A 70-Year-Old Woman and 57-Year-Old Man With Differentiated Thyroid Cancer - Episode 7

Patient Case 2: A 57-Year-Old Man With DTC

Marcia S. Brose, MD, PhD, introduces our second patient case, a 57-year-old man with DTC.

Marcia S. Brose, MD, PhD: Case 2 is a 57-year-old man who also has a diagnosis of thyroid cancer. He presented with a solitary nodule in the neck and occasional shortness of breath with intermittent excessive fatigue. His past medical history was unremarkable. On physical exam, he had a palpable hard and fixed solitary nodule in the anterior neck. The clinical work-up and initial treatment revealed a TSH [thyroid-stimulating hormone] of 10.3 µIU/mL, but the other lab investigations were normal. He had an ultrasound of the neck revealing a 2-cm mass near the isthmus of the thyroid and several suspicious lymph nodes ranging from 0.3 to 2.4 cm in size. The ultrasound-guided FNA [fine-needle aspiration] confirmed papillary thyroid cancer with nuclear enlargement, nuclear groove, and no collaring.

The patient underwent a total thyroidectomy with bilateral central node dissection, and the pathology revealed a 2.1-cm papillary thyroid cancer arising in the isthmus of the thyroid with 3 of 7 positive central compartment lymph nodes, the largest of which was 1.8 cm and a positive extranodal extension. Their performance status was stage T2N1MX, and their ECOG performance status was 1. This man was treated with radioactive iodine at 150 millicuries, and a whole-body scan showed uptake in the neck, which was indicative of the thyroid remnant. At that time, he had a CT scan that showed that he had multiple nodules in the lungs that ranged from 0.2 to 0.6 cm in size, and the neck ultrasound showed no evidence of residual disease. His TSH at that time was 0.2 µIU/mL. Thyroglobulin was 68. The physician recommended not initiating systemic therapy and putting the patient on active surveillance.

This is an interesting case because the patient seems like he’s symptomatic. But when we learn about what he had in his chest when we did the CT scans, he has a very minimal amount of disease. He had a tumor burden that I would consider to be low. Somebody asked 1 of my colleagues, what is low, medium, and high [tumor burden]? Her response, which is great, was, “You’ll know it when you see it.” You’ll know a high tumor burden because it’s when you have many nodules that are large, either in the hilum or in the parenchyma. This patient has a low tumor burden, so I doubt that their difficulties with shortness of breath and excessive fatigue are because they have lung nodules. It’s probably more related to the fact that they’re symptomatic and a little on the hypothyroid side. Maybe adjusting and giving them some thyroid hormone replacement might help them feel a little less symptomatic, but I don’t think they’re symptomatic because of thyroid cancer.

He was then treated with radioactive iodine, which is always indicated in a case like this. He didn’t have a lot of neck nodes—or a lot of uptake outside the 1 little area of thyroid remnant—yet he had positive disease on the CT scan. Right away, you know that radioactive iodine for this patient isn’t going to help, so you’re going to be treating this patient with multikinase inhibitors and not any more radioactive iodine.

However, this patient has a very low burden of disease and you don’t know 1 very important thing: how long has that disease been there? There are patients with papillary thyroid cancer, and I’m convinced that some of their nodules have been there for 10 years or more. Before you ever make a decision about whether to treat in a case like this, you need to get another CT scan. Usually, if I don’t know the patient, I do another CT scan 3 months later to pick up whether these are rapidly advancing nodules or if they’re exactly the same. Maybe I would do CT scans to start and then spread them out a little further than every 3 months.

Because this patient has an overall low tumor burden, their prognosis is going to depend on what that low tumor burden and how rapidly it’s progressing. You can’t say much about the prognosis for this patient until you have a follow-up CT scan that tells us whether this is a fairly stable disease, or whether it might be advancing quickly with new nodules showing up in a short time frame, such as 3 months.

This transcript has been edited for clarity.

Case: A 70-Year-Old Woman With Differentiated Thyroid Cancer

Initial presentation

  • A 70-year-old woman presents with a painless “lump on her neck.”
  • PMH: unremarkable
  • PE: palpable, non-tender solitary right-of-the midline neck mass; otherwise unremarkable


Clinical workup and initial treatment

  • Labs: TSH WNL
  • Ultrasound of the neck revealed a 3.4 cm suspicious right mass arising from the right thyroid; 4 suspicious supraclavicular lymph nodes (LNs), largest 2.2 cm in size.
  • Ultrasound-guided FNAB of the thyroid mass and the largest LN confirmed papillary thyroid carcinoma.
  • Patient underwent total thyroidectomy with central compartment and right selective neck dissection.
    • Pathology: 3.4 cm papillary thyroid cancer arising in the right lobe of thyroid, tall-cell features; extrathyroidal extension present;
    • 2 of 6 positive central compartment lymph nodes, largest 1.8 cm
    • 4 of 13 right lateral compartment involved nodes largest 2.2 cm in size, positive extra nodal extension.
  • StageT2N1aMX; ECOG PS 0


    Subsequent treatment and follow-up
  • She was treated with radioactive iodine 150 millicuries
    • Whole body scan showed uptake in the neck, consistent with thyroid remnant but no uptake in the lungs
  • Follow-up at 3 months
    • TSH 0.2 µU/mL, thyroglobulin 28 ng/mL (negative anti-thyroglobulin antibodies)
    • Chest CT scan showed 8 small bilateral lung nodules largest 1.3 cm
    • Follow-up CT neck and chest scan 3 months later was notable for 1-2mm growth in several lung nodules and 3 new distinct 9.5 mm lung nodules
  • Next-generation sequencing was negative for mutations, rearrangements
  • Lenvatinib 24mg po qd was initiated

Case 2: A 57 Year-Old Man With Differentiated Thyroid Cancer

Initial presentation

  • A 57-year-old man presents with a solitary nodule on the neck and occasional shortness of breath and intermittent excessive fatigue
  • PMH: unremarkable
  • PE: palpable, hard and fixed solitary nodule in the anterior neck


Clinical workup and initial treatment

  • Labs: TSH 10.3 µU/mL; all others WNL
  • Ultrasound of the neck revealed a 2 cm mass near the isthmus of the thyroid; several suspicious lymph nodes ranging from 0.3-2.4 cm in size
  • Ultrasound-guided FNAB: confirmed papillary thyroid carcinoma; with nuclear enlargement and nuclear grooves, no colloid seen
  • Patient underwent total thyroidectomy with bilateral central neck dissection
    • Pathology: 2.1 cm papillary thyroid cancer arising in isthmus of the thyroid, 3 of 7 positive central compartment lymph nodes, largest 1.8 cm, positive extra nodal extension
  • StageT2N1MX; ECOG PS 1


Subsequent treatment and follow-up

  • He was treated with radioactive iodine 150 millicuries
    • Whole body scan showed uptake in the neck; indicative of thyroid remnant
  • Follow-up at 3 months TSH 0.2 µU/mL, thyroglobulin 68 ng/mL
  • Neck US showed no evidence of residual disease in thyroid bed, no suspicious neck nodes. Chest CT was done: 4 lung lesions that were 0.3 and 0.6 cm in size
  • The physician recommended not initiating systemic therapy and putting the patient on active surveillance