# 3.7cm Papillary Carcinoma....



## nel

Had TT on Apr. 9, 2014 with removal of some lymph nodes. Pathology results today.

*Microscopic Examination*:

Slides were examined and showed a large nodule of papillary carcinoma involving the right lobe and measures 3.7 x 2.5 x 2.5cm. Otherwise, the thyroid tissue shows lymphocytic thyroiditis. Immunostains for 1 & 2 show positive staining supporting the diagnosis of papillary carcinoma. In addition, examination of the sections show nuclear features of papillary carcinoma.

Goes into *thyroid gland worksheet*.

Not sure what 'radiation exposure: indeterminate' means?

or 'tumor focality: unifocal'

Tumor: Papillary carcinoma

Variant: follicular

Cytomorphology: Onocytic or oxyphilic

Tumor capsule: totally encapsulated

Tumor capsular invasion: present Extent: minimal

Margins: Margins uninvolved by carcinoma. Distance of invasive carcinoma to closest margin: 0.5mm (not much distance......)

*Macroscopic Examination*:

Talks about specimen consisting of 'nodule, tissue with a staples query blood clot, nodular tissue, tan tissue & adipose tissue' submitted for frozen section.

The specimen consists of a 22g total thyroidectomy that is 5.2 x 5.0 x 2.4cm collectively. There is a long suture denoting the lateral left aspect and a short the lateral anterior. Two nodules are identified on the lateral lower aspect of the left side that are 3.0 and 6.0mm. An additional nodule is identified in the left upper isthmus that is 0.3cm. Goes into the colour scheme. (The US in Nov. 2013 didn't say anything about nodules on left side of isthmus?)

The right lobe consists of a 15g, 5.0cm from upper to lower, 3.09cm from left to right, and 2.3cm thick lobe of thyroid that is bulging at the anterior aspect. The cut surface shows a tan-white and grey nodular lesion that extends from mid upper to mid lower lobe and is 3.7 x 2.5 x 2.5cm, and presses on the anterior posterior aspects. Grossly the lesion does not appear to extend through the capsule. The remaining lobe is unremarkable.

The left lobe weighs 5g and is 4.0cm from upper to lower, 2.5cm from right to left and 1.4cm from anterior to posterior. The cut surface is reddish-brown and appears grossly unremarkable.

Further down worksheet says: Ninety-six percent of the tissue is submitted in 23 cassettes. Other specimens on cassettes submitted then says 'all tissue submitted in two cassettes'. Does this mean all tissue was examined?

Even though is says 'no regional lymph node met' can they still be in other lymph nodes (ie. under chin etc.)?

I called Dr. office to see if they send thyroid and specimen for 2nd examination, but she said that was final since 2 pathologists signed off on it.

She wasn't sure about RAI. Because tumor was over 2cm and under 4cm, not sure......what do you think? Any advice would be appreciated. I'm currently nursing my 8month old. I am so scared....could this come back, did she get it all.....It's been almost 11months since I noticed the goiter & the FNA said benign which was FALSE.....she didn't use US guided FNA and only took 2 samples. She recommended to re-check, not to worry, 'she's been doing this for years'. Re-checked with US in Nov. 2013, nodule was 3.4cm. I asked for referral to ENT.

Thanks for listening.....


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## joplin1975

Nel, here is the link to ATA's revised treatment guidelines for thyroid cancer: http://thyca.org/download/document/409/DTCguidelines.pdf

It's a heavy document, but if you look on pages 16-17, you'll see the section referencing RAI.

RAI would be a must if your tumor was greater than 4cms. Since it's pretty dang close *and* since you have a follicular variant, I, personally, would opt to do RAI. However, if I were nursing, I'd wait until the baby was weaned and then do the RAI. It's not a decision that you have to make *right now*...you can put it off for months.

At this point, I wouldn't be too worried about having the slides re-examined. It is what it is...now you have to figure out how to minimize recurrence, which involves TSH suppression and possibly RAI.


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## nel

If the entire nodule/tumor was 3.7cm, why did the FNA show benign?

The final pathology didn't say anything about hurthle, which was indicated on the FNA report.

Could feel some lymph nodes under my ear/chin area since maybe Feb./14, ENT asked if I had a cold.....cold symptoms yes, I guess....even though lymph nodes showed benign around thyroid, could it be in other nodes? idk....

Thanks you for the link Joplin. I had a quick look at it, lots of information & overwhelming......

I was praying that with the hurthle the thyroid/nodule would be benign & thyroiditis? I worried constantly before, now it is all I will do. Is it still there, will it come back, RAI increases risk of other can. (ie. breast), do I change my diet (ie. gluten?) etc.....I have some good cries....Hope & pray I'm here for my kids & to see my grandchildren grow up.

