A 73-Year-Old Woman With Differentiated Thyroid Cancer

September 25, 2020

Andrew G. Gianoukakis, MD, of Harbor-UCLA Medical Center, describes the rationale for treating a patient with RAI-refractory differentiated thyroid cancer with systemic therapy.

Case: A 73-Year-Old Woman With Differentiated Thyroid Cancer

Initial Presentation

A 73-year-old woman complains of a “lump” on her neck, with occasional swelling and dysphagia
PMH: obese; BMI 32
PE: palpable, nontender neck mass

Clinical Work-up and Initial Treatment

Labs: TSH 1.1 µU/mL; all others WNL
Ultrasound of the neck revealed a 3.0 cm mass in the right lobe of the thyroid; several suspicious lymph nodes ranging from 0.2-3.0 cm in size
Ultrasound-guided FNAB: confirmed papillary thyroid carcinoma
Patient underwent total thyroidectomy with bilateral central neck dissection
Pathology: 3.0 cm papillary thyroid cancer arising in right lobe of the thyroid, 2 of 5 positive central compartment lymph nodes, largest 1.4 cm, positive extra nodal extension
StageT2N1MX; ECOG PS 0

Subsequent Treatment and Follow-up

She was treated with radioactive iodine
- Levothyroxine to suppression was added to treatment regimen
Follow-up at 6 months TSH 0.4 µU/mL, thyroglobulin 4 ng/mL
- Neck US unremarkable
Follow-up 12 months TSH 0.3 µU/mL, thyroglobulin 18 ng/mL
- US of the neck was unremarkable
- CT of the chest showed 10 lung nodules, largest 1.2 cm in size
Administered radioactive iodine 150 millicuries
- Post therapy scan showed no lung or other uptake
Follow-up at 2 years TSH 0.3 µU/mL, thyroglobulin 30 ng/mL
- Chest CT increasing number and size of lung nodules; largest 1.6 cm
- Patient was asymptomatic and deemed radioactive iodine refractory
Systemic therapy with lenvatinib 24 mg PO qDay considered