The patient is a hearty 85yo gentleman who presented with a right neck mass, subsequently diagnosed as metastatic papillary thyroid CA. The patient underwent total thyroidectomy with right modified radical neck dissection. He had Hashimoto's thyroiditis with Hurthle cell changes and a focal hyperplastic nodule. No primary CA found in the thyroid. He had 6/16 nodes positive for metastatic papillary CA. He was treated with 156 mCi I 131 subsequently. A whole body I 131 scan done 2 weeks later revealed 3 areas of focal uptake in the contralateral neck suggestive of nodes, one at angle of mandible and two near the sternal notch. He has no palpable disease. Thyroglobulin- 1.2, TSH- 96.8 ,Thyroglobulin antibody- positive. Can I 131 treatment be repeated or does this patient require a contralateral neck dissection?
Clifford Gelman, MD Melbourne, FL
In the first place, the Tg blood value is probably of no use because Tg auto-antibodies do interfere with the tests for Tg. If this patient would be below his seventies and healthy I would probably prefer neck dissection at the left side probably by the technique of node picking rather than a modified radical one. However as the growth rate of papillary cancer is very slow and considering the age of the patient, you may consider a further treatment with 131I and follow-up of the neck with US. By the way, are the found locations on 131-I scanning showing nodes on US? Is there US evidence for enlarged nodes that are not showing on 131I scanning? If there is full confirmation of findings between these techniques I would prefer 131-I treatment with US follow-up. However if there are "US positive nodes' but 131-I negative, I would rather consider surgery. Kind regards,