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Thyroid Factor

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Differentiated (papillary and follicular) thyroid carcinoma (DTC) generally is characterized by an indolent course with low morbidity and mortality and is among the most curable cancers [1]. In most cases, initial treatment for DTC is total thyroidectomy, with lymph node dissection in case of papillary thyroid carcinoma. In case of persistent disease or when the TNM (tumor, node, metastasis) or any other scoring system predicts a high risk of recurrence, the surgery may be followed by administration of a large activity of 131-iodine (131I) to ablate remnant tissue and any residual disease. Patients then are placed on levothyroxine (L-T4) treatment to decrease serum thyroid-stimulating hormone (TSH), while avoiding L-T4 overdosage.

Because DTC may recur at any time for years after initial treatment, and L-T4 therapy is lifelong, long-term follow-up is necessary. Since the estimated European population of dTc patients and survivors is 200000 [2], any follow-up protocol will affect the safety and quality of life of a large population and exert an important impact on health economics.

In recent years, the spectrum of patients with DTC has changed. In part due to incidental findings on neck ultrasonography (US) for non-thyroid indications, a larger number of thyroid tumors, mainly papillary, are being discovered at an earlier stage, accounting for the increased incidence of the disease [2-4]. Also, the quality of initial surgery has improved, as well as the sensitivity of the methods used for detecting persistent disease. As a result, the risk of recurrence in patients with no obvious disease after initial treatment is much lower than previously reported, and is probably less than 5%. In these patients, follow-up should be guided by a protocol with a high negative predictive value, to exclude from unnecessary investigations those with a nonsignificant risk of recurrence. It should also be sensitive enough to identify the few individuals who have a previously unrecognized risk of recurrence and therefore merit a closer follow-up. Indeed, patients with distant metastases or persistent disease after incomplete thyroid surgery should be treated and followed up according to specific protocols, and will not be considered in this review.

The follow-up protocol of patients with no clinically obvious residual disease after initial treatment includes three important elements addressing recent findings (Figure 19.1) [5,6]. First, up to now the same protocol is applied to all DTC patients who have been treated postoperatively with radioiodine. Second, the protocol uses recombinant human thyroid-stimulating hormone (rhTSH) as the "gold standard" to obtain TSH stimulation for diagnostic follow-up. Third, the protocol virtually obviates diagnostic total-body scan (dxTBS) and highlights the importance of neck US in the follow-up.

This review details the follow-up protocol that can be applied to the majority of

Figure 19.1 Recommended protocol for follow-up of differentiated thyroid carcinoma in patients who have received thyroidectomy and radioiodine ablation [5]. Patients with distant metastases, or incomplete thyroid surgery, or with anti-Tg antibodies should be followed up according to other specific protocols. FT3, free triiodothyronine; L-T4, L-thyroxine, rhTSH, recombinant human thyroid-stimulating hormone;Tg,serum thyroglobulin measurement;TSH,thyroid-stimulating hormone;US,ultrasonography;TBS,total-body scan.*In each institution, the Tg threshold should be determined after rhTSH stimulation for each assay method. **Any suspicious finding on neck US warrants FNA with cytological evaluation and measurement of Tg concentration in the aspirate. ***This interval depends on exact Tg level and on the clinical context.

Figure 19.1 Recommended protocol for follow-up of differentiated thyroid carcinoma in patients who have received thyroidectomy and radioiodine ablation [5]. Patients with distant metastases, or incomplete thyroid surgery, or with anti-Tg antibodies should be followed up according to other specific protocols. FT3, free triiodothyronine; L-T4, L-thyroxine, rhTSH, recombinant human thyroid-stimulating hormone;Tg,serum thyroglobulin measurement;TSH,thyroid-stimulating hormone;US,ultrasonography;TBS,total-body scan.*In each institution, the Tg threshold should be determined after rhTSH stimulation for each assay method. **Any suspicious finding on neck US warrants FNA with cytological evaluation and measurement of Tg concentration in the aspirate. ***This interval depends on exact Tg level and on the clinical context.

DTC patients and then describes particular conditions.

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