67-Year-Old Woman With Differentiated Thyroid Cancer

Lori Wirth, MD: This case is a 67-year-old woman who initially presented with a painless lump in her neck. Her medical history was unremarkable. She was seen by her primary care physician, who noticed a palpable nontender solitary right-of-the-midline neck mass, and the physical exam was otherwise unremarkable.

Laboratories were ordered, and these included the TSH [thyroid-stimulating hormone] and antithyroglobulin antibodies, which were within normal limits. An ultrasound of the neck was performed as well. This showed a suspicious 3.6-cm mass arising from the right lobe of the thyroid and 3 suspicious right supraclavicular masses, the largest of which was 2 cm in size.

An ultrasound-guided fine-needle aspiration was done of the large thyroid mass as well as the largest lymph node in the right supraclavicular neck. Both of these showed papillary thyroid carcinoma.

The patient then was referred to surgery and underwent a total thyroidectomy with central compartment dissection as well as right selected neck dissection. Pathology from that showed a 3.6-cm papillary thyroid carcinoma arising from the right lobe of thyroid with tall-cell features.

There was extrathyroidal extension that was present. Two of 6 central compartment nodes were involved, the largest of which was 1.6 cm, and there was no extranodal extension. Three of 13 right lateral compartment nodes were involved, the largest of which was 2 cm, and extranodal extension was noted in that specimen.

Therefore she had a stage T2, N1, MX papillary thyroid carcinoma. The patient had an excellent performance status with an ECOG performance status of 0.

Following surgery, the patient was referred to endocrinology and was given an empiric dose of radioactive iodine, 150 mCi.

The whole-body scan following the administration of the radioactive iodine showed uptake in the neck only, which is most consistent with a thyroid remnant.

She then entered a follow-up, and in follow-up at 6 months the TSH was suppressed appropriately at 0.1 mU/L, and the thyroglobulin level measured 24 ng/mL. The patient then had a neck ultrasound that was unremarkable and a CT [computed tomography] scan of the chest. This showed a number of bilateral lung nodules, approximately 10, the largest of which was 1.1 cm.

She had no treatment at that time. However, she remained in active surveillance and had repeat neck and chest CT scan 3 months later. At that point there was minimal growth in several of the lung modules, 1 to 2 mm. However, there were also 2 new distinct 8-mm lung nodules. The thyroglobulin level was increased at that time as well. Treatment with lenvatinib at 24 mg a day was initiated.

In terms of the prognosis for this patient, patients who have iodine-refractory differentiated thyroid cancer live for a number of years. We know from a review of the patient population by Cosimo Durante that was published in 2006 that the 10-year survival for this patient population is only 10%. However, many patients live for a number of years with this diagnosis. The median overall survival for these patients in the Durante series was less than 5 years.

What we don’t have great data on at this point is in the era of treatment with MKI [multikinase inhibitor] therapy exactly what the median overall survival is because we don’t have long-term follow-up from patients that have been enrolled in the modern era of MKI therapies. But I think it’s safe to say that from the time of initial diagnosis of radioiodine-refractory DTC [differentiated thyroid cancer] with treatment, we’re seeing median survivals well longer than 5 years at this point in most patients.

Transcript edited for clarity.

Case: A 67-Year-Old Woman With Differentiated Thyroid Cancer

Initial presentation

• A 67-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

• Labs: including TSH, anti-Tg antibodies WNL
• Ultrasound of the neck revealed a 3.6 cm suspicious right mass arising from the right thyroid; 3 suspicious supraclavicular largest 2.0 cm in size
• Ultrasound-guided FNAB of the thyroid mass and the largest lymph node confirmed papillary thyroid carcinoma
• Patient underwent total thyroidectomy with central compartment and right selective neck dissection
• Pathology: 3.6 cm papillary thyroid cancer arising in right lobe of thyroid, tall-cell features; extrathyroidal extension present; 2 of 6 positive central compartment lymph nodes, largest 1.6 cm, no extra nodal extension; 3 of 13 right lateral compartment involved nodes largest 2 cm, positive extra nodal extension
• StageT2N1MX; ECOG PS 0

Treatment and Follow-Up

• She was treated with radioactive iodine 150 millicuries
  • Whole body scan showed uptake in neck only consistent with thyroid remnant
• Follow-up at 6 months TSH 0.1 mU/L; thyroglobulin 24 ng/mL
• Chest CT scan showed 10 small bilateral lung nodules largest 1.1 cm
• Follow-up CT neck and chest scan at 3 months was notable for a 1-2 mm growth in several lung nodules and 2 new distinct 8 mm lung nodules
• Lenvatinib 24 mg PO qDay was initiated