Exclusion of thyroid cancer based on imaging studies

Ultrasound is the recommended staging modality for papillary thyroid cancer. Surgeons proficient in US assessment of the neck and experienced in the management of papillary thyroid cancer (PTC) appear uniquely qualified to assess the lateral cervical lymph nodes for metastatic disease. Of 310 patients treated for PTC between 2000 and 2008, 109 underwent surgeon-performed ultrasound (SUS) of the lateral neck preoperatively. Fine needle aspiration was performed on suspicious lateral lymph nodes. SUS findings were compared with FNA cytology and results of postoperative imaging studies. The sensitivity and negative predictive value of SUS were 88% and 97%, respectively. Four patients were found to have missed metastatic disease within 6 months. No patient underwent a nontherapeutic neck dissection. SUS combined with US-guided FNA of suspicious lymph nodes can accurately stage PTC to reliably direct surgical management.

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A Case of a Rare Association Between Right Thyroid Hemiagenesis, Lingual Thyroid, and Papillary Thyroid Cancer

US Endocrinology ◽

10.17925/use.2017.13.01.01 ◽

2017 ◽

Vol 13 (01) ◽

pp. 01

Author(s):

Umal Azmat ◽

John E Phay ◽

Theodoros Teknos ◽

James Bekeny ◽

Fadi Nabhan ◽

...

Keyword(s):

Thyroid Cancer ◽

Thyroid Nodules ◽

Pregnant Patient ◽

Left Lobe ◽

Lingual Thyroid ◽

Nodal Disease ◽

Imaging Studies ◽

Developmental Abnormalities ◽

Thyroid Hemiagenesis ◽

Initial Surgery

Lingual thyroid and thyroid hemiagenesis are rare thyroid developmental abnormalities. These conditions can be present with other thyroid diseases, whether functional ones involving abnormal thyroid hormone levels, or structural ones such as presence of thyroid nodules, however the association with thyroid cancer and lingual thyroid or thyroid hemiagenesis is rare. In addition to that, when thyroid hemiagenesis is present, it is usually in the left lobe. We describe here a pregnant patient who presented with metastatic cervical nodes from thyroid cancer who was found on imaging to have right thyroid hemiagenesis. After she underwent an initial surgery for thyroid cancer and metastatic nodal disease, she was then later discovered to have a lingual thyroid. In this case we report this extremely rare combination and also discuss the potential implications of this association on the diagnosis and management of these patients particularly initial surgery and imaging studies needed for the thyroid cancer.

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Comparison of 68Ga PET/CT to Other Imaging Studies in Medullary Thyroid Cancer: Superiority in Detecting Bone Metastases

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2018-00193 ◽

2018 ◽

Vol 103 (9) ◽

pp. 3250-3259 ◽

Cited By ~ 10

Author(s):

Luciana Audi Castroneves ◽

George Coura Filho ◽

Ricardo Miguel Costa de Freitas ◽

Raphael Salles ◽

Raquel Ajub Moyses ◽

...

Keyword(s):

Thyroid Cancer ◽

Bone Metastases ◽

Medullary Thyroid Cancer ◽

Imaging Studies ◽

Medullary Thyroid ◽

Pet Ct

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Improved detection of medullary thyroid cancer with radiolabeled antibodies to carcinoembryonic antigen.

Journal of Clinical Oncology ◽

10.1200/jco.1996.14.4.1209 ◽

1996 ◽

Vol 14 (4) ◽

pp. 1209-1217 ◽

Cited By ~ 33

Author(s):

M Juweid ◽

R M Sharkey ◽

T Behr ◽

L C Swayne ◽

A D Rubin ◽

...