My apologies for asking as I'm sure you have repeated this over and over again. what is TSH suppression? I see all of your numbers you've posted, lower the number the better I assume?

Scared of the RAI, heard you have to follow iodine diet & you have to seclude yourself for a few days to a week depending. How many 'months' I wonder can you put if off for I wonder?

Do you have to get your hymagloben (sp?) checked often? or do a RAI uptake to see if thyroid tissue is left?

Thanks again, appreciate your feedback & advice.


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## joplin1975

It's overwhelming and scary right now, I get that 100%.

That said, thyroid cancer is so easily treatable that they are considering no longer calling it cancer. They may just classify it as a growth of undetermined significance. So, it's not a death sentence, more like a semi-chronic condition that require monitoring.

Recurrences of thyroid cancer do happen. Usually in the first two years, but it can happen anytime. Again, I get how scary that sounds, but really, if you are conscientious about yearly monitoring, religiously take your meds to keep your TSH suppressed, and generally self-aware and practice about health, you are almost guaranteed to die of something unrelated to thyroid cancer.

Recall that the FNA only takes a tiny bit of cells and likely your nodule isn't all cancer cells. So, the FNA missed the cancer. It can and does happen frequently.

I do not stick to any particular diet (i.e., gluten free etc) as it seems to have no impact on how I feel overall, but it's entirely personal. I don't think there are lifestyle changes that really impact the likelihood of recurrence. That said, it seems like most thyca patients try to be a bit more thoughtful about overall health. I stick to a low carb, high protein diet and try to have fruits or veggies at every meal. I exercise regularly. Beyond that, I think enjoying life and being happy is my real goal.

TSH suppression refers to the practice of keeping your TSH low, slightly hyperthyroid. The idea being that TSH is a *stimulating* hormone. By keeping your TSH low, you keep minimize the stimulating influence of TSH which minimizes the chance of recurrence. ATA guidelines for someone at my stage recommends keeping the TSH between 0.1-0.5.

Yes, there is a slight increased likelihood of secondary cancers with RAI. Certainly, it's a personal decision. No thyroid surgery can get rid of all the thyroid tissue. Because my cancer was not encapsulated and was already in my lymph nodes, the chance of recurrence was very, very high, whereas the chance of secondary cancers so relatively low. For me, RAI was a no-brainer. You can delay RAI for years, if you prefer.

My protocol was a pre-WBS (that is, whole body radioiodine scan), RAI (100mCi), and then a post-RAI WBS (to determine that the cells were "up taking" the RAI and dying...then one year later, I had another WBS, a full neck ultrasound, and bloodwork that checked thyroglobulin (Tg) and thyroglobulinAB (TgAB)...the on year later, a WBS and Tg/TgAB...next year, I'll just have an ultrasound and blood work with WBSs very five years. I didn't do the LID when I had the RAI but they changed their protocols and I did do it for the annual WBSs. It was no big deal. Annoying, but nothing awful. The isolation period for the RAI for me was 10 days, more strict at first, but then stepped down very three days. By day 5, I was out running errands, I just stayed away from people. Again, an inconvenience, but not anything awful.

I plan to be around for a long, long time. Thyroid cancer isn't going to change that.


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## KeepOnGoing

To try and answer some of your questions:

1. I had 3 FNAs and a total of 10 samples taken - none of which found my PTC. It was 2cm when it was removed, so I had a bit of a "how did you miss THAT?" moment and the ENT pointed out that it was like a needle in a haystack - which just happened to miss the important bits. 2 of these FNAs were ultrasound guided, so that didn't help. It hasn't just happened to us two, either. I was so grateful that I proceeded to having my nodule removed so that I found out about the PTC in time.

2. RAI is an interesting question. There is definitely a move away from doing it in all circumstances. Mine was follicular variant, too - 2cm and fully encapsulated. I had no lymph node involvement and eventually decided NOT to have RAI - though I like to think I'm holding it in reserve in case I need it later. My oncologist is happy he can spot a recurrence despite the fact that I haven't had RAI.

3. I have my thyroglobulin checked every 3 months at the moment, because it developed a bit of a "wobble" about 6 months ago, so they upped the frequency of testing to keep an eye on it. I hasten to add that it's been perfectly normal (eg undetectable) ever since, but yes, it gave me a few anxious moments! I've never had a WBS (NB I'm in the UK and treatment appears to be rather different here...)

