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Aggressive MTC with Post-op Elevated CT and CEA

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Question

I hope you can help with this lady I saw recently. She is a 59 y/o who was initially diagnosed with papillary thyroid ca after FNA of mass on right thyroid. Surgical path surprisingly revealed medullary thyroid ca – initial pathology showed a dominant lesion in the right lobe 3.5 cm and a second 1.5 cm. There was infiltration through the thyroid capsule into parathyroidal soft tissue and there was positive vascular lymphatic invasion. 2 of 2 LN in the central compartment were positive. On the superior right, 3 of 3 nodes were positive; inferior right 7 of 7 nodes were positive and right lateral nodes 2 of 3 were positive. The left lobe showed no disease. One week after surgery – calcitonin was 64.9 ( no baseline was done as initial dx was papillary ca ) and CEA was 69.6. Ret onc was negative. 24 urine met/cat were negative. CT of neck, head, chest and abdomen were all normal.

Now, 2 and 1/2 months after initial labs were drawn and the radical neck surgery – her repeat calcitonin level is 132 pg/ml and CEA is 37.9 on exam I do not feel enlarged LN. I have ordered an US of her neck and results of which are not back.

My questions are: with almost doubling of calcitonin levels almost 3 months postsurgery ( 64 – 132 ) where else should I look for if the US of neck is negative? Should I refer her for another neck exploration ? Repeat CT of neck and chest even if the first one was done less than 3 months ago? HOw significant is a calcitonin of 132in terms of prognosis?

Maria Mercado MD, Overland Park, KS 66213

Response

Information on what you mean by RET oncogene was negative would be of interest? Exactly what was done? Any family history or exams or calcitonins? The data (so far) suggests the tumor is a sporadic non-familial MTC,. And an aggressive type rather than the very slow moving type. I suppose residual neck tumor on nodes on R (or L) are still an important possibility. I agree that it seems illogical to repeat the CAT scans in just 2 1/2 months. A PET scan might show something, but often with small lesions is not helpful. A bone scan is easy to do, but also probably unrewarding. The elevated CT and CEA + nodes and invasion are ominous.

If all your exams are unrevealing, treatment options are limited. Obviously you will remove any found lesions if possible, but re-operation on the R at this time seems inappropriate unless US or CAT or MRI is suggestive. Meticulous dissection on the L could be done, especially if US is suggestive. No current chemo or other medical treatment has known value at this point in her course. Radiotherapy “blindly” to the mantle area is possible, but considered useless by many in the field. We need new treatments in this disease.

L De Groot, MD