Keyword(s):

Thyroid Cancer ◽

Carcinoembryonic Antigen ◽

Medullary Thyroid Cancer ◽

Imaging Studies ◽

Medullary Thyroid ◽

Primary Surgery ◽

Occult Disease ◽

Iodine 131 ◽

Iodine 123 ◽

Magnetic Resonance Imaging Mri

PURPOSE This investigation was undertaken to assess the targeting of established and occult medullary thyroid cancer (MTC) with radiolabeled monoclonal antibodies (MAbs) reactive with carcinoembryonic antigen (CEA). PATIENTS AND METHODS Twenty-six assessable patients with known (n = 17) or occult (n = 9) MTC were studied with radiolabeled anti-CEA MAbs. Scintigraphic images were collected to determine targeting of tumor lesions. RESULTS The targeting results of technetium 99m (99mTc)-,iodine 123 (123I)-, and iodine 131 (131I)-labeled anti-CEA antibodies (all directed against the same epitope of CEA) indicated that all these reagents were capable of detecting established and occult MTC. The sensitivity for detection of known sites of disease ranged from 76% to 100% for the various anti-CEA MAbs used, when compared with computed tomography (CT), magnetic resonance imaging (MRI), bone scan, or other imaging modalities. Moreover, the antibody scan was positive in seven of nine patients with occult disease (patients with negative conventional imaging studies, but who had elevated calcitonin and/or CEA levels). Three of seven patients underwent surgery and the disease was confirmed by histopathology in all three. CONCLUSION Anti-CEA MAbs are excellent agents for imaging recurrent, residual, or metastatic MTC. The high lesion sensitivity in patients with known lesions, combined with the ability to detect disease, may make these agents ideal for staging patients, monitoring disease pretherapy or posttherapy, and especially for evaluating patients with recurrent or persistent hypercalcitonemia or CEA elevations after primary surgery. Analogous to radioiodine in the evaluation of patients with differentiated thyroid cancer, radiolabeled anti-CEA MAbs may achieve a similar role in diagnosing and monitoring patients with MTC.

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MON-448 Detection of Thyroid Cancer Recurrence in Patients with Positive Thyroglobulin Antibody Receiving Immunoglobulin Therapy

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1117 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Adeyinka Taiwo ◽

Ayotunde Dokun

Keyword(s):

Thyroid Cancer ◽

Thyroid Nodule ◽

Immune Globulin ◽

Cancer Recurrence ◽

Immunoglobulin Therapy ◽

Imaging Studies ◽

Thyroglobulin Antibody ◽

Thyroglobulin Level ◽

Antibody Levels ◽

Thyroid Cancer Recurrence

Abstract Introduction: Differentiated thyroid cancers such as papillary and follicular thyroid cancer make up more than 90% of all thyroid cancers. The presence of thyroglobulin autoantibodies makes interpretation of the thyroglobulin level unreliable, as it could be falsely low or falsely high. Studies have shown that rising thyroglobulin antibody levels, could be used to monitor for disease recurrence in patients with negative thyroglobulin and imaging studies. However, there are challenges in detecting recurrence in patients with normal thyroglobulin level and thyroid imaging studies, who are on lifelong immunoglobulin therapy and who have increasing thyroglobulin antibody levels. Clinical case: A 63 yr old female was found to have an incidental left thyroid nodule at age 48yrs from a carotid ultrasound. She underwent US guided FNA of the thyroid nodule and was found to have papillary thyroid cancer. She had total thyroidectomy a month later, with removal of a 1.4cm primary, with no evidence of extrathyroidal extension, clear margins and no evidence of lymphovascular invasion – Stage T1bN0M0. There was left level 6 neck dissection with no carcinoma identified in the 2 lymph nodes removed. She received 105.3 mCi radioactive iodine (RAI) and whole body thyroid scan done 7 days later revealed, increased uptake involving the thyroid bed likely residual thyroid tissue. Activity was noted inferolateral to the right thyroid bed which most likely represents a lymph node. There was no evidence of distant metastasis. She was commenced on levothyroxine post operatively. Her other past medical history is significant for idiopathic urticaria and angioedema, immune deficiency disorder with low IgG and IgM and asthma. She was commenced on monthly IV immunoglobulins 5yrs post RAI therapy, due to recurrent sinusitis, rhinitis and chronic diarrhea. She was later transitioned to weekly SQ immune globulin – Hizentra which she is on till date. Over the past 15 years, serial neck ultrasounds post radioiodine ablation have been negative for recurrence. Her TSH ranged 14.91 to 0.04 (ref 0.27-4.2 uiu/ml) and thyroglobulin (Tg) titer remains <0.1 (ref <0.1). Her thyroglobulin antibody titers have trended up from <0.2 (ref <2.0) 5yrs post RAI therapy to 49 (ref <4 iu/ml)) on her most recent test this year. She is currently undergoing further work up to rule out recurrence of her cancer. In our review of the literature we found one report that showed use of Liquid Chromatography–Mass Spectrometry (LC-MS) was able to differentiate thyroid cancer recurrence in an individual with positive antithyroglobulin antibody receiving immunoglobulin therapy. Conclusion: In patients with negative Tg levels, but elevated thyroglobulin antibody while receiving immune globulin therapy, thyroglobulin antibody levels may not be a reliable indicator of thyroid cancer recurrence. Measurement of Tg levels using a LC-MS may provide some clarity.