4. I'm nearly 2 years on from diagnosis and have ultrasounds every 6 months - moving now to once a year, so long as the latest thyroglobulin result is good. I'm told that it is unlikely to recur. Everything has been fine. After a few months, I've found that you just get on with your life and forget about it - only to be reminded when you have your next round of tests etc. Even if it does come back, it's generally extremely treatable. I'll probably be run over by a bus when I'm 96!

5. One of the main ways of stopping it from coming back is to get your TSH to as near zero as you can. This has been tricky for me, as I don't seem to be able to do that without all sorts of hyper symptoms, which are a pain. We're still working on it, but in the meantime my TSH is generally "low enough" not to worry anyone. This is probably the hardest part of the whole process in my own personal experience - getting a level of medication where I feel well and my oncologist feels happy. Not that this has stopped me working and doing the things I want to do - I just haven't felt 100% some of the time.

6. It is perfectly normal and reasonable to be anxious and upset at this stage - I know I was! I remember texting a friend at 5am because I couldn't sleep and was fed up of crying. I didn't even notice the time until I got her reply, asking what on earth I was doing texting at that time in the morning? I found that once I'd got a plan and knew what was going to happen next etc, the anxiety reduces gradually. Meanwhile, try to be kind to yourself! I found it helped to talk to a counsellor.

Sorry about the length of this reply - I remember so clearly how I felt and just wanted to reassure you that it will get better. There are lots of lovely people on here (like Joplin!) who have kept me sane.


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## nel

THANK YOU so much for taking the time to reply....you have no idea how much it means....

This might sound strange, but at times I feel a bit better than I have in years.....(more energy, not as much anxiety, considering a job change). I don't know if it's from being told PTC and looking at things differently now? Though I am still very scared.

My thinking....when I needed motivation, especially after nodule was found...."well, you never know about the future, but at least the windows are washed, or laundry is done etc.)

Keeping you TSH suppressed is done by taking your thyroid medication daily? (ie. I am on synthroid 112mg). The lower the number the better or that depends on a few factors? This should be monitored every 3-6months for the first few years along with thyroglobulin TG & TGab? Is TG your white blood?

Eat well, exercise....if you notice anxiety, low energy again, swollen glands, this might indicate recurrence?

I haven't had any bloodwork since surgery, except for calcium. Surgery was Apr. 9/14. The ENT referred me to a Dr. in nuclear medicine. I have an appt. next week to go over pathology & her recommendations regarding RAI. I thought an ENDO would review, but wonder if the Dr. in nuclear medicine will want to push for RAI? idk...Because the nodule/tumor (not sure what to call it) was 3.7cm, I'm thinking I'll have to do the RAI at some point. Would TSH, Thyroglobulin & having an ultrasound assist in monitoring for recurrence?

10 FNA samples, did any of them come back inconclusive? I thought since pathology showed the entire nodule was PTC, the FNA would have read inconclusive or suspicious? Maybe she missed the nodule? Wasn't done by US. FNA report said benign follicular with hurthle. Pathology didn't say anything about hurthle, but lymphocytic thyroiditis.

Thank you again, I truly appreciate your information & advice. You have helped so much & am thankful you both continue to use this message board to help others.


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## KeepOnGoing

There are 2 reasons why I stick around here - one is that I keep learning more about my condition, which can only help. The other is that, when I was diagnosed, I never, ever, met anyone who'd actually had thyroid cancer (still haven't, come to that). It's all very well being told about the excellent survival rates etc, but it only became real when I discovered this forum and found real people who'd been there, got the t-shirt and were getting on with their lives!

Thyroglobulin is, I think, a protein found in your blood which is secreted by thyroid cells. If you've not got a thyroid (esp if you have RAI) then there should be no thyroglobulin in your blood and finding some there might suggest a recurrence. I haven't had RAI and sometimes my thyroglobulin wobbles a bit, so we are looking long-term at this - one dodgy result does not make a recurrence.

Some people (like me) have thyroglobulin antibodies, which can muddy the waters a little. I gather that some people's antibodies decline with time, but mine have been remarkably consistent. The oncologist looks at the two figures together to decide what is going on.

Keeping your TSH suppressed does indeed involve taking your tablets every morning. You will need regular blood tests (every 8 weeks or so) and probably a few tweeks in your medication before you get there, which can be a bit of a pain but nothing terrible. For example, I'm now on 175mcg thyroxine and 10mcg cytomel (T3) and that's probably about to change again.

Quite frankly if you notice anxiety, low energy etc, it's much more likely to mean that you need an adjustment to your medication rather than a recurrence. I have swollen glands whenever I'm ill, so it's taken me a while to stop imagining that it's come back every time I have a cold!

