Case presentation: Papillary Thyroid Cancer

J Munday

Endocrine Nurse Specialist, Portsmouth

Endocrine Nurses Training Course 9-11 September 2004
Wills Hall, Stoke Bishop, Bristol, BS9 1AE

In 1995 Linda presented to her GP having noticed a lump in her neck that had been there for a month. She was then aged 38, married with two daughters aged 12 and 8. She worked part time as a nurse.

Her GP requested an ultrasound, which was reported as a haemorrhagic cyst in the thyroid. Thyroid Function Tests [TFT’s] were taken which were normal. When the lump was still present six months later she was referred to a surgeon who specialised in thyroid surgery.

In June 1996 a Fine Needle Aspirate [FNA] was performed. This aspirated stale blood. A further ultrasound confirmed a haemorrhagic cyst. Again the TFT’s were normal.

Six months later in December 1996 another FNA was performed, the histology report stated: no abnormal cells. A further ultrasound showed a multi-nodular goitre. TFT’s have changed to a slightly raised TSH with a T4 at the bottom of the normal range.

When seen again a year later in January 1998 there had been no change in the size of the nodule. In the interim Linda had seen her GP complaining of hypothyroid symptoms and had been commenced on thyroxine 50mcgs. In view of the fact that this appeared to be a dominant nodule in a multi-nodular goitre, now hypothyroid and with 2 negative FNA’s Linda was given a choice on future management. Linda was given three options, she could either have surgery to remove the nodule, be discharged, or have another follow-up appointment made for a year’s time. She chose to make another appointment for a year’s time.

However by March 1998 Linda decided she would like surgery to remove the nodule as it was becoming more uncomfortable.

In May 1998 Linda had a Left Partial Thyroidectomy. There were problems with bleeding from the wound during the first six hours post operatively, which was eventually controlled by pressure bandaging and ice packs. Thereafter she made a normal recovery and recommenced thyroxine 50mcgs.

The histology report was available a week later, it read:
Firm nodule 17mm x 12mm x 2mm with appearances of a follicular varient of Papillary Carcinoma. Linda was informed and asked to stop taking her thyroxine. She was told that she would need a completion thyroidectomy and possibly radioactive iodine ablation. She was reassured that the prognosis for this type of cancer is extremely good but was shocked because the previous FNA’s and ultrasounds had not suggested any possibility of malignancy.

In June 1998 Linda had a Completion Thyrolobectomy. 2 days post op she became unwell with a raised temperature, rash and tachycardia this was treated as a possible infection with antibiotics. The histology showed a multi-nodular goitre, no further malignant cells seen.

Two weeks after surgery Linda had an Iodine uptake scan of her neck which showed 4% remaining thyroid tissue so she was referred to the oncologist for consideration of radioactive iodine ablation. The oncologist saw her in July 1998.

Two weeks later Linda was admitted to a side ward on the oncology unit for Radioactive ¹³¹Iodine Ablation. By now she was feeling hypothyroid which was confirmed with TFT’s of TSH 70.7 [0.3-3.8] T-Thyroxine <20 [70-140] Thyroglobulin 3 [0-1]. She was instructed about the isolation procedures required for this treatment then given a dose of Iodine ¹³¹ 3000 Megabecquerels via an oral capsule. She remained an inpatient for three days with her radioactivity levels being monitored twice daily. When these had fallen to a safe level she was allowed home with instructions to follow regarding contact with other people. 48 hours after the RAI Linda developed a sore throat so was commenced on dexamethasone 2mg TDS for 5 days. On day 3 she started thyroid replacement with thyroxine 150 mcgs.

A week later Linda felt unwell nauseated with a sore neck. Her GP contacted her consultant and she was prescribed a further course of Dexamethasone 2 mgs TDS for a further 5 days.

She returned to work in September.

Linda was seen in October 1998 when she was clinically euthyroid, neck examination was normal. In December 1998 it was the same and she was changed to T3 in preparation for a RAI scan.

In January 1999 Linda stopped taking the T3 2 weeks prior to the scan and by the time the scan was due was feeling extremely unwell and had needed to stop work. Her TSH was 88.4 [0.3- 3.8] T-Thyroxine < 20 [70-140] unfortunately thyroglobulin was not measured. A Total Body Scan was performed using iodine 131, which was negative. On the day of the scan Linda recommenced T3 and a few weeks later changed to thyroxine 200mcgs.

Linda was seen in April 1999 by the oncologist when her current dose of thyroxine was 200mcgs, she was clinically and biochemically over replaced, thyroglobulin was negative so thyroxine was reduced to 175mcgs.

Three months later, at outpatient review by the oncologist, Linda reported she had noticed an enlarged right supraclavicular lymph node. The thyroglobulin measurement was negative so she was reassured. Her TSH was suppressed, as required in the follow up of thyroid cancer patients [1], but she had been experiencing palpitations so thyroxine was again reduced. Dose now 150mcgs.

In November 1999 the thyroid surgeon saw Linda. Again the thyroglobulin was negative but the enlarged lymph node was still present so the surgeon offered to remove it. Linda decided she would prefer to have it removed because of her previous experience when ultrasounds and FNA’s had not diagnosed the original tumour. So in December 1999 the lymph node was removed under general anaesthetic. Histology report: 1.2cm lymph node showing reactive changes, no evidence of malignancy.

From then on Linda was seen by the oncologist at increasing intervals. There needed to be further adjustment to her thyroxine replacement because 150mcgs did not completely suppress the TSH but 175 mcgs was too much. Between the oncologist and Linda a regimen was devised using 150 or 175 mcgs on various days. Despite this there have been times when the FT4 has been quite high and once the TSH was not suppressed as required. Over this period the laboratory changed reference ranges and during 2000 started

measuring FT4. Two years ago it was decided to also measure anti-Tg antibodies locally because they affect the interpretation of the thyroglobulin measurement. The table 1 shows Linda TFT results over the next 3 years

Table 1

The current situation:

• Six years post diagnosis Linda is well and clinically euthyroid. She continues to work part time as a nurse.
• Following Total thyroidectomy and Radioactive Iodine Ablation she has always had an undetectable thyroglobulin and anti thyroglobulin. Her total body scan six months post treatment was negative.
• Her dose of thyroxine has been tailored to keep her TSH suppressed but this has at times meant her T4 has exceeded the normal range. However her T3 remains in the normal range and she does not have any associated symptoms.
• The oncologist is now seeing her yearly with repeat TFT’s, thyroglobulin and anti thyroglobulin at each appointment. She will continue on her current doses of thyroxine unless her T3 exceed the normal range.
• Her prognosis is good but she will have life long follow up because the disease has a long natural history, and late recurrences can occur which can be successfully treated. The consequences of supraphysiological T4 replacement needs monitoring especially as the patient ages. [1]

References

1. Guidelines for the management of Thyroid Cancer in Adults. Published by the British Thyroid Association and Royal College of Physicians March 2002.

The opinions expressed in this paper are those of the speaker and do not necessarily reflect the views of the Society