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What Is Follicular Carcinoma Of The Thyroid

Metastatic Follicular Thyroid Carcinoma Secreting Thyroid Hormone And Radioiodine Avid Without Stimulation: A Case Report And Literature Review

Follicular Adenoma And Follicular Carcinoma | Thyroid Neoplasm

Syed A. Abid

1Department of Geriatrics, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA

2Department of Otolaryngology-Head and Neck Surgery, Thyroid Center, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA

3Department of Geriatrics, Department of Otolaryngology-Head and Neck Surgery, Thyroid Center, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA

Abstract

1. Introduction

Follicular thyroid cancer is the second most common type of thyroid malignancy worldwide after papillary thyroid cancer . Its incidence, however, is higher than papillary thyroid cancer in geographic areas of endemic goiter, accounting for 25%40% of cases in areas of iodine deficiency compared to 10% of all cases of thyroid malignancy in iodine-sufficient areas . In the United States, the incidence of follicular thyroid cancer is lower due to adequate dietary iodine .

This is an extremely rare case of a patient who underwent thyroidectomy and radioiodine therapy for an aggressive metastatic thyroid cancer, yet he remained euthyroid as the metastatic tumor cells retained the ability to produce thyroid hormone. A review of the literature on the possible explanation of hormone production by metastatic thyroid cancer and the factors involved in tumor metastasis follows the case presentation.

2. Case Report

3. Postsurgery History

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4. Discussion

Follicular Thyroid Cancer Treatment With Rai : How And How Much Treatment

Follicular thyroid cancer guidelines for post operative treatment with radioactive iodine were last updated in the American Thyroid Association 2015 edition. After your doctor has prepared your body for RAI by either stopping your use of thyroid hormone pills or giving injections of recombinant TSH , they may choose to give you a small dose of RAI and perform a special nuclear scan called a Thyroid Cancer Uptake Study. In this scan, the image will determine if there is any evidence of iodine uptake in the body. Approximately 90% of patients will have some uptake of iodine following a total thyroidectomy. Follicular thyroid cancer is not the only reason that iodine can be taken up by tissue. One such issue is retained thyroid tissue. How much retained thyroid tissue is related to the thoroughness of your thyroid surgeon in performing a total thyroidectomy. The amount of RAI chosen to treat the follicular thyroid cancer is based upon:

  • The level of thyroglobulin while the TSH is elevated for the scan
  • The percent uptake of RAI in the Thyroid Cancer Uptake Scan
  • The follicular thyroid cancer locations of disease
  • Prior RAI treatment doses

What Are The Clinical Features Of Follicular Carcinoma

Follicular carcinomas usually present as slowly enlarging, painless nodules. As a rule, these tumors appear as cold nodules on scintigrams, but some concentrate radioactive iodine. Surgical treatment is curative in more than 80% of cases, and no additional treatment is necessary. Approximately 20% recur locally, and up to 15% may have distant hematogenous metastases. Radioactive iodine may be used for radiotherapy of tumors that take up iodine. The overall prognosis is excellent, and the 10-year survival rate is higher than 90%. The prognosis depends on the size of the tumor, the extent of spread, and the degree of differentiation of the tumor cells.

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Follicular Thyroid Cancer Treatment For Persistent Or Recurrent Disease:

Follicular thyroid cancer treatment for recurrences or persistence depends mainly on where the cancer is, although other factors may be important as well. The recurrence may be found by either thyroglobulin blood tests or imaging studies such as ultrasounds, radioiodine scans, CAT scan or PET imaging.

If there is concern that the follicular thyroid cancer has come back in the neck, an ultrasound-guided biopsy is first done to confirm that it is really cancer. Then, if the follicular thyroid cancer appears to be resectable , surgery is often used. The extent of surgery would depend upon the location or locations of the persistent or recurrent follicular thyroid cancer and the prior surgeries and quality of surgeries that the patient has undergone. The sections of central compartment surgery and lateral neck dissection have been written for you and are appropriate for persistence or recurrent follicular thyroid cancer in either of those locations. We have examples of surgeries for just these types of circumstances for you to watch. Follicular thyroid cancer surgery very effectively manages neck disease, sparing function and cosmetic appearance but should only be performed by very high volume and experienced follicular thyroid cancer surgeons. We have publications establishing our ability to control follicular thyroid cancer recurrences or persistence in the neck approaching 98% in both of these areas of the neck lymph nodes.

Follicular Carcinoma Of The Thyroid Gland

Nomenclature Revision for Encapsulated Follicular Variant ...
What is follicular carcinoma?

Follicular carcinoma is a type of thyroid cancer. The tumour starts from the follicular cells normally found in the thyroid gland and is the second most common thyroid cancer in adults. Follicular carcinoma is more likely to develop in older adults and it is rarely seen in children.

Patients with follicular carcinoma may notice a growth or lump in the front of their neck. An ultrasound performed may show one or more nodules in the thyroid gland. Most tumours are separated from the normal surrounding thyroid gland by a thin tissue barrier called a tumour capsule. Over time, some of the tumour capsule may disappear and large tumours may not have any capsule at all.