And yes, you would have thought that, with a tumour of 2cm which was clearly visible and palpable, one of the FNAs would have got the right result. The last result started off as "suspicious, follicular cells" but was downgraded to benign on appeal!!! Thankfully, they forgot to tell me this and I sought a second opinion based on the "suspicious" result. I guess you're just taking a few cells - if they turn out to be ok, then the assumption is that the rest are ok too.

Keep us updated - I'm thinking of you.


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## joplin1975

My endo sent me to the nuc med people for the RAI consult and treatment and I'll say that, in my case, I found them to be extremely knowledgeable, thoughtful, and very much up-to-date on the latest thinking around RAI (which, two years ago, was still being pushed heavily). I, personally, would prefer a nuc med person over an endo for a consult.



> Keeping you TSH suppressed is done by taking your thyroid medication daily? (ie. I am on synthroid 112mg). The lower the number the better or that depends on a few factors? This should be monitored every 3-6months for the first few years along with thyroglobulin TG & TGab? Is TG your white blood?
> 
> Eat well, exercise....if you notice anxiety, low energy again, swollen glands, this might indicate recurrence?


Yes, your TSH is suppressed by taking your daily medication. More or less, the lower the number the better, but once you get too low and your free t4 and free t3 is too high, you'll start to have issues with quality of life. As such, you have to fiddle around with things to see how low you can go without feeling hyper. For me, my "sweet spot" is a TSH of right around 0.3 with my free t4 right around 1.3ish (I'm a super converter so my free t3 will go through the roof if I get much higher than that).

For the first year, I had my TSH monitored every month (but that was because they messed up my meds). I did not even consider my Tg and TgAB for the first year. I had high, high, high level of antibodies which would inevitably have skewed the numbers. That, plus the fact that RAI works over the course of months. So we just kinda sat back and waited for things to simmer down.

Unfortunately, from everything I've read, there are virtually no signs of recurrence. Foe the first two years, I had WBSs and neck ultrasounds. Now we are weaning off WBSs and depending on Tg, TgAB, and neck ultrasounds. How you monitor is dependent on your treatment plan which is dependent on your pathology. KeepOnGoing and I have different paths and plans, but neither is "wrong." We are just two different people with two different protocols. This is why communicating with your doctor and thinking through your options is so important.

By the way, that standard advice is that the "safe" level of RAI = not exceeding 600mCis of RAI over the lifetime. For reference, I had 100mCi or 1/6th of the lifetime limit. One of my quibbles with the stats related to risks of RAI is that they don't provide clear risks of secondary malignancy in relation to RAI dose. So, I don't think its *just* RAI vs no RAI (although, to be clear, RAI even in small doses has risks), but I do think once needs to look at increasing risks as doses increase. I still can't find good stats regarding that.

In any event, here are two decent articles that discuss risks and recurrence. I think it would be good to read these over before you speak with nuc med:

http://www.ncbi.nlm.nih.gov/pubmed/19281429

http://www.medscape.com/viewarticle/807060


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## nel

Thank you for the valuable information ladies. I had a look at the one attachment joplin1975, the other I wasn't able to read. Slight risk of secondary malignancy after RAI.

It can be confusing & overwhelming...TSH & adjusting correctly free t4 & free t3....have to read more about this, you explanations are so helpful & written so I can understand!

A few other questions. (sorry for all of my questions)......hope you can help with these. If not, should I call ENT to review?

-FNA in June 2013 said benign follicular with hurthle. The pathology from surgery, April 9, 2014 papillary carcinoma, follicular variant. It says "Cytomorphology: Onocytic or oxyphilic" is this hurthle? Hurthle doesn't respond always to RAI?

-9 lymph nodes were removed, is it possible PTC could be in other lymph nodes? Under my ear/chin area I have 2 nodes I can feel swollen for a few months now. Though I have had either a runny/stuffed nose or sore throat.

-does tumor capsule invasion: present -minimal mean vascularity? Have read online that is higher risk of recurrence.

In a different mood than yesterday.....reading online has me scared & somewhat confused with PTC, variants & vascularity.....What if after future bloodwork, ultrasounds or scans they find it was a different variant or TC???

Have heard that TC has been on the rise lately. A student nurse after surgery came into see me, she had her thyroid removed & had to have more lymph nodes removed. She was telling me about the number of people she has seen with TC. The lady drawing blood had a partial removed (I believe she said due to TC). A few people I've talked to had a TT or partial & was benign.

Will see what nuclear medicine Dr. says.


