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Purefollicularthyroidcarcinoma:Impactof Therapyin 214 Patients

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Purefollicularthyroidcarcinoma:Impactof Therapyin 214 Patients CLINICALSCIENCES ThERAPEUTIC NUCLEAR MEDICINE PureFollicularThyroidCarcinoma:Impactof Therapyin 214 Patients RobertL. Young,ErnestL. Mazzaferri,AltonJ. Rahe,andSteven0. Dorfman Wilford Hall USAF Medical Center, Lackland AFB, Texas, Brooks AFB, Texas, and University of Nevada, Reno, Nevada Recordsof 214 patientswith pure follicularthyroidcarcinomawere reviewed in detailto evaluatethe circumstancesof Initial presentationandtherapyon ulti mate outcome.Mean foIiowupwas 8.8 yr. The onlydeathsdirectlyattributableto the thyroidcarcinomaoccurredin patientswith distantmetastasesat the time of presentation.Therewere 20 recurrencesinthe 182 patientsconsideredfree ofdis ease after initialtherapy.Overallrecurrencerate was notaffectedbythe presence of positivecervical nodesor extent of thyroidsurgery.Postoperativerecurrence rate was decreasedby both radiolodineand thyroid-hormonetherapy. Extensive histologicinvasionof the capsuleof the noduleandthyroidappearedto be associ ated with an increase in recurrence rate. Postoperativethyroid-hormoneis re quiredtherapy in all patientswith pure follicularthyroidcarcinoma.Radioiodine therapy is indicatedin patientswith extensiveinvasionand we favor its use in all patients. J NucI Med 21: 733—737,1980 It isgenerallyconsideredthatpurefollicularthyroid manner, reflecting the clinical situation as well as the carcinoma is more malignant than the papillary forms. bias ofthe attending physician. We evaluated the bearing Previous studies have indicated that a major determinant of clinical presentation, pathology, and various forms of in prognosis in follicular carcinoma is the extent of local therapy on survival and recurrence rate. Major emphasis invasion within the thyroid at the time ofdiagnosis (1, is on recurrence rate, since very few patients died of the 2). The relative role of various forms of therapy in de disease. termining prognosis is not clear. Reasons for the lack of clarity include the indolent nature of the disease and METHODS reportsemphasizingonlyoneor twoaspectsof therapy. We have previously discussed these concepts in detail for Details of method of analysis have been published papillary carcinoma (3). In addition, follicular carci previously (3). Basically, microfilm records of all pa noma is less common than papillary and it is difficult to tients entered into the armed forces tumor registry were acquire a series large enough for meaningful statistical reviewed by one of the authors. At the time ofour orig analysis. Some older series pooled mixed papillary-fol inal report, there were not sufficient patients with pure licular carcinoma with pure follicular, which even further follicular carcinoma for analysis. Since that time, the confuses analysis. registry was expanded to include some Army and Navy This report is a retrospective analysis of 214 patients hospitals in addition to new cases entered from Air Force with follicular thyroid carcinoma who were treated by hospitals. The pathologic classification used in this study a number of different physicians in many different was that approved by a committee of the American hospitals. Patients were treated in an individualized Thyroid Association with slight modification by Hazard (4). All surgical specimens identified as cancer, or pos sibly cancer, at any military hospital are routinely re Received Oct. 25, 1979; revision accepted March 3, 1980. For reprints contact: Colonel Robert L. Young, USAF, MC, viewed at the Armed Forces Institute of Pathology Chairman, Dept. of Endocrinology and Metabolism (SGHME), (AFIP). For the purpose ofthis study, the AFIP inter Wilford Hall USAF Medical Ctr., LacklandAFB, TX 78236. pretation was used. For inclusion here, all available Volume 21, Number 8 733 YOUNG, MAZZAFERRI, RAHE. AND DORFMAN histologic material, including lymph nodes and recurrent of undifferentiatedsmall- or large-cellcarcinomain or metastatic disease, had to contain only follicular dc additiontothefollicularcomponents.Threeof thefour ments. subsequently have died of undifferentiated carcinoma. Tumor recurrence was judged to have occurred if a Statusof thepatientswasthat recordedasof March biopsy-proven lesion was documented in a patient con 1978. Only patients with at least 1yr of follow-up were sideredfreeofdiseasefollowinginitialtherapy.A patient included. Follow-up was obtained in 95% of patients. All was defined as being free of disease after therapy if the thoselostto follow-upwerefreeof diseaseat the time surgeon stated that all gross tumor was removed and that lost. Mean follow-up was 8.8 yr, with a standard devia physicalexamination2—3moaftersurgerywasnormal tionof 5yr. Meanagewas35±I2yr at thetimeof di except for