REFERENCES: Following are some general references. The plan is to provide a more complete set of references, but it will take time.  I'll start with those that are least specialized and progress.

 

T. C. Freidman and W. Yu, The Everything Health Guide to Thyroid Disease.  This is a fairly general book but it has some things in it that were new to me including some of the complications of thyroid disease (Chapter 18) and good thyroid nutrition (Chapter 19). 

 

A.L. Rubin, Thyroid for Dummies. This also is a general book. It is not really for dummies.  My impression is that it covers most or all of the material in Freidman and Yu and has more detailed discussions.   

 

Kenneth Ain and Sara Rosenthal, The Complete Thyroid Handbook. This book is a great introduction to the thyroid and some of its possible problems, but it does not address tall cell thyroid cancer.

 

American Cancer Society (2009) Quick Facts; Thyroid Cancer.  A short, quick book about thyroid cancer. A sort of pocket manual. On pages 33-38 it has a very clear guide to the relationship between p,T,N, M numbers and so-called "stages". Also, it relates the stage to 5-year mortality rate --the percentage of patients who live at least 5 years after bing diagnosed.

 

Kenneth Ain's website: http://www.thyroidcancerdoctor.com/help.html . From reading his website and from comments of others, my understanding is that Dr. Ain generally treats thyroid cancers more aggressively than most experts.  But in his own practice and research he also focuses on hard-to-treat cases. 

 

D. Van Nostrand, G. Bloom, L. Wartofsky, Thyroid Cancer: A Patient’s Guide.  This could be called a thyroid cancer patient's handbook.  A downloadable, free version is on the ThyCa website. 

THYROGLOBULIN: Thyroglobulin, TG, is a marker for thyroid cancer but its presence, especially at low levels, does not necessarily mean that there is a recurrence. New "second generation tests" (such as Beckman-Coulter) are ultrasensitive. But do you need to have stimulated rTSH? The article below addresses this question and provides some empirical observations relating recurrence to basal TH levels. My non-specialist summary is: If your basal TG (while taking levothyroxine) is <.1 or <1.5 then it is highly probable a TSH-stimulated TG test would not provide significantly different information and you are very unlikely to have a recurrence. If your basal TG is > 1.5 and you have other risk factors then you are much more likely to have a recurrence. The likelihood goes up with basal TG and with risk factors.

 

P. Malandrino, A. Latina, S. Marescalca. A. Spardo, C. Regalbuto, R.A. Fulco, R. Vigneneri, and G. Pelleritit. Risk-Adapted Management of Differentiated Thyroid Cancer Assessseb by a Sensitive Measurement of Basal Serum Thyroglobulin. J. Clin. Endocrin Meta. 2011.

An easier-to-read version with further references appears at

http://www.thyroid.org/wp-content/uploads/publications/clinthy/volume23/issue6/clinthy_v236_15_16.pdf

 

The above study was motivated by the question of whether an rTSH study is needed or whether basal TG will give nearly as reliable answers.  See the American Thyroid Assocation article on TG testing with rTSH stimulation. My non-specialist summary is: If you respond well to treatment and your TG is <2.5 when stimulated by rTSH, then according to the American Thyroid Association the likelihood of a recurrence is small.

See http://www.thyroid.org/patient-thyroid-information/ct-for-patients/vol-4-issue-3/vol-4-issue-3-p-7-8/

 

Acknowledgements: I thank "Cabro" and other writers on www.thyca.org for informing me of the existence of ultrasensitive TG tests.

 

 

TALL CELL THYROID CANCER

 

From my readings and my understanding of these, thyroid cancer accounts for only about 2% of all cancers and tall cell variant (TCV) thyroid cancers are estimated to account for approximately less than 10% of thyroid cancers. So it seems that about 2 (or fewer)  out of 1000 cancers are tall cell variant thyroid cancers. (These are rough summary statistics. Different studies give slightly different estimates.) Sorry to say this but many endocrinologist may never had a patient with TCV thyroid cancer.

 

Most published research that I’ve looked at either estimates percentages and relates these percentages to recurrence and mortality or discusses technical issues such as what proportion of cancerous thyroid cells should be used to designate thyroid cancer as “tall cell”. (Probably, the fewer the better, from the perspective of someone who has or has had thyroid cancer.) My impression is that really little is known about TCV. But the study cited below indicates that TCV is more aggressive than typical papillary thyroid cancer (the usual sort).

