A 55-year-old man presented for a regular follow-up to your office 6 months ago ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. A TSH level was normal. Subsequently, he underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan did not reveal any lymphadenopathy. He underwent total thyroidectomy combined with RAIU therapy and was started on levothyroxine. The patient arrives for follow up visit at 6 months. His TSH level at 6 month is less than 0.1. He denies any symptoms such as palpitations or chest pain or heat intolerance. His weight is unchanged. Most appropriate next step in management?
a) Reduce levothyroxine dose
b) Discontinue levothyroxine
c) Obtain serum thyroglobulin level
d) Obtain anti-thyroglobulin antibodies and serum thyroglobulin levels.
e) Radio-iodine scan
A
a
A. TSH suggesting excessive T3 – T4 level in blood
C Both TSH & thyroglobulin are follow up markers, TSH matters less as it is a stimulant to thyroid so having less TSH is fine till pt c/o palpitation or other hyperthyroid s/s. Thyroglobulin measures the activity of thyroid.
C
and keep TSH undetectable
A, There is no point to measure thyroglobulin since the thyroid already removed. Reduce levothyroxine
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I think its best to reduce the levo thyroxine dose.
Dr Red, what is the answer pls.
a
c
tsh must be lower than normal. and thyroglobulin must check to look how the metastasis tumor functioning if present.
e
A
in c/o postthyroidectomy due to pappilary Ca need to keep tsh level between 0.1 to 0.3 and f’up observation.
Answer E
Low TSH levels in the bloodstream reduce tumoral growth rates and reduce recurrence rates of well-differentiated thyroid carcinomas. The extent to which TSH should be suppressed is controversial. Most authors recommend reducing TSH levels to 0.1 mU/L. This level provides adequate thyroid suppression while avoiding deleterious cardiac and bone effects of profound thyroid suppression.
Patients are regularly monitored every 6-12 months with serial radioiodine scanning and serum thyroglobulin measurements after surgery and radioiodine therapy. Thyroglobulin is a useful marker of tumor recurrence because well-differentiated thyroid cancers synthesize thyroglobulin. However, it is useful only after total thyroid ablation. Serum thyroglobulin is measured at the time of follow-up thyroid scanning, during the withdrawal of thyroid hormone or the administration of recombinant TSH. Serum antithyroglobulin antibodies are measured in addition to thyroglobulin because their presence invalidates the assay. Thyroglobulin antibody levels should be obtained with each thyroglobulin measurement. Rising thyroglobulin level after thyroid ablation suggests recurrence.
Because we do not know the status of thyroglobulin and anti thyroglobulin antibodies before treatment, the best answer is thyroide scan.
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I guess it makes sence to investigate any remenance of further thyroid tissue still existing after thyroidectomy and ablation with RAIU.