Abstract
Well-differentiated thyroid carcinoma (WDTC) generally has a favorable prognosis. However, patients with distant metastatic disease experience progression of disease with a higher mortality. A subset of patients not previously described may challenge the conventional dogma regarding the progressive nature of all metastatic WDTC. Through analysis of our database, we identified patients with distant metastatic WDTC and persistent, minimally progressive disease. In all patients, persistent metastatic disease was confirmed via tissue biopsy, abnormal PET scan, and/or biochemical elevations in thyroglobulin or antibody levels. Progression of disease was monitored clinically and with repeat imaging. We describe five patients with WDTC and pulmonary metastases, aged 8–43 years at diagnosis. All patients underwent initial surgery and radioactive iodine (RAI) ablation, with some receiving multiple treatments. Persistent pulmonary metastatic disease was confirmed over decades (mean 22 years, range 8–42 years) with minimal progression despite no further treatment beyond thyroid hormone suppression. Persistent disease was biopsy-proven in all patients at a mean of 9.6 years from last RAI treatment. All patients had elevated thyroglobulin or anti-thyroglobulin antibody levels, while three demonstrated metabolically active disease with positive FDG uptake on PET scan, and one patient with persistent radioactive iodine avid pulmonary metastasis 36 years after her last RAI treatment. This case series demonstrates that some patients with distant metastases, even if metabolically active and radioactive iodine resistant, remain stable for decades without further treatment. Clinical awareness of such patients and continual reassessment of disease risk following initial therapy are crucial as aggressive treatment may not be necessary.
Highlights
IntroductionWhile the incidence of thyroid cancer has nearly tripled in the past three decades, mortality rates have remained stable [1, 2, 3]
Well-differentiated thyroid cancer is common, identified, and often curable
While the majority of deaths from thyroid carcinoma [2] are those with distant metastatic disease [23, 25, 26], our data demonstrate a remarkable diversity in the natural progression of patients with advanced thyroid cancer
Summary
While the incidence of thyroid cancer has nearly tripled in the past three decades, mortality rates have remained stable [1, 2, 3]. This underscores the widespread success in identifying, treating, and thereby limiting disease-related harm in most affected individuals [4, 5]. This is true for both localized and metastatic disease. Though there may be benefits to this approach, especially for patients with advanced disease, increasing evidence confirms that such a standardized approach to care may not be effective for all patients [10, 11, 12]
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