Whenever a thyroid nodule is diagnosed or suspected to be thyroid carcinoma on cytology of the fine-needle aspiration (FNA) sample, the patient must be treated with total thyroidectomy, with or without lymphadenectomy depending on whether there is evidence of secondary lymph node involvement. In our department, after this initial treatment and histological confirmation of thyroid carcinoma (papillary or follicular), the patient is referred to the doctors of the Oncology Section for a first assessment visit, to determine the type of tumour and the stage of the disease (step 1).
At this visit, after an initial interview to reconstruct the clinical history, especially for patients referred from other centres and therefore operated on elsewhere, the patient is examined and has a neck ultrasound scan and a blood sample to assess their metabolic status. Radiometabolic therapy with 131-I to ablate the thyroid remnant is also planned at this visit. For this second part, two days of attendance at the Oncology Day Service (DSA) are scheduled. During these two days, tests are carried out in collaboration with the Nuclear Medicine Section of our Department, to assess both the iodine uptake of the thyroid remnant and its functional activity by measuring serum thyroglobulin, which after surgery becomes a specific and sensitive marker of this disease. At this point the patient is treated with 131-I and then stays in a protected room for 1 or 2 days, depending on the amount of 131-I given. A whole-body scintigraphy is then performed (step 2).
The patient is discharged from the Oncology Day Service (DSA) with an appointment for an outpatient check-up after about 6 months at the oncology outpatient clinic (step 3). At this visit, besides the medical examination, a neck ultrasound scan and a blood sample are performed. The results will determine the next stage, which can be of two types. In the first case, the patient is seen again after a further 6 months at the Oncology Day Service (DSA) for a stimulation test with recombinant human TSH for thyroglobulin. On this occasion they will also have routine blood tests and tests specific to thyroid disease. They will need to stay for 5 days, during which blood samples are taken every day, because this is the time required for the test to be informative (step 4).
Based on this result, the patient may be declared in clinical remission or started on a new radiometabolic treatment. In the other case, the patient is in any event started on a second radiometabolic treatment (step 5).
The new radiometabolic treatment will be planned jointly by the Oncology Day Service (DSA) and Nuclear Medicine. An outpatient check-up is then repeated after a further 6 months, and the patient returns to the situation of step 3. The whole pathway is planned automatically, with set dates agreed with the patient.
The pathway for patients with medullary thyroid carcinoma is different, because this tumour does not respond to radiometabolic treatments. The patient is followed as an outpatient and/or in the day service (DSA), depending on whether they need a simple medical visit with a neck ultrasound scan and a baseline blood sample to measure calcitonin (the marker of this tumour), or staging with a total-body CT scan, bone scintigraphy, PET, etc. All patients with medullary thyroid carcinoma have a blood sample taken for genetic analysis.
More seriously ill patients with more aggressive disease are followed by the staff of the Oncology Section as inpatients in the Endocrinology ward. Any chemotherapy is given directly during these hospital stays.
Fine-needle aspiration (FNA)
Thyroid ultrasound scan
Blood sample
Nuclear Medicine
Oncology visit