 

So what to do? My non-specialist opinion is that, if you have TCV, an experienced endocrinologist may recommend a higher dose of RAI and  would keep a closer watch on your TG levels. It is good to always get a copy of your reports and also to keep watch yourself. If your TG is positive but low, keep watch for changing trends. (But if your TSH level changes then your TG can be expected to change in the same direction.) And there are different tests so it’s good to try to find out the details of the test used. In my experience, by the way, physicians may not be forthcoming about the actual test used. This is perhaps, from their viewporit, it is just a technical matter and they themselves do not know.

 

My other non-specialist opinion is that a good diet (with little sugar), and lots of exercise cannot hurt and may help. And both make life much better anyway. You cannot be wrong in cutting back on sugar, white bread, white rice, doughnuts, cookies, and all that other junk food.  Every time you look at that stuff, think "junk."

 

Scharukh Jalisi,1 Tiffiny Ainsworth,2 and Michael LaValley3: Prognostic Outcomes of Tall Cell Variant Papillary Thyroid Cancer: A Meta-Analysis, Journal of Thyroid ResearchVolume (2010), Article ID 325602, 4 pagesdoi:10.4061/2010/325602. Research Article. http://www.hindawi.com/journals/jtr/2010/325602/

 

There is also the issue of measurement of TG.  That will be a new section.

 

 

 

RECURRENCE

 

The following article relates to any sort of differentiated thyroid cancer but also to TCV since it may be more likely to reoccur. It may be most interesting to thyca people who have some "suggestions" of a possible recurrence. The article proposes that ultrasound is more effective than TG monitoring in the detection of recurrence. The conclusion is that "An ultrasound finding of a hypoechoic thyroidectomy bed lesion with internal vascularity and size greater than 6 mm is highly sensitive in predicting recurrence. Serum Tg levels were less sensitive than ultrasound in detection of recurrence in the thyroid bed."

 

Only 30 lesions in 27 patients were considered. On further reading of the article, its only conclusion that I find convincing is that "Big is Bad."  The authors take over 6mm as the definition of "big".  Regarding whether "hypoechoic" is an indicator of cancer recurrence, the authors considered only 30 nodules in 27 patients.  Of these, 21 of the 22 associated with recurrences were hypoechoic.  But 3 of the 3 found to be negative for recurrence were also hypoechotic. I do not see how this tells us that a hypoechoic node is likely to be a carcinoma. 100% of recurrences (22 out of 22) exhibited vascularity but so did 2 (2 out of 3) deemed negative for recurrence.  Vascularity is not a good signal but the numbers of samples seems too small.

 

The article makes intriguing references to lymph nodes, including a statement that "thyroid cancer that spreads to lymph nodes involves a preexisting lymph node." I do not understand why "preexisting" except, I suppose, the lymph node was already there before thyca. But thyroid cancer in lymph nodes is apparently better than recurrence in the thyroid bed, which may require more difficult and also more delicate surgery. The article also states that "lymph node involvement has been well described" and gives some references, so I have more reading to do.

 

A. Kamaya, M. Cross. H. Akatsu and R.B. Jeffrey. (2012) "Recurrence in the thyroidectomy bed: Sonographic findings." American Journal of Roentgenology. 

Here is a link: http://www.ajronline.org/content/196/1/66.full.pdf+html

Lymph Nodes

 

The best article that I have found is "Diagnostic approaches ...", listed below.   Apparently it is difficult to know whether lymph nodes represent metastasis.  The characteristics of an ultrasound of a lymph node that indicate a strong liklihood of thyroid cancer in the lymph node are: 

(a) presence of cacification, (b) cystic change, (c) loss of an echogenic fatty helium. (d) hyperechogenicity, (e) round shape and (f) abnormal vascularity on color Doppler images.   [(c) is debated.]

 

 First, let me note that there may be some typos in the article above by Kamaya and co-authors.  Perhaps the 21 associated with recurrence were hyperechoic rather than hypoecholc.

  

 The conclusion of this article on lymph nodes is that "the most accurate ultrasound criterion to differentiate metastatic from benign lymph nodes was ...any of the suspicious ultrasound characteristics (except (c), loss of fatty hilium), even if they do not contain malignant cells on cytology.



Now that may not be completely comprehensible, but if you see your ultrasound reports and see any of the suspicious characteristics listed above, you could ask your physician. 



Yu-Mee Sohn, Jim Young Kwak, Eun-Kyung Kim, Hee Jung Moon, Soo Jin Kim and Min Jung Kim (2010) "Diagnostic approach for evaluation of lymph node metastasis from thyroid cancer using ultrasound and fine-needle aspiration biopsy." American Journal of Roentgenology, on-line at http://www.ajronline.org/content/194/1/38.long