are problematic, then the dose may be reduced.
The staging of the thyroid cancer will determine the degree of thyroid-hormone-suppression "chemo" therapy. Most patients will require a TSH goal that is well below what would be recommended for patients with hypothyroidism due to non-thyroid-cancer reasons. Your endocrinologist will check your blood work at this time to determine if you are on the correct dose of thyroid hormone. A general rule of thumb is that most patients require 2.1 times their body weight in kilograms of T4 equivalents. At each visit your endocrinologist may make adjustments to your thyroid hormone dosing.
5. Neck and Thyroid Bed/Lateral Neck Ultrasound
Following surgery, neck ultrasound to evaluate the thyroid bed and central and lateral neck nodal compartments should be performed at 6–12 months and then periodically, depending on the patient’s risk for recurrent disease and thyroglobulin status. Your endocrinologist will perform this specialized neck ultrasound. A regular "thyroid ultrasound" is not sufficient to locate metastatic disease in the neck.
6. Withdrawal or Thyrogen Stimulated Whole body scan and Thyroid Bed/ Lateral Neck Ultrasound
A patient with a thyroid cancer history may have one or more whole body iodine scans done after the surgery . This scanning requires may or may not require discontinuation of thyroid hormone for 3 weeks (Path A or Path B) or stimulation with thyrogen (Path C or Path D). It depends on the instructions of your endocrinologist. Blood testing called withdrawal or stimulated thyroglobulin will also be drawn to see if there is biochemical evidence of thyroid cancer.
7. General Surveillance
Thyroglobulin levels, thyroglobulin antibodies, and TSH values will determine if the thyroid hormone replacement dosage is correct. Thyrglobulin is a marker of thyroid tissue in general. After a thyroid surgery and radioactive iodine treatment, thyroglobulin can be used as a monitoring parameter for thyroid cancer recurrence. Depending on the findings of thyroglobulin, ultrasound, and whole body scanning, your Houston Thyroid and Endocrine endocrinologist will order subsequent testing. If these tests are unremarkable then no further tests may be needed depending on the circumstances. Otherwise, various imaging tests will be used to locate the disease recurrence over the lifetime of the patient. How often a patient is scheduled for visits with Houston Thyroid and Endocrine will depend on each patient's individual circumstances.