Thyroid cancer is the most common endocrine malignancy, and data show the incidence has risen substantially. The most common subtype is papillary thyroid cancer, comprising 80-85% of cases, and the majority of the rise in thyroid cancer cases is due to the small (This patient has a solitary papillary thyroid microcarcinoma (See Fig. 1aProposed modification, not present in the original 2009 initial risk stratification system. Reprinted with permission from Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.To help further assess the patient's risk of persistent disease, thyroglobulin (Tg) measurement (either TSH stimulated or nonstimulated) 3-4 weeks post-operatively is recommended (option B). In low risk papillary thyroid cancer patients, such as the one in this case, a thyroglobulin concentration 2 ng/dL.Increase in her levothyroxine dosing (option A) may be appropriate after assessment of TSH, but would not be the best course of action at this time.
Her fatigue cannot reliably be attributed to her thyroid hormone status without assessment of her current TSH concentration.Assessment of the tumor specimen for a BRAFV600E somatic mutation (option C) is not routinely recommended. For intrathyroidal papillary microcarcinoma, the presence of BRAFV600E does not affect the low risk classification. Although BRAF V600E positive papillary thyroid cancers are higher risk in some cases, there are no recommendations to manage thyroid cancer any differently based on BRAF status.PET-CT scanning (option D) is not indicated because her low-risk papillary thyroid carcinomas (PTC) makes it highly unlikely that she has aggressive metastatic disease that would be detected on further imaging.A second operation to explore and remove central neck (level VI) lymph nodes for this patient with low risk papillary thyroid cancer is not indicated (option E).
Removal of lymph nodes is indicated if there is evidence of lymph node metastases in that area. The role of a prophylactic (without clinical evidence of disease) dissection level VI lymph node remains controversial, given uncertainty regarding any survival benefit in the setting of demonstrable increases in surgical risks (such as hypoparathyroidism and vocal cord paralysis). Prophylactic level VI lymph node dissection should be considered when there is more advanced local disease (T3 or T4) or clinically involved lateral neck nodes.