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## joplin1975

If you had hurthle cell carcinoma, you'd have a pathology report that said "hurthle cell carcinoma." And, likely, your treatment path would be significantly accelerated. I don't know, specifically, what onocytic or oxyphilic means, but hurthle cells are found in people with Hashi's so if you see that word, my guess is that's what its related to.

Also, your post-op path is considered the gold standard for classifying and describing your cancer. It won't change later with bloodwork and scans (which cannot determine the type of cancer).

Yes, follicular variant does tend to be a touch more aggressive, but it's still considered exceptionally easy to treat with an great prognosis. Having that variant might push you into the RAI category, but again, you'll have to chat with the nuc med people.

Most cancerous nodes are found proximate to the thyroid and if they travel, the tendency is to travel downward, toward the chest. Very rarely does it go "up" into the chin area. If you have a concern, just ask for an ultrasound.


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## nel

Thank you Joplin1975 for answering my questions & your feedback. I'll mention the lymph nodes to my family dr. in a few weeks. Need to ask him about increasing my anxiety meds.....worry, worry about everything it seems like to the point of almost wanted to throw up.....Will see what nuc. medicine dr. says next week. Thanks again


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## joplin1975

Oh, I totally get that...and, by the way, if I ever sound flip about the whole cancer thing, it's only because I've had a couple of years to process the whole thing. 

My biggest regret was not asking for anxiety meds when I really, really needed them. So, I say, ask away!


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## nel

Met with the Dr. in Nuclear Medicine & her intern. The intern asked some questions about family history, previous radiation exposure & went over the pathology report. Based on 1) PTC with follicular & Onocytic & Oxypilic variant (which she said was common) 2)encapsulated 3)no lymph nodes 4)3.7cm -being less than 4cm an American & Canadian Thyroid Association guideline. They will re-check with bloodwork & ultrasound of neck & lymph nodes in 3months. They did blookwork at this appt.

Dr. mentioned they don't like to give RAI, unless you absolutely need it. Can't guarantee whether it will recur or not.

Of course after I left I had a few other questions & some things I should have said. To me, based on variant, size & vascularity I'll probably need RAI at some point.

What are you thoughts? Thanks.


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## joplin1975

nel, I think they are following the new guidelines which are meant to protect you from secondary malignancies. It just means more consistent monitoring and vigilance, but I think as long as they stay on top of things, you'll be ok.

The "nice" think about RAI is that they can do it weeks, months, even years after surgery, so if it all reoccurs, it is going to be ok.


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## nel

By consistent monitoring and vigilance, do you mean bloodwork & ultrasounds regularly? Every 3months?

The Nuclear Medicine office called today to say calcium was good & continue with dosage of synthroid & rocotrol based on bloodwork. I requested a copy of the labs, but I have to pay $25 & mail a letter with other information to get the report. Or, my doctor can fax request (maybe ENT can do this). I just assumed they could mail, fax or email a copy of the labs.

Thank you so much Joplin, appreciate your time & feedback!


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## cherrysaculo

Greetings to everyone.

I am new to this group, I came across the site when I was researching about this illness. I am the guardian of a cancer patient Male 54 yo. Recently diagnosed with Thyroid CA last week.

Gross and MICROSCOPIC DESCRIPTION:
Specimen labeled "left internal neck mass" consists of a brown tan topale tan, rubbery to firm, irregular tissue measuring 5.3x2. 3x2. 0cm. Cut sections reveal gray-brown to brown tan, firm cut surfaces. 2SS, B2.
Microscopic examination shows lymphoid tissue that is infiltrated by malignant neoplastic cells forming finger like projections. These are lined by a layer of low columnar cells exhibiting nuclear grooving, comewith intranuclear inclusion and optically clear nuclei.

Pathologic Diagnosis:  METASTATIC CARCINOMA PROBABLY FROM PAPILLARY 
CARCINOMA OF THE THYROID GLAND.
CLINICAL CORRELATION IS WARRANTED.

We have not seen a doctor, the patient is unaware that he has cancer, he read the result but incapable of interpreting it. I decided not explain further because I wanted to prepare properly how to say it. Patient resides in Tacloban and he only came to manila for surgery last week to have that lump/tumor (which was noticed for 2 years growing bigger)

That being said, the size of the tumor alone is stage 3/4. I am no medical practitioner to asses the case, I am simply researching and trying to learn everything I can to be knowledgeable on this topic.

As per the head neck sugeon, he will undergo to a total thyroidectomy. I'm in the stage of collecting thoughts of people to help us prepare for this fight. I was hoping some of you guys may have some advises

Thank you


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