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NEOADJUVANT LENVATINIB IN ADVANCED UNRESECTABLE MEDULLARY THYROID CARCINOMA: A CASE REPORT

AACE Clinical Case Reports ◽

10.4158/accr-2019-0365 ◽

2020 ◽

Vol 6 (2) ◽

pp. e73-e78

Author(s):

Hubert Golingan ◽

Brian Hunis ◽

Allan C. Golding ◽

David N. Bimston ◽

R. Mack Harrell

Keyword(s):

Thyroid Cancer ◽

Thyroid Carcinoma ◽

Tyrosine Kinase ◽

Medullary Thyroid Carcinoma ◽

Residual Disease ◽

Tumor Resection ◽

Surgical Excision ◽

Imaging Studies ◽

Serum Calcitonin ◽

Medullary Thyroid

Objective: Medullary thyroid carcinoma, a rare form of thyroid cancer, is typically managed with surgical excision. However, in patients with locally-invasive tumors, an aggressive surgical attempt may result in unnecessary morbidity. Neoadjuvant tyrosine kinase inhibition has been utilized to downstage tumors prior to surgical excision but its role in thyroid cancer treatment is not well-established. We describe the potential role that lenvatinib, a tyrosine kinase inhibitor, may have as a neoadjuvant agent in advanced locoregional medullary thyroid carcinoma. Methods: Our patient presented with a large left thyroid mass and bulky left lateral neck lymphadenopathy. Imaging studies revealed a hypervascular and locally-invasive tumor with metastatic central and left lateral lymphadenopathy. A lymph node biopsy cytologic evaluation and plasma calcitonin concentration of 32,926 pg/mL were consistent with medullary thyroid carcinoma. Rearranged during transfection germline mutation testing was negative. A multidisciplinary team of physicians deemed the patient a poor surgical candidate and recommended 4 months of neoadjuvant lenvatinib therapy to reduce tumor burden with a subsequent reassessment of resectability. Given the tumor's hypervascularity, lenvatinib was chosen due its potent vascular endothelial growth factor receptor inhibition, as well as its availability at our institution. Results: Lenvatinib therapy resulted in rapid regression of tumor volume (approximately 70% reduction) as documented by computed tomography and ultrasound. Surgery after 4 months of treatment resulted in a 99% reduction in serum calcitonin and imaging studies 6 months later showed no residual disease. Conclusion: Lenvatinib has potential as a neoadjuvant agent in advanced medullary thyroid carcinoma, and permitted tumor resection in this previously inoperable patient.

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The Use of Imaging Studies in the Diagnosis and Management of Thyroid Cancer and Hyperparathyroidism

Surgical Oncology Clinics of North America ◽

10.1016/s1055-3207(18)30230-8 ◽

1999 ◽

Vol 8 (1) ◽

pp. 145-169 ◽

Cited By ~ 22

Author(s):

Charles James ◽

Michael Starks ◽

Dougald C. MacGillivray ◽

Jonathan White

Keyword(s):

Thyroid Cancer ◽

Imaging Studies ◽

Diagnosis And Management

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Undetectable pre-ablation thyroglobulin levels in patients with differentiated thyroid cancer: it is not always what it seems

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302013000400004 ◽

2013 ◽

Vol 57 (4) ◽

pp. 292-306

Author(s):

Fabián Pitoia ◽

Maria F. Bueno ◽

Erika Abelleira ◽

Maria E. Salvai ◽

Liliana Bergoglio ◽

...