postoperative changes. All recurrences were agnosis.Seventy-twopercent of the patients were initially identified as new abnormalities in the physical women. Men and women did not differ significantly (p examination or chest radiogram in patients who had > 0.1)in ages,clinicalpresentation,or recurrence,and normal examinations postoperatively. Four patients were the sexes were therefore combined for analysis. judged to have recurrence without histologic confirma Patients presenting with distant metastases. Seven tion. They were free of disease as defined above, and patients had distant metastases at the time of initial developed new clinically enlarged lymph nodes 2-5 yr diagnoses,andtheonlydeathsdueto follicularthyroid after initial therapy. The nodes were visualized with carcinomawerein theseseven.Their briefcase histories I- I31 scanning and disappeared after I- 131 therapy. follow. Extent of thyroid surgery was judged from review of Case 1. A 68-year-old man presented in 1967 with two operativereportsanddividedinto lobeandisthmusor vertebral fractures. In 1961 , he had had a subtotal thy less (limited thyroidectomy) compared with total thy roidectomy for thyrotoxicosis. Details of the specimen roidectomy.In manycases,it wasnot possibleto tell from this operation were not available, but no malig whetherthe total thyroidectomywasintra- or extra nancywasdiagnosed.Biopsiesof thevertebrae,andof capsular. For the purpose of the report, total thyroid the cervical and mediastinal lymph nodes, all showed ectomy means that the operative report indicated re follicular thyroid carcinoma. He had a total thyroidec moval of all or almost all thyroid tissue and the surgeon tomy, with no carcinoma identified in the thyroid. He stated that this constituted a total thyroidectomy. was treated with a total of 500 mCi of iodine-I 31 and Size of the malignant nodule and extent of capsular 2,300 rads of cobalt-60 to each bone lesion. Progressive orvascularinvasionofthemalignantnodulewasjudged involvement of the spine occurred, and he died 5 yr later from the original pathology report and AFIP report. at home. Only those with extensive description and specific Case2.A 79-year-oldwomanwithnopreviousknown comments about the degree of histologic invasion were thyroid disease presented with a pathologic fracture of used for analysis. Histologic invasion was classified as the pelvis. She had an enlarged left lobe of the thyroid. “little―if therewereonly a few isolatedmicroscopic The entire lobe was involved with follicular carcinoma, areas of infiltration of capsule, which did not penetrate which invaded surrounding musculature. There was no into the surrounding thyroid parenchyma. “Moderate obvious lymph-node involvement. No pulmonary lesions invasion―was defined as isolated microscopic areas of were definitely identified. She was treated with 190 mCi invasion through the capsule of the nodule, with minimal of iodine-i 31. She remained bedridden and had a pro or no infiltration of parenchyma. “Extensiveinvasion― gressive downhill course, dying ofcongestive heart fail was defined as several areas of microscopic and occa ure2yr afterdiagnosis.No autopsywasperformed. sionally gross capsular invasion, with extensive in Case3.A 43-year-oldwomanpresentedwitha6-mo volvement of parenchyma and vesselsoutside the capsule history of an enlarging sternal mass and a 3-mo history of the nodule. of thyrotoxicosis.On presentation,shewasclinicallyand biochemically thyrotoxic, with a large right lobe of the thyroid, a 5- X 7-cm sternal mass, and multiple pulmo RESULTS nary nodules. Total thyroidectomy and biopsy of the Of the I,500 patients with primary thyroid neoplasm mass both showed follicular thyroid carcinoma. Thyro in the registry, 2 14 ( I4%) were finally judged to have toxicosis recurred 1 mo postoperatively. Over the next follicular carcinoma. One hundred and sixty (40%) pa year, she received a total of 950 mCi of iodine- 131and tients initially diagnosed by local pathologists as follic 5,200 rads of cobalt-60 irradiation to the sternal mass. ular carcinoma were reclassified by the AFIP as mixed The mass resolved and there was a partial but transient papillary-follicular tumors. Reclassification was highest response in both the lung lesions and the thyrotoxicosis. in patients diagnosed before I970, but occasionally pa Ultimately, she was treated with methimazole and tients diagnosed after I970 were also reclassified. An combination chemotherapy. She died of pulmonary additional four patients were reclassified because the hemorrhage 2 yr after diagnosis. AFIP diagnosis indicated the presence ofdefinite areas Case 4. A 46-year-old man presented with a 3-cm 734 THE JOURNAL OF NUCLEAR MEDICINE CLINICALSCIENCES THERAPEUTIC NUCLEAR MEDICINE thyroid nodule and multiple pulmonary metastases. 34 71@t0l.@ !)*;Mr@ ,@9 There were no nodes
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