PAPILLARY AND FOLLICULAR CANCER OF THE THYROID

Management strategies: Management of papillary and follicular cancer o f the thyroid Varies somewhat between centers because of the generally good prognosis and the absence of well-controlled therapeutic trials. The internationally recognized TNM system is widely used to modulate treatment and follow-up to the individual situation. Primary treatment : Surgery is indicated in well-differentiated thyroid cancer Total thy roidectomy is required for clinically patent tumors (greater than or e qual to 1 cm) and small tumors (greater than or equal to 1 cm) recogni zed prior to surgery. For small tumors found at histology examination, reoperation is discussed in terms of prognosis. Post-operative 131-io dine is indicated when surgical resection is incomplete or in case of unfavorable prognosis. External radiotherapy is currently reserved for exceptional cases with unremoved tumoral tissue unresponsive to 131-i odine. Follow-up: All operated patients are given L-thyroxine to achie ve euthyroidism and low TSH levels (< 0.1 mu U/ml). Early detection of relapse is based on combined thyroglobulin assay and whole body 131-i odine scintigraphy. Both are performed during the first year of follow -up after a period of thyroid hormone withdrawal. Human recombinant TS H will soon be available allowing selection of patients with a detecta ble thyroglobulin level after stimulation; these patients should have a 131-iodine scintigram. If thyroglobulin remains undetectable during L-thyroxine treatment, an annual dosage is indicated and other exams a re unwarranted. Relapse: Surgery is indicated in case of small areas o f active recurrent tumoral tissue in a cervical location. If a high-se nsitivity scintigram does not show iodine uptake, the surgical procedu re is completed by radiotherapy or possibly chemotherapy with doxorubi cin. Small recurrent tumors in other areas respond to 131-iodine (3.7 GBq). Surgery, 131-iodine and radiotherapy are usually indicated for l arge ectopic recurrences. Chemotherapy is ineffective. Current protoco ls: Standard primary therapy generally provides cure and most patients are followed by annual thyroglobulin and TSH assays. Other exploratio ns beginning with a whole-body 131-scintigram may be indicated in sele cted patients.