The thyroid gland

The thyroid is a U-shaped gland located in the front of the neck. The normal thyroid gland is divided into right and left lobes that are connected in the middle by the isthmus. Some people also have another small lobe above the isthmus called the pyramidal lobe.

The thyroid gland makes thyroid hormone. Most of the cells in the thyroid gland are called follicular cells. The follicular cells connect together to form small round structures called follicles. Thyroid hormone is stored in a material called colloid which fills the centre of follicles.

How do pathologists make this diagnosis?

Fine needle aspiration
Tumour size
Tumour capsule invasion

Follicular carcinoma can show two patterns of invasion:

Vascular invasion
Lymphatic invasion
Extra thyroidal extension

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Surgical Treatment Of Ftc

Facing the difficulties of preoperative diagnosis, there is general consensus about how to surgically approach patients with follicular lesions. Basically, all patients diagnosed with solitary thyroid nodules with an indeterminate result in FNAC and/or the clinical suspicion of malignancy , should receive comprehensive information about the therapeutic options. This includes the well-known limitations, e.g., to intraoperatively distinguish minimally invasive, angioinvasive and widely invasive subtypes . Before surgery, patients should be made aware that the decision whether to perform lobectomy or thyroidectomy can be made intraoperatively by the surgeon. Depending on the histopathological result, in case of an initial lobectomy, secondary surgery may be necessary to perform a completion thyroidectomy.

Prognosis & Survival Rate

Generally, the prognosis or survival rate of persons diagnosed with follicular thyroid cancer is good. This is a curable and manageable type of thyroid cancer. In addition, it has a good prognosis especially when the person is younger than 40 years of age, without vascular invasion or perhaps extracapsular extension of the thyroid cancer. The overall staging of follicular thyroid cancer is staged into I to IV. The chance of survival lowers as the person goes into the thyroid stages. However, it is impossible to predict the outcome of the individual person. The prognosis is based on variety of factors like response of treatment given, early diagnosis, which leads to good prognosis, age, gender and management of the disease condition. According to experts, there is a five to ten year survival rate for persons with follicular thyroid cancer that is based on cancer survival statistics. The cancer survival statistics should be cautiously interpreted for this kind of statistic is being measured every interval of five years.

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T Categories For Follicular Thyroid Cancer

TX: Primary tumor cannot be assessed.

T0: No evidence of primary tumor.

T1: The tumor is 2 cm across or smaller and has not grown out of the thyroid.

  • T1a: The tumor is 1 cm across or smaller and has not grown outside the thyroid.
  • T1b: The tumor is larger than 1 cm but not larger than 2 cm across and has not grown outside of the thyroid.

T2: The tumor is more than 2 cm but not larger than 4 cm across and has not grown out of the thyroid.

T3: The tumor is larger than 4 cm across, or it has just begun to grow into nearby tissues outside the thyroid.

T4a: The tumor is any size and has grown extensively beyond the thyroid gland into nearby tissues of the neck, such as the larynx , trachea , esophagus , or the nerve to the larynx. This is also called moderately advanced disease.

T4b: The tumor is any size and has grown either back toward the spine or into nearby large blood vessels. This is also called very advanced disease.

How Is Pediatric Follicular Thyroid Cancer Diagnosed

Follicular carcinoma of Thyroid

The core evaluation of follicular thyroid carcinoma includes an initial comprehensive visit with a member of the Thyroid team as well as a blood draw to evaluate the function of the thyroid gland, an ultrasound of the thyroid and neck, and a fine needle aspiration biopsy of the thyroid mass.

  • Ultrasound is a non-invasive test that uses sound waves to develop pictures of the thyroid gland.
  • Fine needle aspiration involves a very small needle that is used to remove a sample of thyroid tissue that will then be analyzed by an expert pathologist who will assess for the presence of any cancer.

Based on the results of these and possible additional studies, a treatment plan will be recommended.

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Follicular Thyroid Cancer Treatment With Radioactive Iodine

Follicular thyroid cancer, itself, is not an indication for RAI treatment. RAI treatment is a type of internal radiation therapy. RAI treatment was the first true “targeted therapy” developed in the treatment of cancer. The follicular thyroid cancer patient swallows a radioactive iodine form of iodine called iodine 131 in a liquid or pill form. The RAI is absorbed through digestion and circulated throughout the body in bloodstream. Follicular thyroid cancer cells can pick up the radioactive iodine wherever they are located in the body.

If you had a follicular thyroid cancer, 25 years ago, you would have almost certainly been treated with surgery and RAI. Today, only approximately 20% of all follicular thyroid cancer patients undergo post-0perative RAI treatment. RAI therapy is primarily beneficial only when the follicular thyroid cancer patient has undergone a total thyroidectomy for their follicular thyroid cancer.

Follicular thyroid cancer should only undergo RAI treatment in instances where the risk of the follicular thyroid cancer coming back is greater than the potential risks of RAI therapy itself. In follicular thyroid cancer treatment, there is no urgency for the rapid delivery of RAI. RAI can be given as early as 4-5 weeks following total thyroidectomy but can be delayed for months or even years following surgery.

