What to Do with an Incidental 1mm Papillary Cancer?

Question

What is the appropriate workup and treatment plan for a 41 yo female who underwent right total thyroidectomy for what was initially felt to be a single hot nodule with symptoms of hoarseness, localized pain and enlargement? Path report revealed 1 large encapsulated adenoma as well as several smaller nodules. An incidental finding unrelated to any nodule and without vascular involvement was a 1 mm papillary carcinoma, follicular variant. Should this patient be evaluated and treated as stage 1 papillary cancer with total thyroidectomy plus minus RAI, with hormone suppression or should the finding be considered incidental and followed annually?

Thank you.

Mark J. Krzyston, MD
1175 Cook Rd. Ste 225
Orangeburg, SC 29118

Response

If the contralateral side was normal at operation and normal by US, and careful review of pathology reveals no evidence of malignancy in any of the nodules, I believe following the patient on T4 replacement with periodic US exams is sufficient. If the contralateral side was abnormal at op or on US, the abnormality would have to be evaluated independently "de novo" by appropriate studies such as US and FNA. Tiny (1-4mm) papillary cancer foci are found in 6% or more of autopsy series, and clearly in most cases carry a benign prognosis. But there are occasional reports of metastases from tiny primary foci, and obviously larger tumors must have grown from such small foci originally.

Leslie J De Groot, MD