I wanted to run something by you. I have a 71 yo discovered to have a 3.5cm follicular-variant of papillary which extends past the "inked specimen margins" into soft tissue - but has no know nodal mets. The surgeon who referred her to me says he "looked" at the nodes - but did not do a central plucking. She has DM, HTN, dyslipidemia and to top it off - had a CT scan with contrast the week of her surgery. I believe this patient to be a stage 2 patient and I'd like to actually treat her with thyrogen because of her age and co-morbidities. I have several questions - do you agree that she is a candidate for a thyrogen-stimulated treatment?; how long would you wait to treat after she received the dye load (does using thyrogen make a difference) and lastly - what kind of I131 dose would you choose? i would greatly appreciate youR input in this challenging case.
Marie L. Griffin, M.D.
At age 71 with direct extension outside the gland the patient would be Stage 3 in our simple classification and considered rather high risk.I believe that theusual approach would be to wait several (6) weeks after the Iodide load, prep with either rhTSH or the half-dose withdrawal program, and administer a dose such as 100mCi, although some people might even give a higher dose. It would bebest to check urinary iodine before treating to know that it is back down to a reasonable level- for example near 400ug/day. Actually, my own approach- considered archaic by some- would be to do a pre-therapy 2 mCi whole body scan to determine that there is potentially therapeutic neck uptake, and to assess possible mets elsewhere. Has a neck US been done to look for possible tumor mass or neck nodes, which might be better treated by surgical removal? It would be useful at this point to measure TG, which could give you some indication of residual tumor burden, especially if very low, or really elevated. It will be important to check neck uptake with a scan 5-7 days post-treatment, and to follow the patient with serial TGs.
L De Groot, MD