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What Is Thyroid Cancer

    Thyroid cancer is a malignant tumour that starts in the cells of the thyroid. Malignant means that it can invade, or grow into, and destroy nearby tissue. It can also spread, or metastasize, to other parts of the body.

    The thyroid is part of the endocrine system. It is a small gland in the front of the neck below the larynx and near the trachea . It has a right and left lobe, one on each side of the trachea. The lobes are joined by a thin piece of tissue called the isthmus.

    The thyroid is mainly made up of follicular cells and C cells. Follicular cells make thyroid hormones. These hormones help break down food into energy. They also help control body functions such as body temperature, heart rate and breathing. C cells make the hormone calcitonin, which helps control the level of calcium in the blood.

    Cells in the thyroid sometimes change and no longer grow or behave normally. These changes may lead to non-cancerous, or benign, conditions such as hypothyroidism, hyperthyroidism, thyroid nodules, thyroiditis or goitre.

    In some cases, changes to thyroid cells can cause cancer. The most common types of thyroid cancer are papillary carcinoma and follicular carcinoma. They are usually grouped together as differentiated thyroid cancer, which makes up more than 90% of all thyroid cancers.

    There Are Different Types Of Thyroid Cancer

    Aggressive variants of follicular cell derived thyroid ...

    Thyroid cancer can be described as either:

    Well-differentiated tumors can be treated and can usually be cured.

    Poorly differentiated and undifferentiated tumors are less common. These tumors grow and spread quickly and have a poorer chance of recovery. Patients with anaplastic thyroid cancer should have molecular testing for a mutation in the BRAFgene.

    Medullary thyroid cancer is a neuroendocrine tumor that develops in C cells of the thyroid. The C cells make a hormone that helps maintain a healthy level of calcium in the blood.

    See the PDQ summary on Childhood Thyroid Cancer Treatment for information about childhood thyroid cancer.

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    Pathologic Evaluation And Immunohistochemistry

    Formalin-fixed , routinely processed, hematoxylin and eosin-stained tissue sections including the entire capsule of the tumor were evaluated independently by 2 pathologists . Two blocks with capsule vascular invasion identified on H& E stained slides or suspicious for vascular invasion from each case were chosen for immunohistochemical study.

    Paraffin-embedded blocks were sectioned, deparaffinized, rehydrated, and blocked with methanolic 3% hydrogen peroxide. Antigen retrieval was performed in citrate buffer . The immunohistochemical stains for CD31 , CD34 , and D2-40 on these slides were performed in an automated immunostainer with appropriate positive and negative controls. The detection was performed with Iview DAB detection kit . All slides were counterstained with hematoxylin and then were evaluated independently by 2 pathologists .

    Follicular Thyroid Cancer Treatment

    Follicular thyroid cancer treatment depends upon the stage of the cancer , the patient’s overall health, and the patients desires. This section discusses the typical treatment options for your follicular thyroid cancer. Treatment decision making is based upon three important factors:

    • What is the optimal treatment for the follicular thyroid cancer
    • What are the patient’s desires
    • What are the capabilities and outcomes of the thyroid cancer team

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    Subtypes: Hrthle Cell Carcinomas And Insular Carcinoma

    Follicular thyroid carcinomas with predominantly oxyphilic cells caused by metaplastic changes, with overabundance of large mitochondria, are known as Hürthle cell, oncocytic, or Askanazy cell carcinomas ,17 although they are distinct from Hürthle cell variants of papillary carcinoma.14 Hürthle cell adenomas are distinguished from carcinomas by noting the absence of capsular or vascular invasion in the same way as follicular adenomas are distinguished from carcinomas. HCFC is half as common as nonoxyphilic follicular carcinomas and is considered to be clinically more aggressive. This may be related to a higher rate of loss of radioiodine uptake in these tumors18 however, they seem to have the same prognosis as nonoxyphilic follicular cancers,19 particularly when matched for extent of local invasion at presentation.20

    Jahangir Moini, … Raheleh Ahangari, in, 2020

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    Thyroid Cancer: Adenoma, Papillary, Follicular, Medullary, Anaplastic for USMLE Step 1

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    Follicular Thyroid Cancer Surgery In Sites Other Than The Neck

    Follicular thyroid cancer surgery is uncommonly proposed as a treatment approach when disease has spread to distant sites. Although surgery is not commonly proposed for distant spread of follicular thyroid cancer, consideration for surgery for distant disease is based upon the expert thyroid cancer team evaluation and considers the following issues:

    • Where is the follicular thyroid cancer distant disease located?
    • What are the risks and benefits of surgery?
    • Are there other sites of distant spread?
    • What follicular thyroid cancer treatments have already been used?
    • What were the outcomes of other treatments for the follicular thyroid cancer?
    • How fast is the follicular thyroid cancer growing?
    • What are the patient’s treatment desires?
    • What are the other treatment options?
    • What is the follicular thyroid cancer pathologic type (what do the cells look like under the microscope?
    • What are the follicular thyroid cancer genetic mutations found?

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