------------------------------------------------------------------------------- Folder: Private mail Date: Thu 15 Feb 2001 3:51A (Arrived: Thu 15 Feb 2001 7:36A) From: Steven Dankle, skdankle@wi.rr.com To: pmaksimovich, 5:7211/2.3957 Subject: follicular variant of pappilary thyroid carcinoma ------------------------------------------------------------------------------- Reply-To: otohns@otohns.net From: "Steven Dankle" To: Multiple recipients of list OTOHNS The decision as to what to do next first depends on what was done surgically. In a young person with a follicular variant of papillary that encroaches on the surgical margin suggests to me that perhaps a total thyroidectomy was not done. If this is the case, then step no. 1 is to perform a completion thyroidectomy. There are many arguments favoring this - the follicular variant is more aggressive, the patient is young, the added morbidity risk of a total vs partial thyroidectomy is not significant for experienced thyroid surgeons, and last but by no means least, she will need post-operative I-131 therapy which requires total thyroidectomy. The majority of physicians treating papillary thyroid ca will base the decision of whether or not to treat with post-op I -131 on the size of the primary - if greater than 1.5 to 2 cm, then treat with I-131 post-op. Just a question about the work-up - why do a fine needle aspirate AND a thyroid nuclear scan? There is ample evidence that the initial work-up of a solitary thyroid nodule need include only a serum TSH level and a fine needle aspiration as a matter of routine. Nuclear scans seem to me to have a very limited role - e.g. perhaps in defining an autonomously functioning nodule. But it is of exceedingly little benefit beyond the TSH and FNA in determining the need for surgery. I assume that the FNA showing normal follicular cells means there was an abundance of follicular cells. This alone is an adequate indication for surgical removal - a cellular aspirate with high concentration of follicular cells is suspicious for follicular neoplasms. (Hashimoto's can also be highly cellular). FNA cannot distinguish malignant from benign follicular neoplasms. Since there is a 20% risk of malignancy roughly, one is completely justified in recommending surgery solely on the basis of the FNA in such cases. SK Dankle, MD Milwaukee, Wi "Visit the otohns.net website (http://www.otohns.net)!"