Keyword(s):

Thyroid Cancer ◽

Lymph Nodes ◽

Total Thyroidectomy ◽

Differentiated Thyroid Cancer ◽

False Negative ◽

Imaging Studies ◽

Persistent Disease

OBJECTIVE: To establish the frequency of U Tg (undetectable pre-ablation thyroglobulin) in TgAb- negative patients and to evaluate the outcome in the follow-up. SUBJECTS AND METHODS: We retrospectively reviewed 335 patients' records. Twenty eight patients (9%) had U Tg. Mean follow-up was 42 ± 38 months. All subjects had undergone total thyroidectomy, and lymph nodes were positive in 13 (46%) patients. Tg and TgAb levels were measured 4 weeks after surgery by IMA technology in hypothyroid state. No evidence of disease (NED) status was defined as undetectable (< 1 ng/mL) stimulated Tg and negative Tg-Ab and/or negative WBS, together with normal imaging studies. RESULTS: Seventeen patients (61%) were considered with NED. Four patients (14%) had persistent disease (mediastinum, n = 1, lung n = 2, unknown n = 1), and 7 (25%) had detectable TgAb by other method during their follow-up. CONCLUSIONS: U Tg levels usually is associated to a complete surgery. However, in a low percentage of patients, this may be related to false negative Tg or TgAb measurement.

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MON-453 Dramatic Clinical Response to Lenvatinib in a Pediatric Patient with Advanced Metastatic Papillary Thyroid Carcinoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.121 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Noelia Vanesa Dujovne ◽

Natalia Gazek ◽

Fabian Pitoia ◽

Victor Ayarzabal ◽

Maria Belen Lucero ◽

...

Keyword(s):

Thyroid Cancer ◽

Total Thyroidectomy ◽

Locally Advanced ◽

Neoadjuvant Treatment ◽

Lung Function Test ◽

Thyroid Tumor ◽

Papillary Thyroid ◽

Imaging Studies ◽

Significant Drop ◽

Thyroid Mass

Abstract Introduction: Papillary thyroid cancer (PTC) is the most common thyroid tumor in childhood. Most patients are referred with locally advanced and/or distant disease at the time of diagnosis. Whenever possible, these patients should be offered total thyroidectomy and radioiodine remnant ablation; however, this approach is not always feasible, rendering these tumors unresectable. These critical cases could benefit from neoadjuvant treatment with multikinase inhibitors (MKI) so that standard treatment can be performed. Lenvatinib is an MKI recently approved in many countries throughout the world for the treatment of radioiodine refractory adult differentiated thyroid cancer. Only few pediatric cases have been reported. Case report: A 10-year-old female patient with locally advanced PTC and metastasis to the lungs, who required 3 liters of oxygen due to respiratory failure caused by bilateral miliary lung disease, mistakenly treated as tuberculosis two months previously and referred to our Hospital. A large thyroid mass adhered to deep tissues was confirmed on CT scan, showing a large heterogeneous neck mass with multiple microcalcifications associated with multiple lymph nodes. Both lungs had multiple micro-nodular disease with interstitial involvement. Total thyroidectomy together with lymph-node dissection was planned, but extensive local infiltration made the lesion unresectable and surgery was limited to a thyroid biopsy. The patient required respiratory assistance. Histopathology confirmed the presence of a PTC (diffuse sclerosing variant) with a RET-PTC3 oncogene rearrangement. Eight days after surgery the patient was critical and we decided to indicate the compassionate use of Lenvatinib. The patient was started on oral lenvatinib at a dose of 14 mg daily (14 mg/m/day). Three days later, she clinically improved and nine days post-lenvatinib initiation, the patient was discharged from hospital without need for oxygen therapy. Lab studies showed a rise in thyroglobulin levels in the first month of treatment followed by a significant drop. All Lung Function Test parameters significantly improved. The patient initially had severe restrictive breathing and due to the resting dyspnea with hypoxemia she could not perform the walking test. Two months after treatment onset she could walk 360 meters in six minutes with 96% oxygen saturation. After 4 months on Lenvatinib, imaging studies showed a stable thyroid mass while the pulmonary nodules appeared stable to slightly smaller without evidence of new or progressive disease. Conclusion: On lenvatinib treatment, our patient showed significant clinical improvement, arrest of disease progression, and stable disease on imaging studies. This case shows that lenvatinib may be a beneficial option for children with advanced PTC not amenable to surgery/RAI treatment and may be used as a bridge to these first-line therapies.

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