I am presently managing a 74 year old Caucasian lady with past history of ASHDand breast cancer (1985) who was found to have thyroid nodules on a routine physical. She was and still is asymptomatic. Thyroid function tests within normal limits. Thyroid US revealed a mildly enlarged gland with a dominant 2.5 cm nodule in the right lobe and 2.8 cm nodule in the left lobe. FNAB showed follicular lesion with Hurthle cell features, cannot rule out Hurthle cell neoplasm, on the right, and follicular lesion favor benign follicular nodule on the left. The patient subsequently underwent a right thyroid lobectomy. Frozen section of the right nodule revealed Hurthle cell nodule and the pathologic diagnosis was hurthle cell tumor(21 mm), an occult sclerosing papillary microcarcinoma (2 mm), and small colloid follicular nodules, no obvious malignant features in the Hurthle cell tumor. The report goes on to state that the sclerosing papillary microcarcinoma has nil mitotic activity, absent tumor necrosis, nil encapsulation, nil capsular invasion, absent blood vessel invasion, absent extrathyroid extension, surgical margins free of tumor, TNM pathologic state pT1NXMX.
How do I best manage this patient? Send her for a completion thyroidectomy, ablate, and then follow thyroglobulins? Or just monitor thyroglobulins and suppress TSH levels? Any advice would be greatly appreciated. Thank you in advance.
Patrick Litonjua, MD, Binghamton, NY
If the pathologist can reassure you that after careful exam there is no evidence of capsule or vessel invasion in the Hurthle tumor, I believe you can assume the patient's prognosis is at present very favorable, and do no more than provide T4 to keep TSH in the 0.5-1.5 range. You can of course follow TGs, and should doan US every year or so. I dont think re-op is appropriate, although I wish the original op was more extensive. And RAI would probably require two treatments of 50- 75 mCi to completely ablate, for which we have no clear indication. Best regards,
Leslie J De Groot, MD